Accurate Prognostic Awareness Facilitates, Whereas Better Quality of Life and More Anxiety Symptoms Hinder End-of-Life Care Discussions: A Longitudinal Survey Study in Terminally Ill Cancer Patients' Last Six Months of Life.

PubMed

Tang, Siew Tzuh; Chen, Chen Hsiu; Wen, Fur-Hsing; Chen, Jen-Shi; Chang, Wen-Cheng; Hsieh, Chia-Hsun; Chou, Wen-Chi; Hou, Ming-Mo

2018-04-01

Terminally ill cancer patients do not engage in end-of-life (EOL) care discussions or do so only when death is imminent, despite guidelines for EOL care discussions early in their disease trajectory. Most studies on patient-reported EOL care discussions are cross sectional without exploring the evolution of EOL care discussions as death approaches. Cross-sectional studies cannot determine the direction of association between EOL care discussions and patients' prognostic awareness, psychological well-being, and quality of life (QOL). We examined the evolution and associations of accurate prognostic awareness, functional dependence, physical and psychological symptom distress, and QOL with patient-physician EOL care discussions among 256 terminally ill cancer patients in their last six months by hierarchical generalized linear modeling with logistic regression and by arranging time-varying modifiable variables and EOL care discussions in a distinct time sequence. The prevalence of physician-patient EOL care discussions increased as death approached (9.2%, 11.8%, and 18.3% for 91-180, 31-90, and 1-30 days before death, respectively) but only reached significance in the last month. Accurate prognostic awareness facilitated subsequent physician-patient EOL care discussions, whereas better patient-reported QOL and more anxiety symptoms hindered such discussions. The likelihood of EOL care discussions was not associated with levels of physical symptom distress, functional dependence, or depressive symptoms. Physician-patient EOL care discussions for terminally ill Taiwanese cancer patients remain uncommon even when death approaches. Physicians should facilitate EOL care discussions by cultivating patients' accurate prognostic awareness early in their cancer trajectory when they are physically and psychologically competent, with better QOL, thus promoting informed and value-based EOL care decision making. Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Escalating Health Care Expenditures in Cancer Decedents' Last Year of Life: A Decade of Evidence from a Retrospective Population‐Based Cohort Study in Taiwan

PubMed Central

Hung, Yen‐Ni; Liu, Tsang‐Wu; Wen, Fur‐Hsing; Chou, Wen‐Chi

2017-01-01

Abstract Background. No population‐based longitudinal studies on end‐of‐life (EOL) expenditures were found for cancer decedents. Methods. This population‐based, retrospective cohort study examined health care expenditures from 2001 to 2010 among 339,546 Taiwanese cancer decedents' last year of life. Individual patient‐level data were linked from administrative datasets. Health care expenditures were converted from Taiwan dollars to U.S. dollars by health‐specific purchasing power parity conversions to account for different health‐purchasing powers. Associations of patient, physician, hospital, and regional factors with EOL care expenditures were evaluated by multilevel linear regression model by generalized estimating equation method. Results. Mean annual EOL care expenditures for Taiwanese cancer decedents increased from 2000 to 2010 from U.S. $49,591 to U.S. $68,773, respectively, with one third of spending occurring in the patients' last month. Increased EOL care expenditures were associated with male gender, younger age, being married, diagnosed with hematological malignancies and cancers other than lung, gastric, and hepatic‐pancreatic cancers, and dying within 7–24 months of diagnosis. Patients spent less at EOL when they had higher comorbidities and metastatic disease, died within 6 months of diagnosis, were under care of oncologists, gastroenterologists, and intensivists, and received care at a teaching hospital with more terminally ill cancer patients. Higher EOL care expenditures were associated with greater EOL care intensity at the primary hospital and regional levels. Conclusion. Taiwanese cancer decedents consumed considerable National Health Insurance disbursements at EOL, totaling more than was consumed in six developed non‐U.S. countries surveyed in 2010. To slow increasing cost and improve EOL cancer care quality, interventions to ensure appropriate EOL care provision should target hospitals and clinicians less experienced in providing EOL care and those who tend to provide aggressive EOL care to high‐risk patients. Implications for Practice. Cancer‐care costs are highest during the end‐of‐life (EOL) period for cancer decedents. This population‐based study longitudinally examined EOL expenditures for cancer decedents. Mean annual EOL‐care expenditures for Taiwanese cancer decedents increased from U.S. $49,591 to U.S. $68,773 from the year 2000 to 2010, with one third of spending in patients' last month and more than for six developed non‐U.S. countries surveyed in 2010. To slow the increasing cost of EOL‐cancer care, interventions should target hospitals/clinicians less experienced in providing EOL care, who tend to provide aggressive EOL care to high‐risk patients, to avoid the physical suffering, emotional burden, and financial costs of aggressive EOL care. PMID:28232596

Dances With Denial: Have Medical Oncology Outpatients Conveyed Their End-of-Life Wishes and Do They Want To?

PubMed

Waller, Amy; Douglas, Charles; Sanson-Fisher, Rob; Zdenkowski, Nicholas; Pearce, Angela; Evans, Tiffany; Walsh, Justin

2018-05-01

Objectives: This study surveyed a sample of medical oncology outpatients to determine (1) the proportion who have already discussed and documented their end-of-life (EOL) wishes; (2) when and with whom they would prefer to convey their EOL wishes; (3) the EOL issues they would want to discuss; and (4) the association between perceived cancer status and advance care planning (ACP) participation. Methods: Adult medical oncology outpatients were approached in the waiting room of an Australian tertiary treatment center. Consenting participants completed a pen-and-paper survey assessing participation in ACP, preferences for conveying EOL wishes, timing of EOL discussions, and EOL issues they want to be asked about. Results: A total of 203 patients returned the survey (47% of eligible). EOL discussions occurred more frequently with support persons (47%) than with doctors (7%). Only 14% had recorded their wishes, and 45% had appointed an enduring guardian. Those who perceived their cancer as incurable were more likely to have participated in ACP. If facing EOL, patients indicated that they would want family involved in discussions (85%), to be able to write down EOL wishes (82%), and to appoint enduring guardians (91%). Many (45%) preferred the first discussion to happen when their disease became incurable. Slightly less than one-third thought discussions regarding EOL should be patient-initiated. Most agreed doctors should ask about preferred decision-making involvement (92%), how important it is that pain is managed well (95%), and how important it is to remain conscious (82%). Fewer (55%) wanted to be asked about the importance of care extending life. Conclusions: Many patients would like to have discussions regarding EOL care with their doctor and involve their support persons in this process. Only a small percentage of respondents had discussed EOL care with their doctors, recorded their wishes, or appointed an enduring guardian. The first step requires clinicians to ask whether an individual patient wishes to discuss EOL issues, in what format, and at what level of detail. Copyright © 2018 by the National Comprehensive Cancer Network.

Male-female patient differences in association between end-of-life discussions and receipt of intensive care near death

PubMed Central

Sharma, Rashmi K.; Prigerson, Holly G.; Penedo, Frank J.; Maciejewski, Paul K.

2015-01-01

Background Patient gender plays a significant role in patient-physician communication, patient illness understanding and aggressiveness of end of life (EoL) care. However, little is known about the extent to which gender differences in the effects of EoL discussions on EoL care contribute to gender differences in EoL care. The present study aims to determine if gender differences exist in receipt of intensive care unit (ICU) care near death and in the association between EoL discussions and receipt of ICU EoL care. Methods Multi-site, prospective, cohort study of patients (N=353) with metastatic cancers, identified as terminally ill at study enrollment and interviewed a median of 4.1 months before their deaths. Postmortem chart reviews and caregiver interviews documented ICU stays in the last week of life. Results Patients who received ICU care at the EoL were more likely to be male than those who did not (73% male vs. 52% male, p=0.02). Adjusting for potential confounds, male patients reporting an EoL discussion were less likely to have an ICU stay in the last week of life than male patients with no EoL discussion (AOR=0.26, 95% CI 0.07–0.91; p=0.04). There was no association between EoL discussions and ICU stays near death among female patients. Conclusions Men with advanced cancers are more likely than women to receive aggressive, non-beneficial, ICU care near death. Gender differences in effects of EoL discussions on EoL care likely contribute to, and may even explain, gender differences in receipt of ICU care in the last week of life. PMID:25975179

Impact of Oncologists’ Attitudes Toward End-of-Life Care on Patients’ Access to Palliative Care

PubMed Central

Cerana, Maria Agustina; Park, Minjeong; Hess, Kenneth; Bruera, Eduardo

2016-01-01

Background. It is unclear how oncologists’ attitudes toward end-of-life (EOL) care affect the delivery of care. The present study examined the association between oncologists’ EOL care attitudes and (a) timely specialist palliative care referral, (b) provision of supportive care, and (c) EOL cancer treatment decisions. Methods. We randomly surveyed 240 oncology specialists at our tertiary care cancer center to assess their attitudes toward EOL care using a score derived from the Jackson et al. qualitative conceptual framework (0 = uncomfortable and 8 = highly comfortable with EOL care). We determined the association between this score and clinicians’ report of specialist palliative care referral, provision of supportive care, and EOL cancer treatment decisions. Results. Of the 182 respondents (response rate of 76%), the median composite EOL care score was 6 (interquartile range, 5–7). A higher EOL score was significantly associated with solid tumor oncology (median 7 vs. 6 for hematologic oncology; p = .003), a greater willingness to refer patients with newly diagnosed cancer to specialist palliative care (median, 7 vs. 6; p = .01), greater comfort with symptom management (median, 6 vs. 5; p = .01), and provision of counseling (median, 7 vs. 4; p < .001) but not with cancer treatment decisions. We observed a gradient effect, with higher scores associated with a greater proportion of patients referred to palliative care (score 0–4, 27%; 5, 31%; 6, 32%; 7, 35%; and 8, 45%; p = .007). Conclusion. Greater comfort with EOL care was associated with higher rates of specialist palliative care referral and self-reported primary palliative care delivery. More support and education are needed for oncologists who are less comfortable with EOL care. Implications for Practice: In the present survey of oncology specialists, most reported that they were comfortable with end-of-life (EOL) care, which was in turn, associated with greater provision of primary palliative care and higher rates of referral to specialist palliative care. The results of the present study highlight the need for more support and education for oncologists less comfortable with EOL care because their patients might receive lower levels of both primary and secondary palliative care. PMID:27412394

Impact of Oncologists' Attitudes Toward End-of-Life Care on Patients' Access to Palliative Care.

PubMed

Hui, David; Cerana, Maria Agustina; Park, Minjeong; Hess, Kenneth; Bruera, Eduardo

2016-09-01

It is unclear how oncologists' attitudes toward end-of-life (EOL) care affect the delivery of care. The present study examined the association between oncologists' EOL care attitudes and (a) timely specialist palliative care referral, (b) provision of supportive care, and (c) EOL cancer treatment decisions. We randomly surveyed 240 oncology specialists at our tertiary care cancer center to assess their attitudes toward EOL care using a score derived from the Jackson et al. qualitative conceptual framework (0 = uncomfortable and 8 = highly comfortable with EOL care). We determined the association between this score and clinicians' report of specialist palliative care referral, provision of supportive care, and EOL cancer treatment decisions. Of the 182 respondents (response rate of 76%), the median composite EOL care score was 6 (interquartile range, 5-7). A higher EOL score was significantly associated with solid tumor oncology (median 7 vs. 6 for hematologic oncology; p = .003), a greater willingness to refer patients with newly diagnosed cancer to specialist palliative care (median, 7 vs. 6; p = .01), greater comfort with symptom management (median, 6 vs. 5; p = .01), and provision of counseling (median, 7 vs. 4; p < .001) but not with cancer treatment decisions. We observed a gradient effect, with higher scores associated with a greater proportion of patients referred to palliative care (score 0-4, 27%; 5, 31%; 6, 32%; 7, 35%; and 8, 45%; p = .007). Greater comfort with EOL care was associated with higher rates of specialist palliative care referral and self-reported primary palliative care delivery. More support and education are needed for oncologists who are less comfortable with EOL care. In the present survey of oncology specialists, most reported that they were comfortable with end-of-life (EOL) care, which was in turn, associated with greater provision of primary palliative care and higher rates of referral to specialist palliative care. The results of the present study highlight the need for more support and education for oncologists less comfortable with EOL care because their patients might receive lower levels of both primary and secondary palliative care. ©AlphaMed Press.

Resident reflections on end-of-life education: a mixed-methods study of the 3 Wishes Project

PubMed Central

Centofanti, J; Swinton, M; Dionne, J; Barefah, A; Boyle, A; Woods, A; Shears, M; Heels-Ansdell, D; Cook, D

2016-01-01

Objective The objectives of this study were to describe residents' experiences with end-of-life (EOL) education during a rotation in the intensive care unit (ICU), and to understand the possible influence of the 3 Wishes Project. Design We enrolled dying patients, their families and 1–3 of their clinicians in the 3 Wishes Project, eliciting and honouring a set of 3 wishes to bring peace to the final days of a critically ill patient's life, and ease the grieving process for families. We conducted semistructured interviews with 33 residents who had cared for 50 dying patients to understand their experiences with the project. Interviews were recorded, transcribed verbatim, then analysed using a qualitative descriptive approach. Setting 21-bed medical surgical ICU in a tertiary care, university-affiliated hospital. Results 33 residents participated from internal medicine (24, 72.7%), anaesthesia (8, 24.2%) and laboratory medicine (1, 3.0%) programmes in postgraduate years 1–3. 3 categories and associated themes emerged. (1) EOL care is a challenging component of training in that (a) death in the ICU can invoke helplessness, (b) EOL education is inadequate, (c) personal connections with dying patients is difficult in the ICU and (d) EOL skills are valued by residents. (2) The project reframes the dying process for residents by (a) humanising this aspect of practice, (b) identifying that family engagement is central to the dying process, (c) increasing emotional responsiveness and (d) showing that care shifts, not stops. (3) The project offers experiential education by (a) intentional role modelling, (b) facilitating EOL dialogue, (c) empowering residents to care in a tangible way and (d) encouraging reflection. Conclusions For residents, the 3 Wishes Project integrated many forms of active learning for residents. Practice-based rather than classroom-based programmes may engage trainees to develop EOL skills transferable to other settings. PMID:27033962

Challenges of Providing End-of-Life Care for Homeless Veterans.

PubMed

Hutt, Evelyn; Whitfield, Emily; Min, Sung-Joon; Jones, Jacqueline; Weber, Mary; Albright, Karen; Levy, Cari; O'Toole, Thomas

2016-05-01

To describe challenges of caring for homeless veterans at end of life (EOL) as perceived by Veterans Affairs Medical Center (VAMC) homeless and EOL care staff. E-mail survey. Homelessness and EOL programs at VAMCs. Programs and their ratings of personal, structural, and clinical care challenges were described statistically. Homelessness and EOL program responses were compared in unadjusted analyses and using multivariable models. Of 152 VAMCs, 50 (33%) completed the survey. The VAMCs treated an average of 6.5 homeless veterans at EOL annually. Lack of appropriate housing was the most critical challenge. The EOL programs expressed somewhat more concern about lack of appropriate care site and care coordination than did homelessness programs. Personal, clinical, and structural challenges face care providers for veterans who are homeless at EOL. Deeper understanding of these challenges will require qualitative study of homeless veterans and care providers. © The Author(s) 2015.

Establishing end-of-life boards for palliative care of patients with advanced diseases.

PubMed

Masel, Eva K; Unseld, Matthias; Adamidis, Feroniki; Roider-Schur, Sophie; Watzke, Herbert H

2018-04-01

Interdisciplinary tumor board decisions improve the quality of oncological therapies, while no such boards exist for end-of-life (EOL) decisions. The aim of this study was to assess the willingness of hemato-oncological and palliative care professionals to develop and participate in EOL boards. An aim of an EOL board would be to establish an interdisciplinary and comprehensive care for the remaining lifetime of patients suffering from advanced incurable diseases. Staff from the interdisciplinary teams of all hemato-oncological and palliative care wards in Vienna were invited to anonymously participate in an online survey. 309 professionals responded. 91% respondents reported a need to establish an EOL board, 63% expressed their willingness to actively participate in an EOL board, and 25% were indecisive. Regarding patient presence, 50% voted for an EOL board in the presence of the patients, and 36% voted for an EOL board in the absence of the patients. 95% had the opinion that an EOL board could improve patient care in the last phase of life. 64% stated that the development of an EOL board would be worthwhile, while 28% did not see enough resources available at their institutions. Regarding the desired type of documentation, 61% voted for a centrally available EOL decision, and 31% supported an in-house-based documentation. 94% voted for the availability of an information folder about EOL care. The willingness of professionals to establish an EOL board was very high. Further steps should be taken to implement such boards to improve EOL care.

Reaching common ground: a patient-family-based conceptual framework of quality EOL care.

PubMed

Howell, Doris; Brazil, Kevin

2005-01-01

Improvement in the quality of end-of-life (EOL) care is a priority health care issue since serious deficiencies in quality of care have been reported across care settings. Increasing pressure is now focused on Canadian health care organizations to be accountable for the quality of palliative and EOL care delivered. Numerous domains of quality EOL care upon which to create accountability frameworks are now published, with some derived from the patient/family perspective. There is a need to reach common ground on the domains of quality EOL care valued by patients and families in order to develop consistent performance measures and set priorities for health care improvement. This paper describes a meta-synthesis study to develop a common conceptual framework of quality EOL care integrating attributes of quality valued by patients and their families.

Diversity in Defining End of Life Care: An Obstacle or the Way Forward?

PubMed Central

Gysels, Marjolein; Evans, Natalie; Meñaca, Arantza; Higginson, Irene J.; Harding, Richard; Pool, Robert

2013-01-01

Aim The terms used to describe care at the end of life (EoL), and its definitions, have evolved over time and reflect the changes in meaning the concept has undergone as the field develops. We explore the remit of EoL care as defined by experts in EoL care, from across Europe and beyond, to understand its current usage and meanings. Method A qualitative survey attached to a call for expertise on cultural issues in EoL care was sent to experts in the field identified through the literature, European EoL care associations, and conferences targeted at EoL care professionals. Respondents were asked to identify further contacts for snowball recruitment.The responses were analysed using content and discourse analysis. Results Responses were received from 167 individuals (33% response rate), mainly from academics (39%) and clinical practitioners working in an academic context (23%) from 19 countries in Europe and beyond. 29% of respondents said explicitly that there was no agreed definition of EoL care in practice and only 14% offered a standard definition (WHO, or local institution). 2% said that the concept of EoL care was not used in their country, and 5% said that there was opposition to the concept for religious or cultural reasons. Two approaches were identified to arrive at an understanding of EoL care: exclusively by drawing boundaries through setting time frames, and inclusively by approaching its scope in an integrative way. This led to reflections about terminology and whether defining EoL care is desirable. Conclusion The global expansion of EoL care contributes to the variety of interpretations of what it means. This complicates the endeavour of defining the field. However, when diversity is taken seriously it can open up new perspectives to underpin the ethical framework of EoL care. PMID:23844145

End-of-Life Care and Discussions in Japanese Geriatric Health Service Facilities: A Nationwide Survey of Managing Directors' Viewpoints.

PubMed

Kanoh, Asako; Kizawa, Yoshiyuki; Tsuneto, Satoru; Yokoya, Shoji

2018-01-01

Geriatric health service facilities (GHSFs) play important roles as intermediate care facilities for elderly individuals temporarily when they need rehabilitation before returning home. However, the number of residents spending their end-of-life (EOL) period in such facilities is increasing. To improve the quality of EOL care, end-of-life discussions (EOLDs) are recommended by some guidelines and studies. This study aimed to clarify the current practice of EOL care and EOLDs in GHSFs in Japan. We conducted a nationwide cross-sectional survey by mailing questionnaires about EOL care and EOLDs to 3437 GHSF managing directors. The questionnaire was developed through a literature review and discussion among the researchers and experts. Descriptive statistics summarized the data. We also analyzed the factors related to GHSFs conducting EOLDs using Fisher exact tests. The response rate was 20.7% (713 of 3437). Among the respondents, 75.2% (536 of 713) of GHSFs provided EOL care and 73.1% (521 of 713) conducted EOLDs. The most common reasons for difficulties in providing EOL care included the lack of EOL education for nurses and care workers, and their fear about caring for dying residents. End-of-life discussions were mostly initiated after the deterioration of a resident's condition and were conducted with families by physicians. Statistically significant factors of GHSFs conducting EOLDs included providing EOL education for nurses and care workers, availability of private room for critically ill residents, emergency on-call doctors, and EOL care. Adequate practical staff education programs for EOL care including EOLDs may be crucial for quality of end-of-life care in aged care facilities.

Oncology nurses' perceptions of end-of-life care in a tertiary cancer centre in Qatar.

PubMed

Libo-On, Izette Larraine M; Nashwan, Abdulqadir J

2017-02-02

Nurses who work in oncology settings may lack the knowledge and skills required for end-of-life (EoL) care. A clear understanding of nurses' perceptions of EoL care is crucial for the successful improvement of care for terminally ill patients with cancer. Although many studies have underlined nurses' perspectives on EoL care, this is the first such study conducted on oncology nurses in Qatar. This study primarily sought to measure nurses' perceptions of EoL care at the National Center for Cancer Care and Research (NCCCR) in Qatar. A quantitative, cross-sectional, self-reported study. Nurses at the NCCCR reported their perceptions of EoL care using the Frommelt Attitudes Toward Care of the Dying (FATCOD) scale, which consisted of 30 items scored on a five-point Likert scale. Seventy-eight nurses working in oncology settings completed the tool. Approximately one third (33-35%) of the participants had positive perceptions of EoL care. The majority (67%) of the participants were uncertain or ambivalent regarding EoL events and situations. There was no significant relationship between the participants' profiles and their perceptions of EoL care. However, very few of them had completed educational courses in death and dying. Nurses have an important impact on EoL care, and continuous education is necessary to improve their confidence when they work with dying patients and their families. An in-house programme to help nurses cope with compassionate exhaustion and humanistic and relational care is highly recommended.

Critical Care Nurses' Suggestions to Improve End-of-Life Care Obstacles: Minimal Change Over 17 Years.

PubMed

Beckstrand, Renea L; Hadley, Kacie Hart; Luthy, Karlen E; Macintosh, Janelle L B

Critical-care nurses (CCNs) provide end-of-life (EOL) care on a daily basis as 1 in 5 patients dies while in intensive care units. Critical-care nurses overcome many obstacles to perform quality EOL care for dying patients. The purposes of this study were to collect CCNs' current suggestions for improving EOL care and determine if EOL care obstacles have changed by comparing results to data gathered in 1998. A 72-item questionnaire regarding EOL care perceptions was mailed to a national, geographically dispersed, random sample of 2000 members of the American Association of Critical-Care Nurses. One of 3 qualitative questions asked CCNs for suggestions to improve EOL care. Comparative obstacle size (quantitative) data were previously published. Of the 509 returned questionnaires, 322 (63.3%) had 385 written suggestions for improving EOL care. Major themes identified were ensuring characteristics of a good death, improving physician communication with patients and families, adjusting nurse-to-patient ratios to 1:1, recognizing and avoiding futile care, increasing EOL education, physicians who are present and "on the same page," not allowing families to override patients' wishes, and the need for more support staff. When compared with data gathered 17 years previously, major themes remained the same but in a few cases changed in order and possible causation. Critical-care nurses' suggestions were similar to those recommendations from 17 years ago. Although the order of importance changed minimally, the number of similar themes indicated that obstacles to providing EOL care to dying intensive care unit patients continue to exist over time.

End-of-life care volunteers: a systematic review of the literature.

PubMed

Wilson, Donna M; Justice, Christopher; Thomas, Roger; Sheps, Sam; Macadam, Margaret; Brown, Margaret

2005-11-01

This report presents a review of 1988 and onwards research and other literature on end-of-life (EOL) care volunteers. Only 18 research or case studies articles were identified for an integrative review through a search of nine library databases. A review of this literature revealed three themes: (1) the roles of EOL volunteers, (2) volunteer training and other organizational needs or requirements, and (3) outcomes, particularly the impact of volunteering on volunteers and the impact of volunteers on EOL care. Despite limited statistical evidence, the available literature on EOL care volunteers clearly indicates that considerable potential benefit can be derived from EOL care volunteers' contributions, with their efforts benefiting dying persons, their families, paid EOL staff, and the volunteers themselves. More specifically, willing volunteers, particularly those with diverse skills and abilities, have the potential to significantly and positively impact EOL care in that they can perform many necessary and extra functions of value. Volunteers often augment and enhance the range of EOL care services provided to terminally ill individuals and their families. Volunteers should also be recognized as increasing the accessibility of EOL care. The role of the volunteer is not without challenge, however, both for the individuals who volunteer and the organizations that must orient them and provide a meaningful role for them.

Intensive Care Nurses' Attitude on Palliative and End of Life Care.

PubMed

Tripathy, Swagata; Routray, Pragyan K; Mishra, Jagdish C

2017-10-01

Intensive Care Unit (ICU) nurses have a vital role in the implementation of end of life (EOL) care. There is limited data on the attitude of ICU nurses toward EOL and palliation. This study aimed to investigate knowledge, attitude, and beliefs of intensive care nurses in eastern India toward EOL. A self-administered questionnaire was distributed to delegates in two regional critical care nurses' training programs. Of 178 questionnaires distributed, 138 completed, with a response rate of 75.5*. About half (48.5*) had more than 1 year ICU experience. A majority (81.9*) agreed that nurses should be involved in and initiate (62.3*) EOL discussions. Terms "EOL care or palliative care in ICU" were new for 19.6*; 21* and 55.8* disagreed with allowing peaceful death in terminal patients and unrestricted family visits, respectively. Work experience was associated with wanting unrestricted family visitation, discontinuing monitoring and investigations at EOL, equating withholding and withdrawal of treatment, and being a part of EOL team discussions ( P = 0.005, 0.01, 0.01, and 0.001), respectively. Religiousness was associated with a greater desire to initiate EOL discussions ( P = 0.001). Greater emphasis on palliative care in critical care curriculum may improve awareness among critical care nurses.

Palliative care at the end-of-life in glioma patients.

PubMed

Koekkoek, Johan A F; Chang, Susan; Taphoorn, Martin J B

2016-01-01

The end-of-life (EOL) phase of patients with a glioma starts when symptom prevalence increases and antitumor treatment is no longer effective. During the EOL phase, care is primarily aimed at reducing symptom burden while maintaining quality of life as long as possible without inappropriate prolongation of life. Palliative care during the EOL phase also involves complex medical decisions for the prevention and relief of suffering. We discuss the prevalence and treatment of the most common EOL symptoms, decision making in the EOL phase, the organization of EOL care, and the role of the patient's caregiver. Treating disease-specific symptoms, such as impaired consciousness, seizures, focal neurologic deficits and cognitive disturbances, is a major concern during the EOL phase, as these symptoms may interfere with EOL decision making. Advance care planning is aimed at reaching consensus about possible EOL decisions between all participants, respecting the values of patients and their informal caregivers. In order to prevent the possibility that the patient becomes incompetent to make informed decisions, we recommend initiating EOL conversations at a relatively early stage in the disease course. © 2016 Elsevier B.V. All rights reserved.

Associations Between End-of-Life Discussion Characteristics and Care Received Near Death: A Prospective Cohort Study

PubMed Central

Mack, Jennifer W.; Cronin, Angel; Keating, Nancy L.; Taback, Nathan; Huskamp, Haiden A.; Malin, Jennifer L.; Earle, Craig C.; Weeks, Jane C.

2012-01-01

Purpose National guidelines recommend that discussions about end-of-life (EOL) care planning happen early for patients with incurable cancer. We do not know whether earlier EOL discussions lead to less aggressive care near death. We sought to evaluate the extent to which EOL discussion characteristics, such as timing, involved providers, and location, are associated with the aggressiveness of care received near death. Patients and Methods We studied 1,231 patients with stage IV lung or colorectal cancer in the Cancer Care Outcomes Research and Surveillance Consortium, a population- and health system–based prospective cohort study, who died during the 15-month study period but survived at least 1 month. Our main outcome measure was the aggressiveness of EOL care received. Results Nearly half of patients received at least one marker of aggressive EOL care, including chemotherapy in the last 14 days of life (16%), intensive care unit care in the last 30 days of life (9%), and acute hospital-based care in the last 30 days of life (40%). Patients who had EOL discussions with their physicians before the last 30 days of life were less likely to receive aggressive measures at EOL, including chemotherapy (P = .003), acute care (P < .001), or any aggressive care (P < .001). Such patients were also more likely to receive hospice care (P < .001) and to have hospice initiated earlier (P < .001). Conclusion Early EOL discussions are prospectively associated with less aggressive care and greater use of hospice at EOL. PMID:23150700

Reflections on using biographical approaches in end-of-life care: dignity therapy as example.

PubMed

Lindqvist, Olav; Threlkeld, Guinever; Street, Annette F; Tishelman, Carol

2015-01-01

The therapeutic potential of nonpharmacologic interventions using biographical approaches at the end of life (EoL) is being increasingly recognized, but less attention is paid to processes impeding realization of this potential. In this article, Swedish and Australian researchers reflect on and problematize experiences using one biographical approach, dignity therapy (DT), in EoL care in Sweden. We use this as an example, focusing on critical examination of the process of applying DT in practice, examining frictions experienced in recruiting participants, collecting the data, and creating a biography. We discuss issues regarding agency, which became evident in the recruitment process and choices made about participation, and the power differentials manifested in the interactive process of eliciting stories and crafting them into a final product. We also raise salient questions about how research and practice with biographical approaches in EoL care might better build on and further existing knowledge to better reflect the complexities of everyday life. © The Author(s) 2014.

Occupational Variation in End-of-Life Care Intensity.

PubMed

Hyder, Joseph A; Haring, R Sterling; Sturgeon, Daniel; Gazarian, Priscilla K; Jiang, Wei; Cooper, Zara; Lipsitz, Stuart R; Prigerson, Holly G; Weissman, Joel S

2018-03-01

End-of-life (EOL) care intensity is known to vary by secular and geographic patterns. US physicians receive less aggressive EOL care than the general population, presumably the result of preferences shaped by work-place experience with EOL care. We investigated occupation as a source of variation in EOL care intensity. Across 4 states, we identified 660 599, nonhealth maintenance organization Medicare beneficiaries aged ≥66 years who died between 2004 and 2011. Linking death certificates, we identified beneficiaries with prespecified occupations: nurses, farmers, clergy, mortuary workers, homemakers, first-responders, veterinary workers, teachers, accountants, and the general population. End-of-life care intensity over the last 6 months of life was assessed using 5 validated measures: (1) Medicare expenditures, rates of (2) hospice, (3) surgery, (4) intensive care, and (5) in-hospital death. Occupation was a source of large variation in EOL care intensity across all measures, before and after adjustment for sex, education, age-adjusted Charlson Comorbidity Index, race/ethnicity, and hospital referral region. For example, absolute and relative adjusted differences in expenditures were US$9991 and 42% of population mean expenditure ( P < .001 for both). Compared to the general population on the 5 EOL care intensity measures, teachers (5 of 5), homemakers (4 of 5), farmers (4 of 5), and clergy (3 of 5) demonstrated significantly less aggressive care. Mortuary workers had lower EOL care intensity (4 of 5) but small numbers limited statistical significance. Occupations with likely exposure to child development, death/bereavement, and naturalistic influences demonstrated lower EOL care intensity. These findings may inform patients and clinicians navigating choices around individual EOL care preferences.

Nursing Strategies for Engaging Families of Older Immigrants Hospitalized for End-of-Life Care

PubMed Central

Hutchinson, Alison M; Rawson, Helen; Redley, Bernice

2016-01-01

Background: Engaging with families of older non-English-speaking background (NESB) immigrants hospitalized for end-of-life (EOL) care can be challenging, especially when their cultures, lifeways, and family decision-making processes are unfamiliar to the nurses caring for them. Despite the recognized importance of family engagement when providing EOL care, the issue of ethnic minority family engagement has received little attention in the field. Aim: To explore and describe the strategies nurses use to facilitate engagement with families of older immigrant NESB patients hospitalized for EOL care. Methods: A qualitative descriptive approach was used. Data were collected via in-depth interviews conducted with 22 registered nurses recruited from 4 Australian health services. Findings: Using thematic analysis processes, 5 key strategies were identified: listening and understanding families, encouraging family members to speak first, dealing with angst, redressing naive views about the dying process, and managing intergenerational differences. Underpinning these strategies was a profound “will to engage” with the families and their cultural worldviews. Conclusion: Further cross-cultural comparative research is required to inform evidence-based policies, practice, and education on this issue. PMID:28725839

Decision Making Regarding the Place of End-of-Life Cancer Care: The Burden on Bereaved Families and Related Factors.

PubMed

Yamamoto, Sena; Arao, Harue; Masutani, Eiko; Aoki, Miwa; Kishino, Megumi; Morita, Tatsuya; Shima, Yasuo; Kizawa, Yoshiyuki; Tsuneto, Satoru; Aoyama, Maho; Miyashita, Mitsunori

2017-05-01

Decision making regarding the place of end-of-life (EOL) care is an important issue for patients with terminal cancer and their families. It often requires surrogate decision making, which can be a burden on families. To explore the burden on the family of patients dying from cancer related to the decisions they made about the place of EOL care and investigate the factors affecting this burden. This was a cross-sectional mail survey using a self-administered questionnaire. Participants were 700 bereaved family members of patients with cancer from 133 palliative care units in Japan. The questionnaire covered decisional burdens, depression, grief, and the decision-making process. Participants experienced emotional pressure as the highest burden. Participants with a high decisional burden reported significantly higher scores for depression and grief (both P < 0.001). Multiple regression analyses revealed that higher burden was associated with selecting a place of EOL care that differed from that desired by participants (P < 0.001) and patients (P = 0.034), decision making without knowing the patient's wishes and values (P < 0.001) and without participants sharing their wishes and values with the patient's doctors and/or nurses (P = 0.022), and making the decision because of a due date for discharge from a former facility or hospital (P = 0.005). Decision making regarding the place of EOL care was recalled as burdensome for family decision makers. An early decision-making process that incorporates sharing patients' and family members' values that are relevant to the desired place of EOL care is important. Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Using Social Network Analysis to Investigate Positive EOL Communication.

PubMed

Xu, Jiayun; Yang, Rumei; Wilson, Andrew; Reblin, Maija; Clayton, Margaret F; Ellington, Lee

2018-04-30

End of life (EOL) communication is a complex process involving the whole family and multiple care providers. Applications of analysis techniques that account for communication beyond the patient and patient/provider, will improve clinical understanding of EOL communication. To introduce the use of social network analysis to EOL communication data, and to provide an example of applying social network analysis to home hospice interactions. We provide a description of social network analysis using social network analysis to model communication patterns during home hospice nursing visits. We describe three social network attributes (i.e. magnitude, directionality, and reciprocity) in the expression of positive emotion among hospice nurses, family caregivers, and hospice cancer patients. Differences in communication structure by primary family caregiver gender and across time were also examined. Magnitude (frequency) in the expression of positive emotion occurred most often between nurses and caregivers or nurses and patients. Female caregivers directed more positive emotion to nurses, and nurses directed more positive emotion to other family caregivers when the primary family caregiver was male. Reciprocity (mutuality) in positive emotion declined towards day of death, but increased on day of actual patient death. There was variation in reciprocity by the type of positive emotion expressed. Our example demonstrates that social network analysis can be used to better understand the process of EOL communication. Social network analysis can be expanded to other areas of EOL research, such as EOL decision-making and health care teamwork. Copyright © 2018. Published by Elsevier Inc.

Resident reflections on end-of-life education: a mixed-methods study of the 3 Wishes Project.

PubMed

Centofanti, J; Swinton, M; Dionne, J; Barefah, A; Boyle, A; Woods, A; Shears, M; Heels-Ansdell, D; Cook, D

2016-03-31

The objectives of this study were to describe residents' experiences with end-of-life (EOL) education during a rotation in the intensive care unit (ICU), and to understand the possible influence of the 3 Wishes Project. We enrolled dying patients, their families and 1-3 of their clinicians in the 3 Wishes Project, eliciting and honouring a set of 3 wishes to bring peace to the final days of a critically ill patient's life, and ease the grieving process for families. We conducted semistructured interviews with 33 residents who had cared for 50 dying patients to understand their experiences with the project. Interviews were recorded, transcribed verbatim, then analysed using a qualitative descriptive approach. 21-bed medical surgical ICU in a tertiary care, university-affiliated hospital. 33 residents participated from internal medicine (24, 72.7%), anaesthesia (8, 24.2%) and laboratory medicine (1, 3.0%) programmes in postgraduate years 1-3. 3 categories and associated themes emerged. (1) EOL care is a challenging component of training in that (a) death in the ICU can invoke helplessness, (b) EOL education is inadequate, (c) personal connections with dying patients is difficult in the ICU and (d) EOL skills are valued by residents. (2) The project reframes the dying process for residents by (a) humanising this aspect of practice, (b) identifying that family engagement is central to the dying process, (c) increasing emotional responsiveness and (d) showing that care shifts, not stops. (3) The project offers experiential education by (a) intentional role modelling, (b) facilitating EOL dialogue, (c) empowering residents to care in a tangible way and (d) encouraging reflection. For residents, the 3 Wishes Project integrated many forms of active learning for residents. Practice-based rather than classroom-based programmes may engage trainees to develop EOL skills transferable to other settings. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

How Community Clergy Provide Spiritual Care: Toward a Conceptual Framework for Clergy End-of-Life Education

PubMed Central

LeBaron, Virginia T.; Smith, Patrick T.; Quiñones, Rebecca; Nibecker, Callie; Sanders, Justin J.; Timms, Richard; Shields, Alexandra E.; Balboni, Tracy A.; Balboni, Michael J.

2018-01-01

Context Community-based clergy are highly engaged in helping terminally ill patients address spiritual concerns at the end of life (EOL). Despite playing a central role in EOL care, clergy report feeling ill-equipped to spiritually support patients in this context. Significant gaps exist in understanding how clergy beliefs and practices influence EOL care. Objectives The objective of this study was to propose a conceptual framework to guide EOL educational programming for community-based clergy. Methods This was a qualitative, descriptive study. Clergy from varying spiritual backgrounds, geographical locations in the U.S., and race/ethnicities were recruited and asked about optimal spiritual care provided to patients at the EOL. Interviews were audio taped, transcribed, and analyzed following principles of grounded theory. A final set of themes and subthemes were identified through an iterative process of constant comparison. Participants also completed a survey regarding experiences ministering to the terminally ill. Results A total of 35 clergy participated in 14 individual interviews and two focus groups. Primary themes included Patient Struggles at EOL and Clergy Professional Identity in Ministering to the Terminally Ill. Patient Struggles at EOL focused on existential questions, practical concerns, and difficult emotions. Clergy Professional Identity in Ministering to the Terminally Ill was characterized by descriptions of Who Clergy Are (“Being”), What Clergy Do (“Doing”), and What Clergy Believe (“Believing”). “Being” was reflected primarily by manifestations of presence; “Doing” by subthemes of religious activities, spiritual support, meeting practical needs, and mistakes to avoid; “Believing” by subthemes of having a relationship with God, nurturing virtues, and eternal life. Survey results were congruent with interview and focus group findings. Conclusion A conceptual framework informed by clergy perspectives of optimal spiritual care can guide EOL educational programming for clergy. PMID:26706624

How Community Clergy Provide Spiritual Care: Toward a Conceptual Framework for Clergy End-of-Life Education.

PubMed

LeBaron, Virginia T; Smith, Patrick T; Quiñones, Rebecca; Nibecker, Callie; Sanders, Justin J; Timms, Richard; Shields, Alexandra E; Balboni, Tracy A; Balboni, Michael J

2016-04-01

Community-based clergy are highly engaged in helping terminally ill patients address spiritual concerns at the end of life (EOL). Despite playing a central role in EOL care, clergy report feeling ill-equipped to spiritually support patients in this context. Significant gaps exist in understanding how clergy beliefs and practices influence EOL care. The objective of this study was to propose a conceptual framework to guide EOL educational programming for community-based clergy. This was a qualitative, descriptive study. Clergy from varying spiritual backgrounds, geographical locations in the U.S., and race/ethnicities were recruited and asked about optimal spiritual care provided to patients at the EOL. Interviews were audio taped, transcribed, and analyzed following principles of grounded theory. A final set of themes and subthemes were identified through an iterative process of constant comparison. Participants also completed a survey regarding experiences ministering to the terminally ill. A total of 35 clergy participated in 14 individual interviews and two focus groups. Primary themes included Patient Struggles at EOL and Clergy Professional Identity in Ministering to the Terminally Ill. Patient Struggles at EOL focused on existential questions, practical concerns, and difficult emotions. Clergy Professional Identity in Ministering to the Terminally Ill was characterized by descriptions of Who Clergy Are ("Being"), What Clergy Do ("Doing"), and What Clergy Believe ("Believing"). "Being" was reflected primarily by manifestations of presence; "Doing" by subthemes of religious activities, spiritual support, meeting practical needs, and mistakes to avoid; "Believing" by subthemes of having a relationship with God, nurturing virtues, and eternal life. Survey results were congruent with interview and focus group findings. A conceptual framework informed by clergy perspectives of optimal spiritual care can guide EOL educational programming for clergy. Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Associations between Race and Dementia Status and the Quality of End-of-Life Care.

PubMed

Luth, Elizabeth A; Prigerson, Holly G

2018-04-05

Non-Hispanic black and dementia patients receive more invasive and futile treatment at end of life (EOL) relative to others. Little is known about the relationship between race/ethnicity, dementia, and EOL care quality. Identify the relationship between race/ethnicity, dementia, and proxy reporters' evaluation of EOL care quality in older adults. Latent class analysis (LCA) of national survey data. 1588 deceased Medicare beneficiaries age 65 and older from the National Health and Aging Trends Study (2011-2016). LCA identified three types of quality EOL care using nine measures of symptom management, quality of healthcare encounters, and dignified treatment. Race and dementia were primary predictors of EOL care quality type. Adjusted models controlled for decedent education, sex, marital status, age, number of illnesses, number of hospitalizations, self-rated health, place of death, hospice involvement, and proxy relationship to decedent and familiarity with care. Over 20% of proxies report that dying individuals experienced suboptimal EOL care quality, characterized by pain, sadness, poor communication, and inattention to personal care needs. In adjusted analyses, proxies for non-Hispanic black decedents were less likely to provide negative care assessments than proxies for non-Hispanic white decedents (adjusted odds ratio [AOR]: 0.58; 95% confidence interval [CI]: 0.40-0.86). Proxies for decedents with dementia were less likely to provide negative assessments than proxies for decedents without dementia (AOR: 0.70; 95% CI: 0.51-0.97). Efforts to improve EOL care quality are needed. More positive EOL care quality assessments for non-Hispanic Black and dementia decedents appear counterintuitive given research demonstrating that these groups of individuals are likely to have received suboptimal EOL care. Because caregiver expectations for care may differ by decedent race and dementia status, research is needed to explore the role of caregiver expectations for EOL care to explain these paradoxical findings.

Self-Perceived End-of-Life Care Competencies of Health-Care Providers at a Large Academic Medical Center.

PubMed

Montagnini, Marcos; Smith, Heather M; Price, Deborah M; Ghosh, Bidisha; Strodtman, Linda

2018-01-01

In the United States, most deaths occur in hospitals, with approximately 25% of hospitalized patients having palliative care needs. Therefore, the provision of good end-of-life (EOL) care to these patients is a priority. However, research assessing staff preparedness for the provision of EOL care to hospitalized patients is lacking. To assess health-care professionals' self-perceived competencies regarding the provision of EOL care in hospitalized patients. Descriptive study of self-perceived EOL care competencies among health-care professionals. The study instrument (End-of-Life Questionnaire) contains 28 questions assessing knowledge, attitudes, and behaviors related to the provision of EOL care. Health-care professionals (nursing, medicine, social work, psychology, physical, occupational and respiratory therapist, and spiritual care) at a large academic medical center participated in the study. Means were calculated for each item, and comparisons of mean scores were conducted via t tests. Analysis of variance was used to identify differences among groups. A total of 1197 questionnaires was completed. The greatest self-perceived competency was in providing emotional support for patients/families, and the least self-perceived competency was in providing continuity of care. When compared to nurses, physicians had higher scores on EOL care attitudes, behaviors, and communication. Physicians and nurses had higher scores on most subscales than other health-care providers. Differences in self-perceived EOL care competencies were identified among disciplines, particularly between physicians and nurses. The results provide evidence for assessing health-care providers to identify their specific training needs before implementing educational programs on EOL care.

Organization of nursing and quality of care for veterans at the end of life.

PubMed

Kutney-Lee, Ann; Brennan, Caitlin W; Meterko, Mark; Ersek, Mary

2015-03-01

The Veterans Health Administration (VA) has improved the quality of end-of-life (EOL) care over the past several years. Several structural and process variables are associated with better outcomes. Little is known, however, about the relationship between the organization of nursing care and EOL outcomes. To examine the association between the organization of nursing care, including the nurse work environment and nurse staffing levels, and quality of EOL care in VA acute care facilities. Secondary analysis of linked data from the Bereaved Family Survey (BFS), electronic medical record, administrative data, and the VA Nursing Outcomes Database. The sample included 4908 veterans who died in one of 116 VA acute care facilities nationally between October 2010 and September 2011. Unadjusted and adjusted generalized estimating equations were used to examine associations between nursing and BFS outcomes. BFS respondents were 17% more likely to give an excellent overall rating of the quality of EOL care received by the veteran in facilities with better nurse work environments (P ≤ 0.05). The nurse work environment also was a significant predictor of providers listening to concerns and providing desired treatments. Nurse staffing was significantly associated with an excellent overall rating, alerting of the family before death, attention to personal care needs, and the provision of emotional support after the patient's death. Improvement of the nurse work environment and nurse staffing in VA acute care facilities may result in enhanced quality of care received by hospitalized veterans at the EOL. Copyright © 2015 American Academy of Hospice and Palliative Medicine. All rights reserved.

Patient-family EoL communication and its predictors: Reports from caregivers of Latino patients in the rural U.S.-Mexico border region.

PubMed

Ko, Eunjeong; Lee, Jaehoon; Ramirez, Carlos; Lopez, Denicka; Martinez, Stephanie

2017-10-26

Family caregivers play an important role in end-of-life (EoL) decision making when the patient is unable to make his/her own decisions. While communication about EoL care between patients and family is perhaps a first step toward advance care planning (ACP)/EoL decisions, not every culture puts great value on open communication about this topic. The aims of the present study were to explore EoL communication and the aspects of communication among caregivers of Latino patients in the rural United States (U.S.)-Mexico border region. This study analyzed data from a hospice needs assessment collected from 189 family caregivers of Latino patients at a home health agency in a rural U.S.-Mexico border region. Bivariate tests and logistic regression were used to address our aims. About half of the family caregivers (n = 96, 50.8%) reported to have ever engaged in EoL discussion with patients. Significant predictors of EoL discussion included life-sustaining treatment preference (odds ratio [OR] = 0.44, p < 0.05); knowledge of an advance directive (AD) (OR = 5.50, p < 0.01); and distrust of physicians (OR = 0.29, p < 0.01). Caregivers who preferred extending the life of their loved one even if he/she had to rely on life supports were less likely to engage in EoL communication. Also, caregivers who worried that physicians might want to stop treatments (i.e., "pull the plug") too soon were less likely to do so. Conversely, caregivers who had knowledge about ADs were more likely to engage in EoL communication. EoL communication is a complex process influenced by individual, social, and cultural values and the beliefs of both the patient and his/her family. Inclusion of family caregivers in the ACP process and facilitating culturally tailored EoL communication between patients and family caregivers is important.

Culturally Relevant Palliative and End-of-Life Care for U.S. Indigenous Populations: An Integrative Review.

PubMed

Isaacson, Mary J; Lynch, Anna R

2018-03-01

American Indians/Alaska Natives (AIs/ANs) have higher rates of chronic illness and lack access to palliative/end-of-life (EOL) care. This integrative review ascertained the state of the science on culturally acceptable palliative/EOL care options for Indigenous persons in the United States. Databases searched: CINAHL, PubMed/MEDLINE, SocINDEX, PsycINFO, PsycARTICLES, ERIC, Health Source: Nursing/Academic Edition, and EBSCO Discovery Service 1880s-Present. Key terms used: palliative care, EOL care, and AI/AN. peer-reviewed articles published in English. Findings/Results: Twenty-nine articles were identified, 17 remained that described culturally specific palliative/EOL care for AIs/ANs. Synthesis revealed four themes: Communication, Cultural Awareness/Sensitivity, Community Guidance for Palliative/EOL Care Programs, Barriers and two subthemes: Trust/Respect and Mistrust. Limitations are lack of research funding, geographic isolation, and stringent government requirements. Palliative/EOL care must draw on a different set of skills that honor care beyond cure provided in a culturally sensitive manner.

Communication for end-of-life care planning among Korean patients with terminal cancer: A context-oriented model.

PubMed

Koh, Su Jin; Kim, Shinmi; Kim, Jinshil

2016-02-01

In Korea, patients with terminal cancer are often caught out of the loop in end-of-life (EoL) care discussions. Healthcare professionals also have difficulty engaging in such communication in a variety of healthcare contexts. Therefore, the objective of our study was to develop a communication model for EoL care decision making compatible with the clinical environment in Korea. Using focus-group interview methodology, participants included eight doctors and five nurses who provide EoL care for terminal cancer patients in acute hospital settings or hospice care facilities in various provinces of Korea. Five themes emerged regarding EoL care discussion, which included: (1) timing, (2) responsible professionals, (3) disclosure of bad news, (4) content areas of EoL care discussion, and (5) implementing strategies for EoL care discussions. These themes were based on development of a communication algorithm for EoL discussion among patients with terminal cancer. A structural communication step for delivery of a terminal prognosis was specified at the phase of disclosure of bad news: beginning with determination of a patient's decision-making capability, followed by a patient's perception of his/her condition, a patient's wish to know, family dynamics, and a patient's and/or family's readiness for EoL discussions. The proposed context-oriented communication algorithm could provide a helpful guideline for EoL communication and, accordingly, facilitate meaningful improvements in EoL care in Korean clinical practice. The feasibility of this algorithm has not yet been determined, and its validation in a larger sample of patients with terminal cancers, using a quantitative research methodology, is a priority of research.

Teaching End-of-Life Communication in Intensive Care Medicine: Review of the Existing Literature and Implications for Future Curricula.

PubMed

Zante, Bjoern; Schefold, Joerg C

2017-01-01

End-of-life (EOL) situations are common in the intensive care unit (ICU). Poor communication in respective situations may result in conflict and/or post-traumatic stress disorder in patients' next of kin. Thus, training for EOL communication seems pivotal. Primary objective of the current report was to identify approaches for educational programs in the ICU with regard to EOL communication as well as to conclude on implications for future curricula. A literature review in MEDLINE, EMBASE, and PsychINFO was performed. A total of 3484 articles published between 2000 until 2016 were assessed for eligibility. Nine articles reporting on education in EOL communication in the ICU were identified and analyzed further. The duration of EOL workshops ranged from 3 hours to 3 days, with several different educational methods being applied. Mounting data suggest improved comfort, preparedness, and communication performance in EOL providers following specific EOL training. Due to missing data, the effect of EOL training programs on respective patients' next of kin remains unclear. Few scientific investigations focus on EOL communication in intensive care medicine. The available evidence points to increased comfort and EOL communication performance following specific individual EOL training. Given the general importance of EOL communication, we suggest implementation of educational EOL programs. When developing future educational programs, educators should consider previous experience of participants, clearly defined objectives based on institutional needs, and critical care society recommendations to ensure best benefit of all involved parties.

Impacts of care-giving and sources of support: a comparison of end-of-life and non-end-of-life caregivers in Canada.

PubMed

Williams, Allison M; Wang, Li; Kitchen, Peter

2016-03-01

This is the second in a series of papers that deal with care-giving in Canada, as based on data available from the Canadian General Social Survey (2007). Building on the first paper, which reviewed the differences between short-term, long-term and end-of-life (EOL) caregivers, this paper uniquely examines the caregiver supports employed by EOL caregivers when compared to non-EOL caregivers (short-term and long-term caregivers combined). Both papers employ data from Statistics Canada's General Social Survey (GSS Cycle 21: 2007). The GSS includes three modules, where respondents were asked questions about the unpaid home care assistance that they had provided in the last 12 months to someone at EOL or with either a long-term health condition or a physical limitation. The objective of this research paper was to investigate the link between the impact of the care-giving experience and the caregiver supports received, while also examining the differences in these across EOL and non-EOL caregivers. By way of factor analysis and regression modelling, we examine differences between two types of caregivers: (i) EOL and (ii) non-EOL caregivers. The study revealed that with respect to socio-demographic characteristics, health outcomes and caregiver supports, EOL caregivers were consistently worse off. This suggests that although all non-EOL caregivers are experiencing negative impacts from their care-giving role, comparatively greater supports are needed for EOL caregivers. © 2015 The Authors. Health and Social Care in the Community Published by John Wiley & Sons Ltd.

"End-of-Life Care? I'm not Going to Worry About That Yet." Health Literacy Gaps and End-of-Life Planning Among Elderly Dialysis Patients.

PubMed

Ladin, Keren; Buttafarro, Katie; Hahn, Emily; Koch-Weser, Susan; Weiner, Daniel E

2018-03-19

Between 2000 and 2012, the incident dialysis population in the United States increased by nearly 60%, most sharply among adults 75 years and older. End-of-life (EOL) conversations among dialysis patients are associated with better patient-centered outcomes and lower use of aggressive interventions in the last month of life. This study examined how health literacy may affect engagement, comprehension, and satisfaction with EOL conversations among elderly dialysis patients. Qualitative/descriptive study with semi-structured interviews about health literacy, EOL conversations, and goals of care with 31 elderly dialysis patients at 2 centers in Boston. Themes were interpreted in the context of Nutbeam's health literacy framework. Despite high mortality risk in this population, only 13% of patients had discussed EOL preferences with physicians, half had discussed EOL with their social network, and 25% of participants explicitly stated that they had never considered EOL preferences. Less than 30% of participants could correctly define terminology commonly used in EOL conversations. Analyses yielded 5 themes: (1) Misunderstanding EOL terminology; (2) Nephrologists reluctant to discuss EOL; (3) Patients conforming to socially constructed roles; (4) Discordant expectations and dialysis experiences; and (5) Reconciling EOL values and future care. Patients had limited understanding of EOL terminology, lacked of opportunities for meaningful EOL discussion with providers and family, resulting in uncertainty about future care. Limited health literacy presents a substantial barrier to communication and could lead to older adults committing to an intensive pattern of care without adequate information. Clinicians should consider health literacy when discussing dialysis initiation.

Let's Talk About It: Supporting Family Communication during End-of-Life Care of Pediatric Patients.

PubMed

Marsac, Meghan L; Kindler, Christine; Weiss, Danielle; Ragsdale, Lindsay

2018-05-18

Communication is key in optimizing medical care when a child is approaching end of life (EOL). Research is yet to establish best practices for how medical teams can guide intrafamily communication (including surviving siblings) when EOL care is underway or anticipated for a pediatric patient. While recommendations regarding how medical teams can facilitate communication between the medical team and the family exist, various barriers may prevent the implementation of these recommendations. This review aims to provide a summary of research-to-date on family and medical provider perceptions of communication during pediatric EOL care. Systematic review. Findings from a review of 65 studies suggest that when a child enters EOL care, many parents try to protect their child and/or themselves by avoiding discussions about death. Despite current recommendations, medical teams often refrain from discussing EOL care with pediatric patients until death is imminent for a variety of reasons (e.g., family factors and discomfort with EOL conversations). Parents consistently report a need for honest complete information, delivered with sensitivity. Pediatric patients often report a preference to be informed of their prognosis, and siblings express a desire to be involved in EOL discussions. Families may benefit from enhanced communication around EOL planning, both within the family and between the family and medical team. Future research should investigate a potential role for medical teams in supporting intrafamily communication about EOL challenges and should examine how communication between medical teams and families can be facilitated as EOL approaches.

For patients with terminal chronic illness, does more face-to-face time with a healthcare provider decrease aggressive end-of-life (EOL) care such as ICU admission, feeding tube placement, CPR, or intubation?

PubMed Central

Seaberg, Preston; Hamm, Robert M.; McCarthy, Laine H.

2016-01-01

Clinical Question For patients with terminal chronic illness, does more face-to-face time with a healthcare provider decrease aggressive end-of-life (EOL) care such as ICU admission, feeding tube placement, CPR, or intubation? Answer Inconclusive. Existing evidence does not provide a conclusive answer to this particular question. While multiple prospective, randomized, controlled trials demonstrate an association between increased patient-provider contact time and decreased aggressive EOL care, interventions in those studies contain multiple confounding elements that preclude isolation of the time factor from the other elements in the interventions. There is a need for research focusing on physician-patient communication time and EOL care. Level of Evidence for the Answer A Search Terms Terminal care, palliative care, terminal illness, communication, patient-provider relations, time factors, life support care, resuscitation orders, enteral nutrition Inclusion Criteria Systematic reviews, meta-analyses, and comparative studies published between 2008 and the current date comparing EOL care or EOL care preferences of patients who spend more face-to-face time with a healthcare provider to those of patients who spend less face-to-face time with a healthcare provider. Exclusion Criteria Studies that do not report the primary outcome of interest (EOL care or EOL care preferences) or that do not measure discussion time or provide interventions that include face-to-face discussion. PMID:25796765

Healthcare professionals' perspectives on delivering end-of-life care within acute hospital trusts: a qualitative study.

PubMed

Reid, Colette; Gibbins, Jane; Bloor, Sophia; Burcombe, Melanie; McCoubrie, Rachel; Forbes, Karen

2015-12-01

The quality of end-of-life (EOL) care in acute hospitals is variable and interventions to improve this care, such as EOL care pathways, are not always used. The underlying reasons for this variability are not fully understood. We explored healthcare professionals' views on delivering EOL care within an acute hospital trust in the South West of England. We employed qualitative methods (focus groups, in-depth interviews and questerviews) within a study investigating the impact of a simple EOL tool on the care of dying patients. We invited a range of staff of all grades with experience in caring for dying patients from medicine, surgery and care of the elderly teams to participate. Six focus groups, seven interviews and five questerviews were conducted. Two main themes emerged: (a) delays (difficulties and avoidance) in diagnosing dying and (b) the EOL tool supporting staff in caring for the dying. Staff acknowledged that the diagnosis of dying was often made late; this was partly due to prognostic uncertainty but compounded by a culture that did not acknowledge death as a possible outcome until death was imminent. Both the medical and nursing staff found the EOL tool useful as a means of communicating ceilings of care, ensuring appropriate prescribing for EOL symptoms, and giving nurses permission to approach the bedside of a dying patient. The culture of avoiding death and dying in acute hospitals remains a significant barrier to providing EOL care, even when EOL tools are available and accepted by staff. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Emergency nurses' perception of department design as an obstacle to providing end-of-life care.

PubMed

Beckstrand, Renea L; Rasmussen, Ryan J; Luthy, Karlen E; Heaston, Sondra

2012-09-01

Of the 119.2 million visits to the emergency department in 2006, it was estimated that about 249,000 visits resulted in the patient dying or being pronounced dead on arrival. In 2 national studies of emergency nurses' perceptions of end-of-life (EOL) care, ED design was identified as a large and frequent obstacle to providing EOL care. The purpose of this study was to determine the impact of ED design on EOL care as perceived by emergency nurses and to determine how much input emergency nurses have on the design of their emergency department. A 25-item questionnaire regarding ED design as it affects EOL care was sent to a national, geographically dispersed, random sample of 500 members of ENA. Inclusion criteria were nurses who could read English, worked in an emergency department, and had cared for at least one patient at the EOL. Descriptive statistics were calculated for the Likert-type and demographic items. Open-ended questions were analyzed using content analysis. Two mailings yielded 198 usable responses. Nurses did not report that ED design was as large an obstacle to EOL care as previous studies had suggested. Nurses reported that the ED design helped EOL care at a greater rate than it obstructed EOL care. Nurses also believed they had little input into unit design or layout changes. The most common request for design change was private places for family members to grieve. Thirteen nurses also responded with an optional drawing of suggested ED designs. Overall, nurses reported some dissatisfaction with ED design and believed they had little to no input in unit design improvement. Improvements to EOL care might be achieved if ED design suggestions from emergency nurses were considered by committees that oversee remodeling and construction of emergency departments. Further research is needed to determine the impact of ED design on EOL care in the emergency department. Copyright © 2012 Emergency Nurses Association. Published by Mosby, Inc. All rights reserved.

Rural Emergency Nurses' Suggestions for Improving End-of-Life Care.

PubMed

Beckstrand, Renea L; Smith, Kelly E; Luthy, Karlen E Beth; Macintosh, Janelle L B

2017-05-01

Many patient visits to emergency departments result in the patient dying or being pronounced dead on arrival. The numbers of deaths in emergency departments are likely to increase as a significant portion of the U.S. population ages. Consequently, emergency nurses face many obstacles to providing quality end-of-life (EOL) care when death occurs. The purpose of this study was to identify suggestions that emergency nurses have to improve EOL care, specifically in rural emergency departments. A 57-item questionnaire was sent to 53 rural hospitals in 4 states in the Intermountain West, plus Alaska. One item asked nurses to identify the one aspect of EOL care they would change for dying patients in rural emergency departments. Each qualitative response was individually reviewed by a research team and then coded into a theme. Four major themes and three minor themes were identified. The major themes were providing greater privacy during EOL care for patients and family members, increasing availability of support services, additional staffing, and improved staff and community education. Providing adequate privacy for patients and family members was a major obstacle to providing EOL care in the emergency department, largely because of poor department design, especially in rural emergency departments where space is limited. Lack of support services and adequate staffing were also obstacles to providing quality EOL care in rural emergency departments. Consequently, rural nurses are commonly pulled away from EOL care to perform ancillary duties because additional support personnel are lacking. Providing EOL care in rural emergency departments is a challenging task given the limited staffing and resources, and thus it is imperative that nurses' suggestions for improvement of EOL care be acknowledged. Because of the current lack of research in rural EOL care, additional research is needed. Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.

Health care Professionals' Experiences and Needs When Delivering End-of-Life Care to Children: A Qualitative Study.

PubMed

Bergsträsser, Eva; Cignacco, Eva; Luck, Patricia

2017-01-01

Pediatric end-of-life care (EOL care) entails challenging tasks for health care professionals (HCPs). Little is known about HCPs' experiences and needs when providing pediatric EOL care in Switzerland. This study aimed to describe the experiences and needs of HCPs in pediatric EOL care in Switzerland and to develop recommendations for the health ministry. The key aspect in EOL care provision was identified as the capacity to establish a relationship with the dying child and the family. Barriers to this interaction were ethical dilemmas, problems in collaboration with the interprofessional team, and structural problems on the level of organizations. A major need was the expansion of vocational training and support by specialized palliative care teams. We recommend the development of a national concept for the provision of EOL care in children, accompanied by training programs and supported by specialized pediatric palliative care teams located in tertiary children's hospitals.

Culture and end of life care: a scoping exercise in seven European countries.

PubMed

Gysels, Marjolein; Evans, Natalie; Meñaca, Arantza; Andrew, Erin; Toscani, Franco; Finetti, Sylvia; Pasman, H Roeline; Higginson, Irene; Harding, Richard; Pool, Robert

2012-01-01

Culture is becoming increasingly important in relation to end of life (EoL) care in a context of globalization, migration and European integration. We explore and compare socio-cultural issues that shape EoL care in seven European countries and critically appraise the existing research evidence on cultural issues in EoL care generated in the different countries. We scoped the literature for Germany, Norway, Belgium, The Netherlands, Spain, Italy and Portugal, carrying out electronic searches in 16 international and country-specific databases and handsearches in 17 journals, bibliographies of relevant papers and webpages. We analysed the literature which was unearthed, in its entirety and by type (reviews, original studies, opinion pieces) and conducted quantitative analyses for each country and across countries. Qualitative techniques generated themes and sub-themes. A total of 868 papers were reviewed. The following themes facilitated cross-country comparison: setting, caregivers, communication, medical EoL decisions, minority ethnic groups, and knowledge, attitudes and values of death and care. The frequencies of themes varied considerably between countries. Sub-themes reflected issues characteristic for specific countries (e.g. culture-specific disclosure in the southern European countries). The work from the seven European countries concentrates on cultural traditions and identities, and there was almost no evidence on ethnic minorities. This scoping review is the first comparative exploration of the cultural differences in the understanding of EoL care in these countries. The diverse body of evidence that was identified on socio-cultural issues in EoL care, reflects clearly distinguishable national cultures of EoL care, with differences in meaning, priorities, and expertise in each country. The diverse ways that EoL care is understood and practised forms a necessary part of what constitutes best evidence for the improvement of EoL care in the future.

"Must do CPR??": strategies to cope with the new College of Physicians and Surgeons of Ontario policy on end-of-life care.

PubMed

Hawryluck, Laura; Oczkowski, Simon J W; Handelman, Mark

2016-08-01

The College of Physicians and Surgeons of Ontario recently released a new policy, Planning for and Providing Quality End-of-Life Care. The revised policy is more accurate in its consideration of the legal framework in which physicians practice and more reflective of ethical issues that arise in end-of-life (EOL) care. It also recognizes valid instances for not offering cardiopulmonary resuscitation (CPR). Nevertheless, the policy poses a significant ethical and legal dilemma-i.e., if disputes over EOL care arise, then physicians must provide CPR even when resuscitation would fall outside this medical standard of care. While the policy applies in Ontario, it is likely to influence other physician colleges across Canada as they review their standards of practice. This paper explores the rationale for the mandated CPR, clarifies the policy's impact on the medical standard of care, and discusses strategies to improve EOL care within the policy. These strategies include understanding the help-hurt line, changing the language used when discussing cardiac arrest, clarifying care plans during the perioperative period, engaging the intensive care unit team early in goals-of-care discussions, mentoring hospital staff to improve skills in goals-of-care discussions, avoiding use of the "slow code", and continuing to advocate for quality EOL care and a more responsive legal adjudication process.

End-of-life chemotherapy is associated with poor survival and aggressive care in patients with small cell lung cancer.

PubMed

Zhu, Yingming; Tang, Ke; Zhao, Fen; Zang, Yuanwei; Wang, Xiaodong; Li, Zhenxiang; Sun, Xindong; Yu, Jinming

2018-05-29

Concerns regarding end-of-life (EOL) chemotherapy are being increasingly raised. Tumor chemosensitivity may influence the decision for aggressive chemotherapy near the EOL. Data on EOL chemotherapy in highly chemosensitive tumors, such as small cell lung cancer (SCLC), are scarce. A total of 143 SCLC decedents were consecutively included. Data about clinical factors and treatment modalities were obtained from the electronic medical records. The relationships among EOL chemotherapy, clinical features, overall survival (OS), and aggressive care were investigated. About 64% of patients had chemosensitive disease. In total, 30.8 and 16.1% of patients received EOL chemotherapy within the last 1 and 2 months of life, respectively. Younger age was associated with a higher rate of EOL chemotherapy. We determined that EOL chemotherapy was related to inferior OS not only in the entire group, but also in the chemosensitive subgroup. Furthermore, more intensive care was observed among patients who underwent EOL chemotherapy compared with those who did not. EOL chemotherapy was correlated with shorter survival and more aggressive care in patients with SCLC. More research is needed to develop indications for terminating palliative chemotherapy, to help physicians and patients with their difficult choices.

Characteristics and Correlates of Increasing Use of Surgery in Taiwanese Cancer Patients' Last Month of Life, 2001-2010.

PubMed

Liu, Tsang-Wu; Hung, Yen-Ni; Earle, Craig C; Liu, Tsang-Pai; Liu, Li Ni; Tang, Siew Tzuh

2016-08-01

Surgery offers the potential to relieve symptoms for patients with cancer at the end of life (EOL) but at significant physiological and economic costs. However, the characteristics and correlates of surgery in last month of life (EOL surgery) of patients with cancer have not been comprehensively explored. This population-based study characterized EOL surgery use and identified its correlates. This retrospective cohort study examined administrative data among 339,546 Taiwanese cancer decedents, 2001 to 2010. We classified procedures according to their likely intent. Approximately 1 in 10 (11.44%, range: 11.08%-11.86%) patients underwent EOL surgery with an increasing utilization over time. The intention for EOL surgery was primarily palliative, followed by cancer-directed, nonmalignancy-directed, and diagnostic. EOL surgery for palliative intent increased whereas other intents decreased significantly over time. EOL surgery was more likely among those who were male, younger, and married; not diagnosed with hepatic-pancreatic or lung cancers; had no comorbidity or documented metastatic codes; and survived less than 1 year from diagnosis. The likelihood of EOL surgery use was higher for patients who received care in a teaching hospital with more acute care hospital beds and higher EOL care intensity. Rates of EOL surgery are lower in Taiwan than those reported in the United States. The increasing use of EOL surgery in Taiwan is primarily for palliative intent. Appropriateness of EOL surgery should be carefully evaluated to avoid underutilizing potentially beneficial, palliative-intent surgery and overutilizing cancer-directed and other surgical procedures, especially for physicians working in hospitals with abundant health care resources and a tendency to treat at-risk patients with cancer aggressively.

Racial Differences in Processes of Care at End of Life in VA Medical Centers: Planned Secondary Analysis of Data from the BEACON Trial

PubMed Central

Williams, Beverly R.; Dionne-Odom, J. Nicholas; Redden, David T.; Noh, Hyunjin; Goode, Patricia S.; Kvale, Elizabeth; Bakitas, Marie; Bailey, F. Amos

2016-01-01

Abstract Background: Racial differences exist for a number of health conditions, services, and outcomes, including end-of-life (EOL) care. Objective: The aim of the study was to examine differences in processes of care in the last 7 days of life between African American and white inpatients. Methods: Secondary analysis was conducted of data collected in the Best Practices for End-of-Life Care for Our Nation's Veterans (BEACON) trial (conducted 2005–2011). Subjects were 4891 inpatient decedents in six Veterans Administration Medical Centers. Data were abstracted from decedents' medical records. Multi-variable analyses were conducted to examine the relationship between race and each of 18 EOL processes of care controlling for patient characteristics, study site, year of death, and whether the observation was pre- or post-intervention. Results: The sample consisted of 1690 African American patients (34.6%) and 3201 white patients (65.4%). African Americans were less likely to have: do not resuscitate (DNR) orders (odds ratio [OR]: 0.67; p = 0.004), advance directives (OR: 0.71; p = 0.023), active opioid orders (OR: 0.64, p = 0.0008), opioid medications administered (OR: 0.61, p = 0.004), benzodiazepine orders (OR: 0.68, p < 0.0001), benzodiazepines administered (OR: 0.61, p < 0.0001), antipsychotics administered (OR: 0.73, p = 0.004), and steroids administered (OR: 0.76, p = 0.020). Racial differences were not found for other processes of care, including palliative care consultation, pastoral care, antipsychotic and steroid orders, and location of death. Conclusions: Racial differences exist in some but not all aspects of EOL care. Further study is needed to understand the extent to which racial differences reflect different patient needs and preferences and whether interventions are needed to reduce disparities in patient/family education or access to quality EOL care. PMID:26840851

Racial Differences in Processes of Care at End of Life in VA Medical Centers: Planned Secondary Analysis of Data from the BEACON Trial.

PubMed

Burgio, Kathryn L; Williams, Beverly R; Dionne-Odom, J Nicholas; Redden, David T; Noh, Hyunjin; Goode, Patricia S; Kvale, Elizabeth; Bakitas, Marie; Bailey, F Amos

2016-02-01

Racial differences exist for a number of health conditions, services, and outcomes, including end-of-life (EOL) care. The aim of the study was to examine differences in processes of care in the last 7 days of life between African American and white inpatients. Secondary analysis was conducted of data collected in the Best Practices for End-of-Life Care for Our Nation's Veterans (BEACON) trial (conducted 2005-2011). Subjects were 4891 inpatient decedents in six Veterans Administration Medical Centers. Data were abstracted from decedents' medical records. Multi-variable analyses were conducted to examine the relationship between race and each of 18 EOL processes of care controlling for patient characteristics, study site, year of death, and whether the observation was pre- or post-intervention. The sample consisted of 1690 African American patients (34.6%) and 3201 white patients (65.4%). African Americans were less likely to have: do not resuscitate (DNR) orders (odds ratio [OR]: 0.67; p = 0.004), advance directives (OR: 0.71; p = 0.023), active opioid orders (OR: 0.64, p = 0.0008), opioid medications administered (OR: 0.61, p = 0.004), benzodiazepine orders (OR: 0.68, p < 0.0001), benzodiazepines administered (OR: 0.61, p < 0.0001), antipsychotics administered (OR: 0.73, p = 0.004), and steroids administered (OR: 0.76, p = 0.020). Racial differences were not found for other processes of care, including palliative care consultation, pastoral care, antipsychotic and steroid orders, and location of death. Racial differences exist in some but not all aspects of EOL care. Further study is needed to understand the extent to which racial differences reflect different patient needs and preferences and whether interventions are needed to reduce disparities in patient/family education or access to quality EOL care.

Predictors of and Trends in High-Intensity End-of-Life Care Among Children With Cancer: A Population-Based Study Using Health Services Data.

PubMed

Kassam, Alisha; Sutradhar, Rinku; Widger, Kimberley; Rapoport, Adam; Pole, Jason D; Nelson, Katherine; Wolfe, Joanne; Earle, Craig C; Gupta, Sumit

2017-01-10

Purpose Children with cancer often receive high-intensity (HI) medical care at the end-of-life (EOL). Previous studies have been limited to single centers or lacked detailed clinical data. We determined predictors of and trends in HI-EOL care by linking population-based clinical and health-services databases. Methods A retrospective decedent cohort of patients with childhood cancer who died between 2000 and 2012 in Ontario, Canada, was assembled using a provincial cancer registry and linked to population-based health-care data. Based on previous studies, the primary composite measure of HI-EOL care comprised any of the following: intravenous chemotherapy < 14 days from death; more than one emergency department visit; and more than one hospitalization or intensive care unit admission < 30 days from death. Secondary measures included those same individual measures and measures of the most invasive (MI) EOL care (eg, mechanical ventilation < 14 days from death). We determined predictors of outcomes with appropriate regression models. Sensitivity analysis was restricted to cases of cancer-related mortality, excluding treatment-related mortality (TRM) cases. Results The study included 815 patients; of these, 331 (40.6%) experienced HI-EOL care. Those with hematologic malignancies were at highest risk (odds ratio, 2.5; 95% CI, 1.8 to 3.6; P < .001). Patients with hematologic cancers and those who died after 2004 were more likely to experience the MI-EOL care (eg, intensive care unit, mechanical ventilation, odds ratios from 2.0 to 5.1). Excluding cases of TRM did not substantively change the results. Conclusion Ontario children with cancer continue to experience HI-EOL care. Patients with hematologic malignancies are at highest risk even when excluding TRM. Of concern, rates of the MI-EOL care have increased over time despite increased palliative care access. Linking health services and clinical data allows monitoring of population trends in EOL care and identifies high-risk populations for future interventions.

Improving Caregivers' Perceptions Regarding Patient Goals of Care/End-of-Life Issues for the Multidisciplinary Critical Care Team.

PubMed

Wessman, Brian T; Sona, Carrie; Schallom, Marilyn

2017-01-01

With population aging and growth, use of critical care medicine at the end of life continues to rise, while many critical care providers are not adequately trained regarding goals of care/end-of-life (GOC/EOL) issues. A multidisciplinary intensive care unit (ICU) team intervention regarding GOC/EOL communication will enhance the clinical abilities of all critical care providers when discussing GOC/EOL issues and increase ICU staff comfort level while improving transitions for patients to a comfort care approach. This study was a preintervention/postintervention survey evaluation. This study was conducted at an academic tertiary surgical burn trauma ICU. The intervention was provided to nursing, ancillary staff, house staff, and attending physicians. An initial survey was circulated among the critical care staff for baseline expectations, satisfaction, and understanding of GOC/EOL care. A robust intervention was begun including the creation of a multidisciplinary GOC/EOL team, communication tools for providers, patient-family pamphlets, standardized EOL order sets, and formalized didactic sessions. Subsequently, the same survey was circulated and compared to baseline data. Preintervention/postintervention survey data were reviewed and statistically analyzed. Our survey response rate for preintervention/postintervention was 50.4% and 36.1%, respectively. The intervention generated heightened interest in improving family communication and provided focal direction to foster this growth. Based on the serial surveys regarding our intervention, statistically significant staff improvements were seen in "work stress" (P = .04), "EOL information" (P = .006), and "space allotment" (P = .001). Improved congruence of families and health care providers regarding decision over intensity of care was also noted. We created a novel unit-based multidisciplinary program for improved EOL/GOC approaches in the critical care setting. A similarly formatted program could be adapted by other ICUs. Benefits of such a program include improving caregivers' perceptions regarding EOL/GOC issues and fostering critical care team growth. © The Author(s) 2015.

Association between education in EOL care and variability in EOL practice: a survey of ICU physicians.

PubMed

Forte, Daniel Neves; Vincent, Jean Louis; Velasco, Irineu Tadeu; Park, Marcelo

2012-03-01

This study investigated the association between physician education in EOL and variability in EOL practice, as well as the differences between beliefs and practices regarding EOL in the ICU. Physicians from 11 ICUs at a university hospital completed a survey presenting a patient in a vegetative state with no family or advance directives. Questions addressed approaches to EOL care, as well physicians' personal, professional and EOL educational characteristics. The response rate was 89%, with 105 questionnaires analyzed. Mean age was 38 ± 8 years, with a mean of 14 ± 7 years since graduation. Physicians who did not apply do-not-resuscitate (DNR) orders were less likely to have attended EOL classes than those who applied written DNR orders [0/7 vs. 31/47, OR = 0.549 (0.356-0.848), P = 0.001]. Physicians who involved nurses in the decision-making process were more likely to be ICU specialists [17/22 vs. 46/83, OR = 4.1959 (1.271-13.845), P = 0.013] than physicians who made such decisions among themselves or referred to ethical or judicial committees. Physicians who would apply "full code" had less often read about EOL [3/22 vs. 11/20, OR = 0.0939 (0.012-0.710), P = 0.012] and had less interest in discussing EOL [17/22 vs. 20/20, OR = 0.210 (0.122-0.361), P < 0.001], than physicians who would withdraw life-sustaining therapies. Forty-four percent of respondents would not do what they believed was best for their patient, with 98% of them believing a less aggressive attitude preferable. Legal concerns were the leading cause for this dichotomy. Physician education about EOL is associated with variability in EOL decisions in the ICU. Moreover, actual practice may differ from what physicians believe is best for the patient.

What matters most for end-of-life care? Perspectives from community-based palliative care providers and administrators

PubMed Central

Mistry, Bina; Bainbridge, Daryl; Bryant, Deanna; Tan Toyofuku, Sue; Seow, Hsien

2015-01-01

Objectives There has been little research conducted to understand the essential meaning of quality, community-based, end-of-life (EOL) care, despite the expansion of these services. The purpose of this study was to define what matters most for EOL care from the perspective of a diverse range of palliative care providers in the community who have daily encounters with death and dying. Methods We used interviews to explore the perceptions of providers and administrators from 14 specialised palliative care teams in Ontario, Canada. Participants were prompted with the question ‘What matters most for EOL care?’ Responses were analysed using a phenomenological approach to derive themes depicting the universal essence of EOL care. Results Data from 107 respondents were obtained and analysed, from which 40 formulated concepts emerged; these were further grouped into 9 themes. Of the respondents, 39% were nurses, 19% physicians, 27% were supervisors or executives and 15% other. The most predominate concept was that Patient's Wishes are Fulfilled, cited by almost half the respondents. The most prominent themes were Addressing the Non-physical Needs, Healthcare Teams’ Nature of Palliative Care Delivery, Patient Wishes are Honoured, Addressing the Physical Needs, Preparing for and Accepting Death, Communication and Relationship Development, and Involving and Supporting the Family. Conclusions 9 critical domains of EOL care evolved from the interviews, indicating that quality EOL care extends beyond managing physical pain, but includes a holistic perspective of care, a healthcare team dedicated to the EOL journey and a patient-centred pathway. Tailoring the provision of care to consider these important elements plays a critical role in supporting a positive EOL experience for patients and families. PMID:26124510

End of life care interventions for people with dementia in care homes: addressing uncertainty within a framework for service delivery and evaluation.

PubMed

Goodman, Claire; Froggatt, Katherine; Amador, Sarah; Mathie, Elspeth; Mayrhofer, Andrea

2015-09-17

There has been an increase in research on improving end of life (EoL) care for older people with dementia in care homes. Findings consistently demonstrate improvements in practitioner confidence and knowledge, but comparisons are either with usual care or not made. This paper draws on findings from three studies to develop a framework for understanding the essential dimensions of end of life care delivery in long-term care settings for people with dementia. The data from three studies on EoL care in care homes: (i) EVIDEM EoL, (ii) EPOCH, and (iii) TTT EoL were used to inform the development of the framework. All used mixed method designs and two had an intervention designed to improve how care home staff provided end of life care. The EVIDEM EoL and EPOCH studies tracked the care of older people in care homes over a period of 12 months. The TTT study collected resource use data of care home residents for three months, and surveyed decedents' notes for ten months, Across the three studies, 29 care homes, 528 residents, 205 care home staff, and 44 visiting health care professionals participated. Analysis of showed that end of life interventions for people with dementia were characterised by uncertainty in three key areas; what treatment is the 'right' treatment, who should do what and when, and in which setting EoL care should be delivered and by whom? These uncertainties are conceptualised as Treatment uncertainty, Relational uncertainty and Service uncertainty. This paper proposes an emergent framework to inform the development and evaluation of EoL care interventions in care homes. For people with dementia living and dying in care homes, EoL interventions need to provide strategies that can accommodate or "hold" the inevitable and often unresolvable uncertainties of providing and receiving care in these settings.

A national profile of end-of-life caregiving in the United States

PubMed Central

Ornstein, Katherine A.; Kelley, Amy S.; Bollens-Lund, Evan; Wolff, Jennifer L.

2017-01-01

Family and friends are the predominant providers of end-of-life care (EOL). Yet knowledge of the caregiving experience at the EOL has been constrained by a narrow focus on specific diseases or the “primary” caregiver and methodological limitations due to reliance on convenience samples, or recall biases associated with mortality follow-back study design. Using prospective, linked nationally representative datasets of Medicare beneficiaries and their caregivers, we found that in 2011 900,000 older adults at the EOL received support from 2.3 million paid and unpaid caregivers. Nearly 9 in 10 of these caregivers were family members or unpaid. EOL caregivers provided more extensive care and reported more care-related challenges (e.g., physical difficulty) than non-EOL caregivers. EOL challenges were especially prevalent among caregiving spouses. To meet the needs of older adults at the EOL, families and unpaid caregivers must be better recognized and integrated in care delivery and supportive services must be expanded and made more widely available. PMID:28679804

A palliative approach for heart failure end-of-life care

PubMed Central

Maciver, Jane; Ross, Heather J.

2018-01-01

Purpose of review The current review discusses the integration of guideline and evidence-based palliative care into heart failure end-of-life (EOL) care. Recent findings North American and European heart failure societies recommend the integration of palliative care into heart failure programs. Advance care planning, shared decision-making, routine measurement of symptoms and quality of life and specialist palliative care at heart failure EOL are identified as key components to an effective heart failure palliative care program. There is limited evidence to support the effectiveness of the individual elements. However, results from the palliative care in heart failure trial suggest an integrated heart failure palliative care program can significantly improve quality of life for heart failure patients at EOL. Summary Integration of a palliative approach to heart failure EOL care helps to ensure patients receive the care that is congruent with their values, wishes and preferences. Specialist palliative care referrals are limited to those who are truly at heart failure EOL. PMID:29135524

Trend in and Correlates of Undergoing Radiotherapy in Taiwanese Cancer Patients' Last Month of Life.

PubMed

Hung, Yen-Ni; Cheng, Skye Hung-Chun; Liu, Tsang-Wu; Chang, Wen-Cheng; Chen, Jen-Shi; Tang, Siew Tzuh

2016-09-01

A significant proportion of cancer patients at end of life (EOL) undergo radiotherapy, but this evidence is not from nationwide population-based studies. The aims of this population-based study were to investigate the trend in undergoing radiotherapy among Taiwanese cancer patients' last month of life (EOL radiotherapy) in 2001-2010 and to identify factors associated with EOL radiotherapy. This was a population-based retrospective cohort study analyzing data from Taiwan's national death registry, cancer registry, and National Health Insurance claims for EOL radiotherapy using multilevel generalized linear mixed modeling. Participants were Taiwanese cancer patients (N = 339,546) who died in 2001-2010. Overall, 8.59% (7.97%-9.85%) of patients underwent EOL radiotherapy with a decreasing trend over time. Correlates of EOL radiotherapy included male gender, younger age, residing in less urbanized areas, diagnosis of lung cancer, metastatic disease, death within two years of diagnosis, and without comorbidities. Cancer patients were more likely to undergo EOL radiotherapy if they received primary care from medical oncologists and pediatricians, in a nonprofit, teaching hospital with a larger case volume of terminally ill cancer patients, and greater EOL care intensity. Approximately one-tenth of Taiwanese cancer patients underwent EOL radiotherapy with a decreasing trend over time. Undergoing EOL radiotherapy was associated with demographics, disease characteristics, physician specialty, and primary hospital's characteristics and EOL care practice patterns. Clinical and financial interventions should target hospitals/physicians that tend to aggressively treat at-risk cancer patients at EOL to carefully evaluate the appropriateness and effectiveness of using EOL radiotherapy. Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Trends in Advance Care Planning in Patients With Cancer: Results From a National Longitudinal Survey.

PubMed

Narang, Amol K; Wright, Alexi A; Nicholas, Lauren H

2015-08-01

Advance care planning (ACP) may prevent end-of-life (EOL) care that is nonbeneficial and discordant with patient wishes. Despite long-standing recognition of the merits of ACP in oncology, it is unclear whether participation in ACP by patients with cancer has increased over time. To characterize trends in durable power of attorney (DPOA) assignment, living will creation, and participation in discussions of EOL care preferences and to explore associations between ACP subtypes and EOL treatment intensity as reflected in EOL care decisions and terminal hospitalizations. We analyzed prospectively collected survey data from 1985 next-of-kin surrogates of Health and Retirement Study (HRS) participants with cancer who died between 2000 and 2012, including data from in-depth "exit" interviews conducted with the surrogates after the participant's death. The HRS is a nationally representative, biennial, longitudinal panel study of US residents older than 50 years. Trends in ACP subtypes were tested, and multivariable logistic regression models examined for associations between ACP subtypes and measures of treatment intensity. Trends in the surrogate-reported frequency of DPOA assignment, living will creation, and participation in discussions of EOL care preferences; associations between ACP subtypes and both surrogate-reported EOL care decisions and terminal hospitalizations. From 2000 to 2012, there was an increase in DPOA assignment (52% to 74%, P = .03), without significant change in use of living wills (49% to 40%, P = .63) or EOL discussions (68% to 60%, P = .62). Surrogate reports that patients received "all care possible" at EOL increased during the period (7% to 58%, P = .004), and rates of terminal hospitalizations were unchanged (29% to 27%, P = .70). Limiting or withholding treatment was associated with living wills (adjusted odds ratio [AOR], 2.51; 95% CI, 1.53-4.11; P < .001) and EOL discussions (AOR, 1.93; 95% CI, 1.53-3.14; P = .002) but not with DPOA assignment. Use of DPOA increased significantly between 2000 and 2012 but was not associated with EOL care decisions. Importantly, there was no growth in key ACP domains such as discussions of care preferences. Efforts that bolster communication of EOL care preferences and also incorporate surrogate decision makers are critically needed to ensure receipt of goal-concordant care.

Kokua Mau: a statewide effort to improve end-of-life care.

PubMed

Braun, Kathryn L; Zir, Ana; Crocker, Joanna; Seely, Marilyn R

2005-04-01

Many Americans die in pain, without hospice, and without regard to advance directives, suggesting a need to improve end-of-life (EOL) awareness and services. This paper describes Kokua Mau, a community-state partnership to improve EOL in Hawaii funded by The Robert Wood Johnson Foundation (RWJF). Coalition activities were guided by innovation-diffusion theory, targeting "innovators" and "change agents" within communities and organizations willing to learn about and facilitate improvements to EOL care. Evaluation of a community-wide intervention to improve EOL care. Honolulu, Hawaii. We tracked dissemination of campaign messages by counting numbers of coalition members (including innovators and change agents to carry on the work), individuals reached through awareness and educational offerings, and new EOL projects initiated during and after the initial 3-year RWJF funding. To measure change, we counted the number of legislative policies that were modified by the coalition as well as indicators of hospice utilization, advance directive (AD) completion, support for physician-assisted death, and place of death. In the first 3 years of the project: coalition membership grew to 350 members; EOL care curricula were developed and offered to various target audiences; 17,000 individuals attended educational events; policy changes were facilitated; decreases were seen in proportions of residents supporting physician-assisted suicide; and increases were seen in advance directive completion rates and hospice utilization. Most importantly, after the grant period, coalition members went on to develop and implement new programs to improve care to the dying. Although it will take several years to effect comprehensive and sustained changes in the way death is perceived and the dying process is facilitated, findings suggest that programs based on innovation-diffusion theory can increase EOL awareness and help develop the change agents and role models needed to affect community-wide change over the long term.

Trends in advance care planning in cancer patients: Results from a national, longitudinal survey

PubMed Central

Narang, Amol K.; Wright, Alexi A.; Nicholas, Lauren H.

2015-01-01

Importance Advance care planning (ACP) may prevent end-of-life (EOL) care that is non-beneficial and discordant with patient wishes. Despite long-standing recognition of the merits of ACP in oncology, it is unclear whether cancer patients’ participation in ACP has increased over time. Objective To characterize trends in durable power of attorney (DPOA) assignment, living will creation, and participation in discussions of EOL care preferences, and to explore associations between ACP subtypes and EOL treatment intensity, as reflected in EOL care decisions and terminal hospitalizations. Design Prospectively collected survey data from the Health and Retirement Study (HRS), including data from in-depth “exit” interviews conducted with next-of-kin surrogates following the death of an HRS participant. Trends in ACP subtypes were tested, and multivariable logistic regression models examined associations between ACP subtypes and measures of treatment intensity. Setting HRS, a nationally representative, biennial, longitudinal panel study of U.S. residents over age 50. Participants 1,985 next-of-kin surrogates of HRS participants with cancer who died between 2000 and 2012. Main Outcome and Measures Trends in the surrogate-reported frequency of DPOA assignment, living will creation, and participation in discussions of EOL care preferences, as well as associations between ACP subtypes and surrogate-reported EOL care decisions/terminal hospitalizations. Results From 2000-2012, there was an increase in DPOA assignment (52% to 74%, p=0.03), without change in use of living wills (49% to 40%, p=0.63) or EOL discussions (68% to 60%, p=0.62). Surrogates increasingly reported that patients received “all care possible” at EOL (7% to 58%, p=0.004), and rates of terminal hospitalizations were unchanged (29% to 27%, p=0.70). Both living wills and EOL discussions were associated with limiting/withholding treatment [living will: adjusted odds ratio (AOR)=2.51, 95% confidence interval (CI)=1.53-4.11, p<0.001; EOL discussions: AOR=1.93, 95% CI=1.53-3.14, p=0.002], while DPOA assignment was not. Conclusions and Relevance Use of DPOA increased significantly between 2000 and 2012, but was not associated with EOL care decisions. Importantly, there was no growth in key ACP domains such as discussions of care preferences. Efforts that bolster communication of EOL care preferences and also incorporate surrogate decision-makers are critically needed to ensure receipt of goal-concordant care. PMID:26181909

What evidence is available on end-of-life (EOL) care and Latino elders? A literature review.

PubMed

Cruz-Oliver, Dulce M; Talamantes, Melissa; Sanchez-Reilly, Sandra

2014-02-01

Low-income and minority persons, such as Latinos, encounter substantial barriers in accessing effective end-of-life (EOL) care. This study intends to review current evidence on how to deliver EOL care to Latino elders. Literature search in PubMed and Ovid Web sites of articles indexed in Medline (1948-2011), Cochrane (2005-2011), Embase, and PsychInfo (1967-2011) databases. Articles were included if they contained (1) study participants' race/ethnicity, (2) adults or population older than 60 years, and (3) information related to EOL care. A total of 64 abstracts were reviewed, and 38 articles met the inclusion criteria. After reviewing the quality of evidence, 4 themes were identified and summarized: EOL preferences, hospice, Latino culture, and caregiving. Latino elders have traditional acculturation practices, face EOL decisions with family support, and, if educated, are receptive toward hospice and caregiver support.

Talking about end-of-life preferences in marriage: applying the theory of motivated information management.

PubMed

Rafferty, Katherine A; Cramer, Emily; Priddis, DeAnne; Allen, Mike

2015-01-01

The theory of motivated information management (TMIM) provides one framework to examine information-seeking behaviors, especially in conversations involving sensitive or difficult information such as preferences for end-of-life (EOL) care. The spouse plays a significant role in decision making surrounding EOL care. Consequently, individuals need information about spouses' EOL preferences in order to ensure carrying out those desires. Our findings support the value of TMIM as a framework to understand factors that influence couples' EOL care information-seeking behaviors. In support of the theory, we provide factors that influence the initiation or avoidance of EOL conversations between spouses.

Culture and End of Life Care: A Scoping Exercise in Seven European Countries

PubMed Central

Gysels, Marjolein; Evans, Natalie; Meñaca, Arantza; Andrew, Erin; Toscani, Franco; Finetti, Sylvia; Pasman, H. Roeline; Higginson, Irene; Harding, Richard; Pool, Robert

2012-01-01

Aim Culture is becoming increasingly important in relation to end of life (EoL) care in a context of globalization, migration and European integration. We explore and compare socio-cultural issues that shape EoL care in seven European countries and critically appraise the existing research evidence on cultural issues in EoL care generated in the different countries. Methods We scoped the literature for Germany, Norway, Belgium, the Netherlands, Spain, Italy and Portugal, carrying out electronic searches in 16 international and country-specific databases and handsearches in 17 journals, bibliographies of relevant papers and webpages. We analysed the literature which was unearthed, in its entirety and by type (reviews, original studies, opinion pieces) and conducted quantitative analyses for each country and across countries. Qualitative techniques generated themes and sub-themes. Results A total of 868 papers were reviewed. The following themes facilitated cross-country comparison: setting, caregivers, communication, medical EoL decisions, minority ethnic groups, and knowledge, attitudes and values of death and care. The frequencies of themes varied considerably between countries. Sub-themes reflected issues characteristic for specific countries (e.g. culture-specific disclosure in the southern European countries). The work from the seven European countries concentrates on cultural traditions and identities, and there was almost no evidence on ethnic minorities. Conclusion This scoping review is the first comparative exploration of the cultural differences in the understanding of EoL care in these countries. The diverse body of evidence that was identified on socio-cultural issues in EoL care, reflects clearly distinguishable national cultures of EoL care, with differences in meaning, priorities, and expertise in each country. The diverse ways that EoL care is understood and practised forms a necessary part of what constitutes best evidence for the improvement of EoL care in the future. PMID:22509278

Seeking and Accepting: U.S. Clergy Theological and Moral Perspectives Informing Decision Making at the End of Life.

PubMed

Sanders, Justin J; Chow, Vinca; Enzinger, Andrea C; Lam, Tai-Chung; Smith, Patrick T; Quiñones, Rebecca; Baccari, Andrew; Philbrick, Sarah; White-Hammond, Gloria; Peteet, John; Balboni, Tracy A; Balboni, Michael J

2017-10-01

People with serious illness frequently rely on religion/spirituality to cope with their diagnosis, with potentially positive and negative consequences. Clergy are uniquely positioned to help patients consider medical decisions at or near the end of life within a religious/spiritual framework. We aimed to examine clergy knowledge of end-of-life (EOL) care and beliefs about the role of faith in EOL decision making for patients with serious illness. Key informant interviews, focus groups, and survey. A purposive sample of 35 active clergy in five U.S. states as part of the National Clergy End-of-Life Project. We assessed participant knowledge of and desire for further education about EOL care. We transcribed interviews and focus groups for the purpose of qualitative analysis. Clergy had poor knowledge of EOL care; 75% desired more EOL training. Qualitative analysis revealed a theological framework for decision making in serious illness that balances seeking life and accepting death. Clergy viewed comfort-focused treatments as consistent with their faith traditions' views of a good death. They employed a moral framework to determine the appropriateness of EOL decisions, which weighs the impact of multiple factors and upholds the importance of God-given free will. They viewed EOL care choices to be the primary prerogative of patients and families. Clergy described ambivalence about and a passive approach to counseling congregants about decision making despite having defined beliefs regarding EOL care. Poor knowledge of EOL care may lead clergy to passively enable congregants with serious illness to pursue potentially nonbeneficial treatments that are associated with increased suffering.

A Comparison of the Influence of Anticipated Death Trajectory and Personal Values on End-of-Life Care Preferences: A Qualitative Analysis.

PubMed

Supiano, Katherine P; McGee, Nancy; Dassel, Kara B; Utz, Rebecca

2017-08-17

We examined anticipated preferences for end-of-life (EOL) care in healthy older adults in the context of various terminal disease scenarios to explore the relationship between personal values and diseases and conditions that would influence EOL care choices. Qualitative Descriptive Analysis was used to derive themes and the relationship between EOL preference themes and personal value themes in 365 respondents in a national sample of healthy older adults who completed a survey on their anticipated preferences for end-of-life (EOL) care. Reluctance to burden close others was the most frequently voiced personal value across all conditions affecting EOL preferences, followed by the personal value of quality of life. Concern about whether one's wishes would be honored was more commonly voiced in the context of hypothetical, prospective terminal cancer than in neurological conditions. Respondents who voiced desire for autonomy in how they would die clearly attributed extreme pain as the primary influence on EOL preferences. Comprehensive assessment of patient personal values should include consideration of particular chronic disease scenarios and death trajectories to fully inform EoL preferences. Because personal values do influence EOL preferences, care should be taken to ascertain patient values when presenting diagnoses, prognoses, and treatment options. In particular, patients and families of patients with progressive neurological diseases will likely face a time when the patient cannot self-represent EOL wishes. Early discussion of values and preferences, particularly in the context of cognitive disease is vital to assure patient-directed care.

Caring Decisions: The Development of a Written Resource for Parents Facing End-of-Life Decisions

PubMed Central

Gillam, Lynn; Hynson, Jenny; Sullivan, Jane; Cossich, Mary; Wilkinson, Dominic

2015-01-01

Abstract Background: Written resources in adult intensive care have been shown to benefit families facing end of life (EoL) decisions. There are few resources for parents making EoL decisions for their child and no existing resources addressing ethical issues. The Caring Decisions handbook and website were developed to fill these gaps. Aim: We discuss the development of the resources, modification after reviewer feedback and findings from initial pilot implementation. Design: A targeted literature review-to identify resources and factors that impact on parental EoL decision-making; development phase-guided by the literature and the researchers' expertise; consultation process-comprised a multi-disciplinary panel of experts and parents; pilot evaluation study-hard-copy handbook was distributed as part of routine care at an Australian Children's Hospital. Setting/Participants: Twelve experts and parents formed the consultation panel. Eight parents of children with life-limiting conditions and clinicians were interviewed in the pilot study. Results: Numerous factors supporting/impeding EoL decisions were identified. Caring Decisions addressed issues identified in the literature and by the multidisciplinary research team. The consultation panel provided overwhelmingly positive feedback. Pilot study parents found the resources helpful and comforting. Most clinicians viewed the resources as very beneficial to parents and identified them as ideal for training purposes. Conclusions: The development of the resources addressed many of the gaps in existing resources. The consultation process and the pilot study suggest these resources could be of significant benefit to parents and clinicians. PMID:26418215

Resource use and costs of end-of-Life/palliative care: Ontario adult cancer patients dying during 2002 and 2003.

PubMed

Walker, Hugh; Anderson, Mark; Farahati, Farah; Howell, Doris; Librach, S Lawrence; Husain, Amna; Sussman, Jonathan; Viola, Raymond; Sutradhar, Rinku; Barbera, Lisa

2011-01-01

The objective of this study is to estimate the direct medical cost of end-of-life and palliative (EOL/PAL) care for cancer patients during the last six months of their lives--or, during the period from diagnosis to death, if briefer--in 2002 and 2003, in Ontario, Canada. A linkage of cancer registry and administrative data is used to determine the costs of health care resources used during the EOL/PAL care period. Costs are analyzed by cancer diagnosis, location of death, and type of service. The total Ontario Ministry of Health-funded cost of EOL/PAL care for cancer patients is estimated to be about CAD$544 million per year, with an average per patient cost of about $25,000 in 2002-2003. Our results suggest that acute care consumes 75 percent of EOL/PAL funding and that only a small proportion of health care services used by EOL/PAL care cancer patients is likely to be formal palliative care.

End-of-life care in COPD: a survey carried out with Portuguese pulmonologists.

PubMed

Gaspar, C; Alfarroba, S; Telo, L; Gomes, C; Bárbara, C

2014-01-01

End-of-life (EoL) care is a major component in the management of patients with advanced COPD. Patient-physician communication is essential in this process. To evaluate the practice of Portuguese Pulmonologists in EoL communication and palliative care in COPD. An on-line survey was sent to physicians affiliated to the Portuguese Pneumology Society. We obtained 136 answers from 464 eligible participants (29.3%). About half of the physicians reported that they have rarely introduced EoL discussions with their COPD patients (48.5%). Most had never/rarely suggested decision-making on the use of invasive mechanical ventilation (68.4%). Discussions were described as occurring mostly during/after a major exacerbation (53.7%). Only 37.5% of participants reported treating dyspnoea with opioids frequently/always. Only 9.6% stated that they never/rarely treated anxiety/depression. Most participants perceive the discussion of EoL issues as being difficult/very difficult (89.0%). The reasons most frequently given were feeling that patients were not prepared for this discussion (70.0%), fear of taking away a patient's hope (58.0%) and lack of training (51.0%). Patient and medical staff EoL communication in COPD is still not good enough. Training in this area and the creation of formal protocols to initiate EoL have been identified as major factors for improvement. Copyright © 2013 Sociedade Portuguesa de Pneumologia. Published by Elsevier España. All rights reserved.

Differential impacts of care-giving across three caregiver groups in Canada: end-of-life care, long-term care and short-term care

PubMed Central

Williams, Allison M; Wang, Li; Kitchen, Peter

2014-01-01

Using data from Statistic Canada's General Social Survey Cycle 21 (GSS 2007), this study explores whether differences exist in the impacts of care-giving among three groups of caregivers providing informal care either in the caregiver's or recipient's home, or in other locations within the community: (i) those providing end-of-life (EOL) care (n = 471); (ii) those providing long-term care (more than 2 years) for someone with a chronic condition or long-term illness (n = 2722); and (iii) those providing short-term care (less than 2 years) for someone with a chronic condition or long-term illness (n = 2381). This study lays out the variation in sociodemographic characteristics across the three caregiver groups while also building on our understanding of the differential impacts of care-giving through an analysis of determinants. All three groups of caregivers shared a number of sociodemographic characteristics, including being female, married, employed and living in a Census Metropolitan Area (CMA). With respect to health, EOL caregivers were found to have significantly higher levels of ‘fair or poor’ self-assessed health than the other two groups. Overall, the findings suggest that EOL caregivers are negatively impacted by the often additional role of care-giving, more so than both short-term and long-term caregivers. EOL caregivers experienced a higher proportion of negative impacts on their social and activity patterns. Furthermore, EOL caregivers incurred greater financial costs than the other two types of informal caregivers. The impacts of EOL care-giving also negatively influence employment for caregivers when compared with the other caregiver groups. Consequently, EOL caregivers, overall, experienced greater negative impacts, including negative health outcomes, than did long-term or short-term caregivers. This provides the evidence for the assertion that EOL care-giving is the most intense type of care-giving, potentially causing the greatest caregiver burden; this is shown through the greater negative impacts experienced by the EOL caregivers when compared with the short-term and long-term caregivers. PMID:24172162

Nursing Home Physicians' Assessments of Barriers and Strategies for End-of-Life Care in Norway and The Netherlands.

PubMed

Fosse, Anette; Zuidema, Sytse; Boersma, Froukje; Malterud, Kirsti; Schaufel, Margrethe Aase; Ruths, Sabine

2017-08-01

Working conditions in nursing homes (NHs) may hamper teamwork in providing quality end-of-life (EOL) care, especially the participation of NH physicians. Dutch NH physicians are specialists or trainees in elderly care medicine with NHs as the main workplace, whereas in Norway, family physicians usually work part time in NHs. Thus, we aimed at assessing and comparing NH physicians' perspectives on barriers and strategies for providing EOL care in NHs in Norway and in The Netherlands. A cross-sectional study using an electronic questionnaire was conducted in 2015. All NH physicians in Norway (approximately 1200-1300) were invited to participate; 435 participated (response rate approximately 35%). Of the total 1664 members of the Dutch association of elderly care physicians approached, 244 participated (response rate 15%). We explored NH physicians' perceptions of organizational, educational, financial, legal, and personal prerequisites for quality EOL care. Differences between the countries were compared using χ 2 test and t-test. Most respondents in both countries reported inadequate staffing, lack of skills among nursing personnel, and heavy time commitment for physicians as important barriers; this was more pronounced among Dutch respondents. Approximately 30% of the respondents in both countries reported their own lack of interest in EOL care as an important barrier. Suggested improvement strategies were routines for involvement of patients' family, pain- and symptom assessment protocols, EOL care guidelines, routines for advance care planning, and education in EOL care for physicians and nursing staff. Inadequate staffing levels, as well as lack of competence, time, and interest emerge as important barriers to quality EOL care according to Dutch and Norwegian NH physicians. Their perspectives were mostly similar, despite large educational and organizational differences. Key strategies for improving EOL care in their facilities comprise education and incorporating available palliative care tools and systems. Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Practice and Perceived Importance of Advance Care Planning and Difficulties in Providing Palliative Care in Geriatric Health Service Facilities in Japan: A Nationwide Survey.

PubMed

Yokoya, Shoji; Kizawa, Yoshiyuki; Maeno, Takami

2018-03-01

The provision of end-of-life (EOL) care by geriatric health service facilities (GHSFs) in Japan is increasing. Advance care planning (ACP) is one of the most important issues to provide quality EOL care. This study aimed to clarify the practice and perceived importance of ACP and the difficulties in providing palliative care in GHSFs. A self-report questionnaire was mailed to head nurses at 3437 GHSFs nationwide. We asked participants about their practices regarding ACP, their recognition of its importance, and their difficulties in providing palliative care. We also analyzed the relationship between these factors and EOL care education. Among 844 respondents (24.5% response rate), approximately 69% to 81% of head nurses confirmed that GHSF residents and their families understood disease conditions and goals of care. There was a large discrepancy between the actual practice of ACP components and the recognition of their importance (eg, asking residents about existing advance directive [AD; 27.5% practiced it, while 79.6% considered it important]; recommending completion of an AD [18.1% vs 68.4%], and asking for designation of a health-care proxy [30.4% vs 76.8%]). The EOL care education was provided at 517 facilities (61.3%). Head nurses working at EOL care education-providing GHSFs practiced ACP significantly more frequently and had significantly fewer difficulties in providing palliative care. A large discrepancy was found between GHSF nurses' practice of ACP and their recognition of its importance. Providing EOL care education in GHSFs may increase ACP practices and enhance respect for resident's preferences concerning EOL care.

Attitudes, experiences, and beliefs affecting end-of-life decision-making among homeless individuals.

PubMed

Tarzian, Anita J; Neal, Maggie T; O'Neil, J Anne

2005-02-01

Individuals who are homeless may encounter various barriers to obtaining quality end-of-life (EOL) care, including access barriers, multiple sources of discrimination, and lack of knowledge among health care providers (HCPs) of their preferences and decision-making practices. Planning for death with individuals who have spent so much energy surviving requires an understanding of their experiences and preferences. This study sought to increase HCPs' awareness and understanding of homeless or similarly marginalized individuals' EOL experiences and treatment preferences. Focus groups were conducted with homeless individuals using a semi-structured interview guide to elicit participants' EOL experiences, decision-making practices, and personal treatment preferences. Five focus groups were conducted with 20 inner-city homeless individuals (4 per group) at a free urban health care clinic for homeless individuals in the United States. Sixteen of the 20 participants were African American; 4 were Caucasian. None were actively psychotic. All had experienced multiple losses and drug addiction. Five main themes emerged: valuing an individual's wishes; acknowledging emotions; the primacy of religious beliefs and spiritual experience; seeking relationship-centered care; and reframing advance care planning. The narrative process of this qualitative study uncovered an approach to EOL decision-making in which participants' reasoning was influenced by emotions, religious beliefs, and spiritual experience. Relationship-centered care, characterized by compassion and respectful, two-way communication, was obvious by its described absence--reasons for this are discussed. Recommendations for reframing advance care planning include ways for HCPs to transform advance care planning from that of a legal document to a process of goal-setting that is grounded in human connection, respect, and understanding.

Please Ask Gently: Using Culturally Targeted Communication Strategies to Initiate End-of-Life Care Discussions With Older Chinese Americans.

PubMed

Chi, Han-Lin; Cataldo, Janine; Ho, Evelyn Y; Rehm, Roberta S

2018-01-01

Health-care providers (HCPs) find facilitating end-of-life (EOL) care discussions challenging, especially with patients whose ethnicities differ from their own. Currently, there is little guidance on how to initiate and facilitate such discussions with older Chinese Americans (≥55 years) and their families. To explore communication strategies for HCPs to initiate EOL care discussions with older Chinese Americans in the San Francisco Bay Area. This qualitative (focused) ethnographic study included field observations and individual semistructured interviews with 14 community-dwelling older Chinese Americans who lived independently at home, 9 adult children, and 7 HCPs. Responses were analyzed using open coding, memos, and comparison across participants. The study participants emphasized the importance of assessing readiness for early EOL care discussions. All recommended using indirect communication approaches to determine older Chinese Americans' readiness. Indirect communication can be culturally targeted and applied at both system-wide (ie, health-care system) and individual (ie, HCP) levels. To institutionalize the practice, health-care facilities should implement EOL care discussion inquiries as part of routine during check-in or intake questionnaires. In individual practice, using depersonalized communication strategies to initiate the discussion was recommended to determine older Chinese Americans' readiness. Assessing readiness should be an essential and necessary action for early EOL care discussions. Culturally targeted assessment of older Chinese Americans includes using indirect communication approaches to initiate an EOL care discussion to determine their readiness. In addition to health-care system integration, providers should implement and evaluate proposed EOL discussion initiation prompts with their older Chinese American patients.

Implementing and Evaluating a Four-Year Integrated End-of-Life Care Curriculum for Medical Students.

PubMed

Ellman, Matthew S; Fortin, Auguste H; Putnam, Andrew; Bia, Margaret

2016-01-01

Meeting the needs of patients with life-limiting and terminal illness requires effectively trained physicians in all specialties to provide skillful and compassionate care. Despite mandates for end-of-life (EoL) care education, graduating medical students do not consistently feel prepared to provide this care. We have developed a longitudinal, integrated, and developmental 4-year curriculum in EoL care. The curriculum's purpose is to teach basic competencies in EoL care. A variety of teaching strategies emphasize experiential, skill-building activities with special attention to student self-reflection. In addition, we have incorporated interprofessional learning and education on the spiritual and cultural aspects of care. We created blended learning strategies combining interactive online modules with live workshops that promote flexibility, adaptability, and interprofessional learning opportunities. The curriculum was implemented and evaluated in the 4-year program of studies at Yale School of Medicine. A mixed-method evaluation of the curriculum included reviews of student written reflections and questionnaires, graduating student surveys, and demonstration of 4th-year students' competency in palliative care with an observed structured clinical examination (OSCE). These evaluations demonstrate significant improvements in students' self-reported preparedness in EoL care and perceptions of the adequacy in their instruction in EoL and palliative care, as well as competency in primary palliative care in a newly developed OSCE. A 4-year longitudinal integrated curriculum enhances students' skills and preparedness in important aspects of EoL care. As faculty resources, clinical sites, and curricular structure vary by institution, proven and adaptable educational strategies as described in this article may be useful to address the mandate to improve EoL care education. Teaching strategies and curricular components and design as just described can be adapted to other programs.

End-of-life care for advanced dementia patients in residential care home-a Hong Kong perspective.

PubMed

Luk, James K H; Chan, Felix H W

2017-08-28

Dementia will become more common as the population ages. Advanced dementia should be considered as a terminal illnesses and end-of-life (EOL) care is very much needed for this disease group. Currently, the EOL services provided to this vulnerable group in Hong Kong, especially those living in residential care homes, is limited. The usual practice of residential care homes is to send older residents with advanced dementia to acute hospitals when they are sick, irrespective of their wish, premorbid status, diagnoses and prognosis. This may not accord with what the patients perceive to be a "good death". There are many barriers for older people to die in place, both at home and at the residential care home. In the community, to enhance EOL care to residential care home for the elderly (RCHE) residents, pilot EOL program had been carried out by some Community Geriatric Assessment Teams. Since 2015, the Hospital Authority funded program "Enhance Community Geriatric Assessment Team Support to End-of-life Patients in Residential Care Homes for the Elderly" has been started. In the program, advance care planning (ACP), Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) (non-hospitalized) order will be established and the program will be expected to cover all clusters in Hong Kong by 2018/2019. In hospital setting, EOL clinical plan and EOL ward in geriatric step-down hospitals may be able to improve the quality of death of older patients. In Sep 2015, the Hospital Authority Guidelines on Life-Sustaining Treatment in the Terminally Ill was updated. Amongst other key EOL issues, careful (comfort) hand feeding was mentioned in the guideline. Other new developments include the possible establishment of enduring power of attorney for health care decision and enhancement of careful hand feeding amongst advanced dementia patients in RCHEs.

From vulnerability to passion in the end-of-life care: The lived experience of nurses.

PubMed

Liu, Ying-Chun; Chiang, Hsien-Hsien

2017-12-01

End-of-life (EOL) care is considered to be inherently difficult and vulnerable for patients and nurses. It also seems hard to develop passion for care during these problematic times. This study elucidates how EOL nurses interpret their care experience and how they transform their experience and mindset. This study was conducted by organizing a reflective group based on the concept of group analysis for oncology and hospice nurses to share their experience. Thirteen registered nurses were enrolled from a medical center in northern Taiwan. Data drawn from the group dialogue was derived from six digitally recorded sessions and then analysed alone with the researcher's diaries and participants' feedback sheets. Interpretative Phenomenological Analysis (IPA) was used to analyze the data. The results showed that nurses who provide EOL care actually experience suffering by witnessing patients' suffering. However, the suffering authentically drives the nurses to encounter their own inner selves, to induce the shift of mindset, and then allow them to continuously provide and maintain the passion in EOL care. This study provides a new viewpoint for understanding of EOL nurses' experiences, indicating that this line of work may be recognized as a privilege. We recommend that the setting of a nurse reflective group is important and it may be considered in providing EOL care training for nurses. Hopefully the study results could shed lights for future policies regarding EOL care. Copyright © 2017 Elsevier Ltd. All rights reserved.

Wellness in Sickness and Health (The W.I.S.H. Project): Advance Care Planning Preferences and Experiences Among Elderly Latino Patients.

PubMed

Maldonado, Lauren Y; Goodson, Ruth B; Mulroy, Matthew C; Johnson, Emily M; Reilly, Jo M; Homeier, Diana C

2017-10-25

To assess advance care planning (ACP) preferences, experiences, and comfort in discussing end-of-life (EOL) care among elderly Latinos. Patients aged 60 and older from the Los Angeles County and University of Southern California (LAC+USC) Medical Center Geriatrics Clinic (n = 41) participated in this intervention. Trained staff conducted ACP counseling with participants in their preferred language, which included: (a) pre-counseling survey about demographics and EOL care attitudes, (b) discussion of ACP and optional completion of an advance directive (AD), and (c) post-session survey. Patients were primarily Spanish speaking with an average of 2.7 chronic medical conditions. Most had not previously documented (95%) or discussed (76%) EOL wishes. Most were unaware they had control over their EOL treatment (61%), but valued learning about EOL options (83%). Post-counseling, 85% reported comfort discussing EOL goals compared to 66% pre-session, and 88% elected to complete an AD. Nearly half of patients reported a desire to discuss EOL wishes sooner. Elderly Latino patients are interested in ACP, given individualized, culturally competent counseling in their preferred language. Patients should be offered the opportunity to discuss and document EOL wishes at all primary care appointments, regardless of health status. Counseling should be completed in the patient's preferred language, using culturally competent materials, and with family members present if this is the patient's preference. Cultural-competency training for providers could enhance the impact of EOL discussions and improve ACP completion rates for Latino patients.

Agency behind bars: Advance care planning with aging and dying offenders.

PubMed

Sanders, Sara; Stensland, Meredith; Juraco, Kim

2018-01-01

Aging and terminally ill individuals in U.S. prisons are increasing, making critical the need for appropriate end-of-life (EOL) care and advance care planning (ACP). Applying Bandura's agentic perspective, the authors examined 20 aging/dying offenders' EOL preferences and ACP. Findings include 6 themes: decisions in the shadow of the past, what works best for me, feeling blessed, what is really going on, can anyone be trusted, and turning agency over to someone else. This study provides critical information that will assist professionals who work with dying offenders, as it presents a vivid illustration of their dying process.

Designing and Testing an End-of-Life Discussion Intervention for African American Patients With Heart Failure and Their Families

PubMed Central

Piamjariyakul, Ubolrat; Smith, Carol E.; Werkowitch, Marilyn; Thompson, Noreen; Fox, Maria; Williamson, Karin Porter; Olson, Lori

2017-01-01

There is an escalating prevalence of heart failure (HF) with high mortality. Compared with other races, African Americans face a higher incidence of HF at earlier age of onset, with more rapid progression, and with increased family care burden and greater care costs and disparity in health care services at the end of life (EOL). Concomitant out-of-pocket HF costs and care demands indicate the need for early discussion of palliative and EOL care needs. We therefore developed and pilot tested a culturally sensitive intervention specific to the needs of African American HF patients and their families at the EOL. Our pilot study findings encompass patient and caregiver perspectives and align with the state of EOL science. The ultimate long-term goal of this intervention strategy is to translate into practice the preferred, culturally sensitive, and most cost-efficient EOL care recommendations for HF patients and families. PMID:29081717

Preferences for Life-Sustaining Treatments and Associations With Accurate Prognostic Awareness and Depressive Symptoms in Terminally Ill Cancer Patients' Last Year of Life.

PubMed

Tang, Siew Tzuh; Wen, Fur-Hsing; Hsieh, Chia-Hsun; Chou, Wen-Chi; Chang, Wen-Cheng; Chen, Jen-Shi; Chiang, Ming-Chu

2016-01-01

The stability of life-sustaining treatment (LST) preferences at end of life (EOL) has been established. However, few studies have assessed preferences more than two times. Furthermore, associations of LST preferences with modifiable variables of accurate prognostic awareness, physician-patient EOL care discussions, and depressive symptoms have been investigated in cross-sectional studies only. To explore longitudinal changes in LST preferences and their associations with accurate prognostic awareness, physician-patient EOL care discussions, and depressive symptoms in terminally ill cancer patients' last year. LST preferences (cardiopulmonary resuscitation, intensive care unit [ICU] care, intubation, and mechanical ventilation) were measured approximately every two weeks. Changes in LST preferences and their associations with independent variables were examined by hierarchical generalized linear modeling with logistic regression. Participants (n = 249) predominantly rejected cardiopulmonary resuscitation, ICU care, intubation, and mechanical ventilation at EOL without significant changes as death approached. Patients with inaccurate prognostic awareness were significantly more likely than those with accurate understanding to prefer ICU care, intubation, and mechanical ventilation than to reject these LSTs. Patients with more severe depressive symptoms were less likely to prefer ICU care and to be undecided about wanting ICU care and mechanical ventilation than to reject such LSTs. LST preferences were not associated with physician-patient EOL care discussions, which were rare in our sample. LST preferences are stable in cancer patients' last year. Facilitating accurate prognostic awareness and providing adequate psychological support may counteract the increasing trend for aggressive EOL care and minimize emotional distress during EOL care decisions. Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Certainty and uncertainty about end of life care nursing practices in New Zealand Intensive Care Units: a mixed methods study.

PubMed

Coombs, Maureen; Fulbrook, Paul; Donovan, Sarah; Tester, Rachel; deVries, Kay

2015-05-01

With end-of-life (EOL) central to the nursing role in intensive care, few studies have been undertaken to explore EOL care in the context of New Zealand (NZ) intensive care nursing. To investigate NZ intensive care nurses' experiences of, and attitudes towards EOL care. Sequential mixed methods study using cross sectional survey with follow-on focus groups. NZ intensive care nurses (N=465) across four large tertiary intensive care units (ICUs) were contacted to complete a 43-item web-based survey. A follow-on focus group was conducted in each of the sites to explore specific aspects of the survey findings. 203 fully completed surveys were returned (response rate 44%) from the four ICUs. Over half of nurses surveyed (55%, n=111) disagreed that withholding and withdrawing life support treatment were ethically the same. 78% (n=159) of nurses stated that withholding treatment was ethically more acceptable than withdrawing it. Whilst nurses generally supported reducing inspired oxygen to air for ventilated patients at EOL (71%, n=139) this was also an area that demonstrated one of the highest levels of uncertainty (21%, n=41). Just under a quarter of respondents were also uncertain about the use of continued nutritional support, continued passive limb exercises and use of deep sedation during EOL. The 18 nurses who participated in follow-on focus groups detailed the supportive, culturally sensitive, collaborative environment that EOL was conducted in. However diverse opinions and understandings were held on the use of passive limb and use of fluids at EOL. Whilst results from this NZ study broadly align with European studies, uncertainty about specific areas of EOL practices highlight that further guidance for nurses is required. Copyright © 2015 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

Creating a palliative and end-of-life program in a cure-oriented pediatric setting: the zig-zag method.

PubMed

Harper, Joann; Hinds, Pamela S; Baker, Justin N; Hicks, Judy; Spunt, Sheri L; Razzouk, Bassem I

2007-01-01

Children living with and dying of advanced-stage cancer suffer physically, emotionally, and spiritually. Relief of their suffering requires comprehensive, compassionate palliative and end-of-life (EoL) care.However, an EoL care program might appear inconsistent with the mission of a pediatric oncology research center committed to seeking cures. Here the authors describe the methods used to achieve full institutional commitment to their EoL care program and those used to build the program's philosophical, research, and educational foundations after they received approval. The authors convened 10 focus groups to solicit staff perceptions of the hospital's current palliative and EoL care. They also completed baseline medical record reviews of 145 patient records to identify key EoL characteristics. The authors then crafted a vision statement and a strategic plan, implemented new research protocols,and established publication and funding trajectories. They conclude that establishing a state-of-the-art palliative and EoL program in a cure-oriented pediatric setting is achievable via consensus building and recruitment of diverse institutional resources.

A systematic review of religious beliefs about major end-of-life issues in the five major world religions.

PubMed

Chakraborty, Rajshekhar; El-Jawahri, Areej R; Litzow, Mark R; Syrjala, Karen L; Parnes, Aric D; Hashmi, Shahrukh K

2017-10-01

The objective of this study was to examine the religious/spiritual beliefs of followers of the five major world religions about frequently encountered medical situations at the end of life (EoL). This was a systematic review of observational studies on the religious aspects of commonly encountered EoL situations. The databases used for retrieving studies were: Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid PsycINFO, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. Observational studies, including surveys from healthcare providers or the general population, and case studies were included for review. Articles written from a purely theoretical or philosophical perspective were excluded. Our search strategy generated 968 references, 40 of which were included for review, while 5 studies were added from reference lists. Whenever possible, we organized the results into five categories that would be clinically meaningful for palliative care practices at the EoL: advanced directives, euthanasia and physician-assisted suicide, physical requirements (artificial nutrition, hydration, and pain management), autopsy practices, and other EoL religious considerations. A wide degree of heterogeneity was observed within religions, depending on the country of origin, level of education, and degree of intrinsic religiosity. Our review describes the religious practices pertaining to major EoL issues and explains the variations in EoL decision making by clinicians and patients based on their religious teachings and beliefs. Prospective studies with validated tools for religiosity should be performed in the future to assess the impact of religion on EoL care.

Preparing Pediatric Healthcare Professionals for End-of-Life Care Discussions: An Exploratory Study.

PubMed

Henderson, Amanda; Young, Jeanine; Herbert, Anthony; Bradford, Natalie; Pedersen, Lee-Anne

2017-06-01

Preparedness to initiate end-of-life (EoL) discussions is a confronting and daunting task for all healthcare professionals. We conducted a group interview to explore healthcare professionals' experiences of preparing for EoL discussions with the patient and their family in a pediatric context. To identify what pediatric healthcare professionals consider important when preparing for an EoL discussion. A qualitative design using a group interview. Two open-ended questions were asked: (1) How could preparedness to initiate EoL care discussions between healthcare professionals and the patient and family be enhanced? (2) What education resources/strategies could be developed to support preparation for EoL care discussions? Healthcare professionals, including medical, nursing, and allied health professionals working in pediatric palliative care settings across Queensland, Australia. These settings included major tertiary hospitals, general practice, community, and nongovernment organizations. A convenience sample of 36 healthcare professionals consented to participate in the study. An analysis of the data identified seven themes that had relevance for preparing for an EoL discussion: communication, healthcare professional perspectives, interdisciplinary team role, patient and family perspectives, practical issues, addressing mistakes, and healthcare professional education. Pediatric healthcare professionals confirmed that gaps exist in preparing for an EoL discussion. The findings support a need for further research in two areas. First, a systematic review of interdisciplinary resources that are available to support healthcare professionals in preparing for EoL discussions is recommended. Second, evidence-based interdisciplinary interventions to support pediatric EoL discussions need to be developed and evaluated.

Communication About Advance Directives and End-of-Life Care Options Among Internal Medicine Residents.

PubMed

Rhodes, Ramona L; Tindall, Kate; Xuan, Lei; Paulk, M Elizabeth; Halm, Ethan A

2015-05-01

Despite increasing awareness about the importance of discussing end-of-life (EOL) care options with terminally ill patients and families, many physicians remain uncomfortable with these discussions. The objective of the study was to examine perceptions of and comfort with EOL care discussions among a group of internal medicine residents and the extent to which comfort with these discussions has improved over time. In 2013, internal medicine residents at a large academic medical center were asked to participate in an on-line survey that assessed their attitudes and experiences with discussing EOL care with terminally-ill patients. These results were compared to data from a similar survey residents in the same program completed in 2006. Eighty-three (50%) residents completed the 2013 survey. About half (52%) felt strongly that they were able to have open, honest discussions with patients and families, while 71% felt conflicted about whether CPR was in the patient's best interest. About half (53%) felt strongly that it was okay for them to tell a patient/family member whether or not CPR was a good idea for them. Compared to 2006 respondents, the 2013 cohort felt they had more lectures about EOL communication, and had watched an attending have an EOL discussion more often. Modest improvements were made over time in trainees' exposure to EOL discussions; however, many residents remain uncomfortable and conflicted with having EOL care discussions with their patients. More effective training approaches in EOL communication are needed to train the next generation of internists. © The Author(s) 2014.

Communication About Advance Directives and End-of-Life Care Options Among Internal Medicine Residents

PubMed Central

Rhodes, Ramona L.; Tindall, Kate; Xuan, Lei; Paulk, M. Elizabeth; Halm, Ethan A.

2015-01-01

Background Despite increasing awareness about the importance of discussing end-of-life (EOL) care options with terminally ill patients and families, many physicians remain uncomfortable with these discussions. Objective The objective of the study was to examine perceptions of and comfort with EOL care discussions among a group of internal medicine residents and the extent to which comfort with these discussions has improved over time. Methods In 2013, internal medicine residents at a large academic medical center were asked to participate in an on-line survey that assessed their attitudes and experiences with discussing EOL care with terminally-ill patients. These results were compared to data from a similar survey residents in the same program completed in 2006. Results Eighty-three (50%) residents completed the 2013 survey. About half (52%) felt strongly that they were able to have open, honest discussions with patients and families, while 71% felt conflicted about whether CPR was in the patient’s best interest. About half (53%) felt strongly that it was okay for them to tell a patient/family member whether or not CPR was a good idea for them. Compared to 2006 respondents, the 2013 cohort felt they had more lectures about EOL communication, and had watched an attending have an EOL discussion more often. Conclusions Modest improvements were made over time in trainees’ exposure to EOL discussions; however, many residents remain uncomfortable and conflicted with having EOL care discussions with their patients. More effective training approaches in EOL communication are needed to train the next generation of internists. PMID:24418692

The diverse impact of advance care planning: a long-term follow-up study on patients' and relatives' experiences.

PubMed

Andreassen, Pernille; Neergaard, Mette Asbjørn; Brogaard, Trine; Skorstengaard, Marianne Hjorth; Jensen, Anders Bonde

2017-09-01

Advance care planning (ACP) is a process of discussing and recording patients' preferences for future care, aiming to guide healthcare decisions at the end of life (EOL). To explore nuances in the long-term impact of ACP by studying patient and relative experiences. A qualitative follow-up interview study. Interviews were recorded, transcribed and analysed using thematic synthesis. 3 patients with a life-limiting disease (lung or heart disease), affiliated with a major Danish hospital, and 7 relatives were interviewed 1 year after participating in an ACP discussion. The experiences were diverse. Some patients and relatives felt 'relieved', 'more secure' and more in control due to ACP. To some, ACP had led to open communication rather than 'beating around the bush', and to spending more quality time together. However, others perceived ACP as irrelevant. Some stated that the patient's wishes had not been met regardless of ACP. Others felt that EOL questions cannot be realistically considered until 'you're in the middle of it', because many factors are involved. In one case, participating in ACP led to a patient-relative conflict, resulting in EOL issues being 'tucked away'. The study reveals great diversity in patient and relative experiences of ACP. The study challenges previous research which mainly emphasises ACP as a valuable tool to optimise EOL care. This study stresses the importance of awareness of the highly individual nature of preferences and needs of patients and relatives regarding information, involvement and communication about EOL care. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

End-of-life care in pediatric neuro-oncology.

PubMed

Vallero, Stefano Gabriele; Lijoi, Stefano; Bertin, Daniele; Pittana, Laura Stefania; Bellini, Simona; Rossi, Francesca; Peretta, Paola; Basso, Maria Eleonora; Fagioli, Franca

2014-11-01

The management of children with cancer during the end-of-life (EOL) period is often difficult and requires skilled medical professionals. Patients with tumors of the central nervous system (CNS) with relapse or disease progression might have additional needs because of the presence of unique issues, such as neurological impairment and altered consciousness. Very few reports specifically concerning the EOL period in pediatric neuro-oncology are available. Among all patients followed at our center during the EOL, we retrospectively analyzed data from 39 children and adolescents with brain tumors, in order to point out on their peculiar needs. Patients were followed-up for a median time of 20.1 months. Eighty-two percent were receiving only palliative therapy before death. Almost half the patients (44%) died at home, while 56% died in a hospital. Palliative sedation with midazolam was performed in 58% of cases; morphine was administered in 51.6% of cases. No patient had uncontrolled pain. The EOL in children with advanced CNS cancer is a period of active medical care. Patients may develop complex neurological symptoms and often require long hospitalization. We organized a network-based collaboration among the reference pediatric oncology center, other pediatric hospitals and domiciliary care personnel, with the aim to ameliorate the quality of care during the EOL period. In our cohort, palliative sedation was widely used while no patients died with uncontrolled pain. A precise process of data collection and a better sharing of knowledge are necessary in order to improve the management of such patients. © 2014 Wiley Periodicals, Inc.

CE: Original Research: End-of-Life Care Behind Bars: A Systematic Review.

PubMed

Wion, Rachel K; Loeb, Susan J

2016-03-01

: To conduct a systematic review of the published research literature on end-of-life (EOL) care in prisons in order to determine the current state of the science and suggest implications for nursing practice and areas for future research.Applying the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we performed a comprehensive search of the literature using the following databases: CINAHL, Criminal Justice Abstracts, the National Criminal Justice Reference Service, PsycINFO, PubMed, and Sociological Abstracts. All databases were searched from the time of their inception through June 2014. All English-language articles that reported on original quantitative and qualitative research involving EOL or palliative care delivered to prisoners were included. We abstracted data, using the matrix method, and independently reviewed and graded the evidence on its level of strength and quality in accordance with the Johns Hopkins Nursing Evidence-Based Practice rating scales.Nineteen articles, all published between 2002 and 2014, met the inclusion criteria. Of these, 53% were published between 2009 and 2014, and 58% reported findings from qualitative research. One article reported on research conducted in the United Kingdom; the remaining 18 reported on research conducted in the United States. Capacity (that is, the number of prisoners requiring EOL care and the ability of the prison to accommodate them) and the site of EOL care delivery varied across studies, as did the criteria for admission to EOL or hospice services. Care was provided by prison health care staff, which variously included numerous professional disciplines, corrections officers, and inmate caregivers. The inmate caregivers, in particular, provided a wide array of services and were viewed positively by both EOL patients and health care staff. There are insufficient data to characterize the patients' and inmate caregivers' perceptions of the EOL care staff and the quality of care they provided. The screening criteria applied to inmate caregivers and the training they received varied widely among care programs. Inmates providing EOL care viewed caregiving as a transformational experience. Likewise, prison administrators and health care staff viewed inmate participation positively.This literature review reveals the challenges of providing EOL care to prisoners and may inspire nurses to consider steps they can take individually or within nursing organizations to improve this care and address the unique challenges faced by dying inmates. By being aware of these issues and advocating for best practices, nurses can help inmates at the end of life to have a dignified death.

Critical Care Nurses' Perceptions of End-of-Life Care Obstacles: Comparative 17-Year Data.

PubMed

Beckstrand, Renea L; Lamoreaux, Nicole; Luthy, Karlen E; Macintosh, Janelle L B

Nurses working in intensive care units (ICUs) frequently care for patients and their families at the end of life (EOL). Providing high-quality EOL care is important for both patients and families, yet ICU nurses face many obstacles that hinder EOL care. Researchers have identified various ICU nurse-perceived obstacles, but no studies have been found addressing the progress that has been made for the last 17 years. The aims of this study were to determine the most common and current obstacles in EOL care as perceived by ICU nurses and then to evaluate whether meaningful changes have occurred since data were first gathered in 1998. A quantitative-qualitative mixed methods design was used. A random, geographically dispersed sample of 2000 members of the American Association of Critical-Care Nurses was surveyed. Five obstacle items increased in mean score and rank as compared with 1999 data including (1) family not understanding what the phrase "lifesaving measures" really means, (2) providing lifesaving measures at families' requests despite patient's advance directive listing no such care, (3) family not accepting patient's poor prognosis, (4) family members fighting about the use of life support, and (5) not enough time to provide EOL care because the nurse is consumed with lifesaving measures attempting to save the patient's life. Five obstacle items decreased in mean score and rank compared with 1999 data including (1) physicians differing in opinion about care of the patient, (2) family and friends who continually call the nurse rather than calling the designated family member, (3) physicians who are evasive and avoid families, (4) nurses having to deal with angry families, and (5) nurses not knowing their patient's wishes regarding continuing with tests and treatments. Obstacles in EOL care, as perceived by critical care nurses, still exist. Family-related obstacles have increased over time. Obstacles related to families may not be easily overcome as each family, dealing with a dying family member in an ICU, likely has not previously experienced a similar situation. On the basis of the current top 5 obstacles, recommendations for possible areas of focus include (1) improved health literacy assessment of families followed by earlier directed, appropriate, and specific EOL information; (2) improved physician/team communication; and (3) ensuring patients' wishes are followed as written. In general, patient- and family-centered care using clear and open EOL communication regarding wishes and desires between patients and families, their physicians, and nurses will help decrease common obstacles, thus improving the quality of EOL care provided to dying patients and families.

The Double Parallel Curriculum in Palliative Care: Teaching Learners to Teach End-of-Life Care at the Bedside.

PubMed

Healy, Jennifer; Chappell, Phylliss; Lee, Shuko; Ross, Jeanette; Sanchez-Reilly, Sandra

2017-11-01

Dying is a natural process, yet physicians are often uncomfortable caring for dying patients. Learners have limited exposure to curriculum on caring for dying patients and often navigate these encounters without appropriate skills and confidence. We developed and implemented the Double Parallel Curriculum in Palliative Care (DP-PC): End-of-Life (EOL) module. The DP-PC focuses on teaching third-year medical students (MS3) to not only take care of patients in their last hours of life but give learners the confidence to teach patient's families what to expect as they hold vigil at their loved one's bedside. To develop and implement an educational intervention that improves learners' knowledge and confidence in EOL patient and family care. To expand learner confidence to a dual level (learners become teachers) with a simplified and culturally sensitive electronic bedside teaching tool designed to guide learners and patients/families conversations. Curriculum was completed during MS3 ambulatory rotation and included pre-/posttests, an online case-based module, faculty demonstration, and learner role-play using the bedside teaching tool. A total of 247 participants took the pretest, 222 participants took the posttest, and 222 participants matched the pre-/posttest surveys. Students' knowledge of EOL care and the confidence to teach other learners and families about EOL care significantly improved after completing the curriculum. The DP-PC is a technology-savvy educational intervention that improves learner confidence and knowledge toward caring for dying patients and their families. Easy access, technology-based teaching tools may enhance bedside teaching of health-care learners and improve the care of patients and their families at the end of life.

Financial hardship and the intensity of medical care received near death.

PubMed

Tucker-Seeley, Reginald D; Abel, Gregory A; Uno, Hajime; Prigerson, Holly

2015-05-01

Although end-of-life (EOL) care can present a substantial financial burden for the household, the influence of this burden on the intensity of care received at the EOL remains unknown. The goal of this study was to determine the association between financial hardship and intensive care in the last week of life. The Coping with Cancer (CwC) Study is a longitudinal, multisite cohort study of terminally ill cancer patients and their informal caregivers, September 2002-February 2008. Patients (N = 281) were followed from baseline to death, a median of 4.4 months after baseline assessment. Intensive care was defined as the use of resuscitation and/or ventilation in the patient's last week of life. Financial hardship was measured at study baseline as a positive response to whether the household had to use all or most of their savings because of the family member's illness. Twenty-nine percent reported financial hardship, and 9% received intensive EOL care. Patients reporting financial hardship had a 3.22 (95% CI: 1.38, 7.53) higher likelihood of receiving intensive EOL care compared with patients not reporting financial hardship. After adjusting for sociodemographic characteristics and patient preferences, patients reporting financial hardship had a 3.05 (95% CI: 1.22, 7.62) higher likelihood of receiving intensive EOL care. The depletion of a family's financial resources is a significant predictor of intensive EOL care, over and above the influence of sociodemographic characteristics and patient preferences. Copyright © 2014 John Wiley & Sons, Ltd.

Caring for the dying patient in the ICU--the past, the present and the future.

PubMed

Fridh, Isabell

2014-12-01

The aim of this paper is to present the state of the science concerning issues in end-of-life (EOL) care which have an impact on intensive care nurses possibilities to provide nursing care for dying patients and their families. The perspective of families is also illuminated and finally ethical challenges in the present and for the future are discussed. The literature review revealed that the problem areas nurses report concerning EOL care have been the same over three decades. Most problems are related to inter-disciplinary collaboration and communication with the medical profession about the transition from cure to comfort care. Nurses need enhanced communication skills in their role as the patient's advocate. Education in EOL care and a supportive environment are prerequisites for providing EOL care. Losing a loved one in the ICU is a stressful experience for close relatives and nursing care has a profound impact on families' memories of the EOL care given to their loved ones. It is therefore important that ICU nurses are aware of families' needs when a loved one is dying and that follow-up services are appreciated by bereaved family members. Ethical challenges are related to changed sedation practices, organ donation, globalisation and cultural sensitivity. Copyright © 2014 Elsevier Ltd. All rights reserved.

Worldwide end-of-life practice for patients in ICUs.

PubMed

Wong, Wai-Tat; Phua, Jason; Joynt, Gavin M

2018-04-01

Published data and practice recommendations on end-of-life (EOL) generally reflect Western practice frameworks. Understanding worldwide practices is important because improving economic conditions are promoting rapid expansion of intensive care services in many previously disadvantaged regions, and increasing migration has promoted a new cultural diversity previously predominantly unicultural societies. This review explores current knowledge of similarities and differences in EOL practice between regions and possible causes and implications of these differences. Recent observational and survey data shows a marked variability in the practice of withholding and withdrawing life sustaining therapy worldwide. Some evidence supports the view that culture, religion, and socioeconomic factors influence EOL practice, and individually or together account for differences observed. There are also likely to be commonly desired values and expectations for EOL practice, and recent attempts at establishing where worldwide consensus may lie have improved our understanding of shared values and practices. Awareness of differences, understanding their likely complex causes, and using this knowledge to inform individualized care at EOL is likely to improve the quality of care for patients. Further research should clarify the causes of EOL practice variability, monitor trends, and objectively evaluate the quality of EOL practice worldwide.

Decision-Making of Patients With Implantable Cardioverter-Defibrillators at End of Life: Family Members' Experiences.

PubMed

Lee, Mei Ching; Sulmasy, Daniel P; Gallo, Joseph; Kub, Joan; Hughes, Mark T; Russell, Stuart; Kellogg, Anela; Owens, Sharon G; Terry, Peter; Nolan, Marie T

2017-07-01

Many patients with advanced heart failure (HF) experience the life-extending benefits of implantable cardioverter-defibrillators (ICD), but at the end stage of HF, patients may experience shocks with increasing frequency and change the plan for end-of-life (EOL) care including the deactivation of the ICD. This report describes family members' experiences of patients with ICD making decisions at EOL. Understanding the decision-making of patients with ICD at EOL can promote informed decision-making and improve the quality of EOL care. This pilot study used a mixed methods approach to test the effects of a nurse-guided discussion in decision-making about ICD deactivation (turning off the defibrillation function) at the EOL. Interviews were conducted, audiotaped, and transcribed in 2012 to 2013 with 6 family members of patients with advanced HF and ICDs. Three researchers coded the data and identified themes in 2014. Three main themes described family members' experiences related to patients having HF with ICDs making health-care decision at EOL: decision-making preferences, patients' perception on ICD deactivation, and communication methods. Health-care providers need to have knowledge of patients' decision-making preferences. Preferences for decision-making include the allowing of appropriate people to involve and encourages direct conversation with family members even when advance directives is completed. Information of ICD function and the option of deactivation need to be clearly delivered to patients and family members. Education and guidelines will facilitate the communication of the preferences of EOL care.

Death in the Digital Age: A Systematic Review of Information and Communication Technologies in End-of-Life Care.

PubMed

Ostherr, Kirsten; Killoran, Peter; Shegog, Ross; Bruera, Eduardo

2016-04-01

End-of-life (EOL) communication plays a critical role in ensuring that patients receive care concordant with their wishes and experience high quality of life. As the baby boomer population ages, scalable models of end-of-life communication will be needed to ensure that patients receive appropriate care. Information and communication technologies (ICTs) may help address the needs of this generation; however, few resources exist to guide the use of ICTs in EOL care. The primary objective was to identify the ICTs being used in EOL communication. The secondary objective was to compare the effectiveness of different ICTs in EOL communication. The study was a systematic review, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We systematically searched seven databases for experimental and observational studies on EOL communication between doctors and patients using ICTs, published in 1997-2013. The review identified 38 relevant articles. Eleven types of technology were identified: video, website, telephone, videoconferencing, e-mail, telemonitoring, Internet search, compact disc, fax, PalmPilot, and short message service (SMS) text messaging. ICTs were most commonly used to provide information or education, serve as decision aids, promote advance care planning (ACP), and relieve physical symptom distress. The use of ICTs in EOL care is a small but growing field of research. Additional research is needed to adapt older, analog technologies for use in the digital age. Many of the interventions discussed in this review do not take full advantage of the affordances of mobile, connected health ICTs. The growing evidence base for e-health applications in related fields should guide future interventions in EOL care.

Measuring the quality of end of life management in patients with advanced kidney disease: results from the pan-Thames renal audit group.

PubMed

McAdoo, Stephen P; Brown, Edwina A; Chesser, Alistair M; Farrington, Ken; Salisbury, Emma M

2012-04-01

Despite a recent increased awareness of the need for quality End of Life (EOL) care for patients with advanced kidney disease, there is no established method for measuring or auditing outcomes relating to EOL care in this population. We designed a one-page proforma, which was used to collect data on various aspects of EOL care relating to all deaths of patients on dialysis and patients dying on specialist renal wards, over a predefined 8-week period in 10 hospitals in London and South-East England. One hundred and thirty-eight deaths were recorded over the 8-week study period. The majority of patients (83%) were receiving maintenance haemodialysis prior to their terminal presentation. About 69% of deaths occurred during an in-patient hospital admission-of these, 36% were considered 'unexpected' and most quality markers of good EOL management were significantly less likely to be achieved in these patients, including use of palliative care strategies, good symptom control and overall quality of death. Thirty-six per cent of patients were from various ethnic minorities, and in this group, there was a trend towards lower use of palliative care pathways and lower rates of withdrawal from dialysis. This study confirms that it is possible to measure many important outcomes relating to quality of EOL care using a proforma completed at the time of death. Our findings suggest that many aspects of good EOL care are under-achieved in our region. This, in part, is due to a failure to recognize the worsening trajectory of the deteriorating patient, resulting in missed opportunities for EOL care planning and appropriate symptom control. Our observations suggest that there is a need for improved education and training in this area, particularly in detection of the dying patient, the value of advance care planning and the utility of tools such as the Liverpool Care Pathway.

A systematic review of religious beliefs about major end-of-life issues in the five major world religions

PubMed Central

CHAKRABORTY, RAJSHEKHAR; EL-JAWAHRI, AREEJ R.; LITZOW, MARK R.; SYRJALA, KAREN L; PARNES, ARIC D.; HASHMI, SHAHRUKH K.

2018-01-01

Objective The objective of this study was to examine the religious/spiritual beliefs of followers of the five major world religions about frequently encountered medical situations at the end of life (EoL). Method This was a systematic review of observational studies on the religious aspects of commonly encountered EoL situations. The databases used for retrieving studies were: Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid PsycINFO, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. Observational studies, including surveys from healthcare providers or the general population, and case studies were included for review. Articles written from a purely theoretical or philosophical perspective were excluded. Results Our search strategy generated 968 references, 40 of which were included for review, while 5 studies were added from reference lists. Whenever possible, we organized the results into five categories that would be clinically meaningful for palliative care practices at the EoL: advanced directives, euthanasia and physician-assisted suicide, physical requirements (artificial nutrition, hydration, and pain management), autopsy practices, and other EoL religious considerations. A wide degree of heterogeneity was observed within religions, depending on the country of origin, level of education, and degree of intrinsic religiosity. Significance of results Our review describes the religious practices pertaining to major EoL issues and explains the variations in EoL decision making by clinicians and patients based on their religious teachings and beliefs. Prospective studies with validated tools for religiosity should be performed in the future to assess the impact of religion on EoL care. PMID:28901283

End of life care in sub-Saharan Africa: a systematic review of the qualitative literature.

PubMed

Gysels, Marjolein; Pell, Christopher; Straus, Lianne; Pool, Robert

2011-03-09

End of life (EoL) care in sub-Saharan Africa still lacks the sound evidence-base needed for the development of effective, appropriate service provision. It is essential to make evidence from all types of research available alongside clinical and health service data, to ensure that EoL care is ethical and culturally appropriate. This article aims to synthesize qualitative research on EoL care in sub-Saharan Africa to inform policy, practice and further research. It seeks to identify areas of existing research; describe findings specifically relevant to the African context; and, identify areas lacking evidence. Relevant literature was identified through eight electronic databases: AMED, British Nursing Index & Archive, CINAHL, EMBASE, IBSS, MEDLINE, PsycINFO, and the Social Sciences Citation Index; and hand searches. Inclusion criteria were: published qualitative or mixed-method studies in sub-Saharan Africa, about EoL care. Study quality was assessed using a standard grading scale. Relevant data including findings and practice recommendations were extracted and compared in tabular format. Of the 407 articles initially identified, 51 were included in the qualitative synthesis. Nineteen came from South Africa and the majority (38) focused on HIV/AIDS. Nine dealt with multiple or unspecified conditions and four were about cancer. Study respondents included health professionals, informal carers, patients, community members and bereaved relatives. Informal carers were typically women, the elderly and children, providing total care in the home, and lacking support from professionals or the extended family. Twenty studies focused on home-based care, describing how programmes function in practice and what is needed to make them effective. Patients and carers were reported to prefer institutional care but this needs to be understood in context. Studies focusing on culture discussed good and bad death, culture-specific approaches to symptoms and illness, and the bereavement process. The data support or complement the findings from quantitative research. The review prompts a reconsideration of the assumption that in Africa the extended family care for the sick, and that people prefer home-based care. The review identifies areas relevant for a research agenda on socio-cultural issues at the EoL in sub-Saharan Africa.

What can we learn from simulation-based training to improve skills for end-of-life care? Insights from a national project in Israel.

PubMed

Brezis, Mayer; Lahat, Yael; Frankel, Meir; Rubinov, Alan; Bohm, Davina; Cohen, Matan J; Koslowsky, Meni; Shalomson, Orit; Sprung, Charles L; Perry-Mezare, Henia; Yahalom, Rina; Ziv, Amitai

2017-11-06

Simulation-based training improves residents' skills for end-of-life (EOL) care. In the field, staff providers play a significant role in handling those situations and in shaping practice by role modeling. We initiated an educational intervention to train healthcare providers for improved communication skills at EOL using simulation of sensitive encounters with patients and families. Hospital physicians and nurses (n = 1324) attended simulation-based workshops (n = 100) in a national project to improve EOL care. We analyzed perceptions emerging from group discussions following simulations, from questionnaires before and after each workshop, and from video-recorded simulations using a validated coding system. We used the simulation setting as a novel tool for action research. We used a participatory inquiry paradigm, with repetitive cycles of exploring barriers and challenges with participants in an iterative pattern of observation, discussion and reflection - including a description of our own responses and evolution of thought as well as system effects. The themes transpiring included lack of training, knowledge and time, technology overuse, uncertainty in decision-making, poor skills for communication and teamwork. Specific scenarios demonstrated lack of experience at eliciting preferences for EOL care and at handling conflicts or dilemmas. Content analysis of simulations showed predominance of cognitive utterances - by an order of magnitude more prevalent than emotional expressions. Providers talked more than actors did and episodes of silence were rare. Workshop participants acknowledged needs to improve listening skills, attention to affect and teamwork. They felt that the simulation-based workshop is likely to ameliorate future handling of EOL situations. We observed unanticipated consequences from our project manifested as a field study of preparedness to EOL in nursing homes, followed by a national survey on quality of care, leading to expansion of palliative care services and demand for EOL care education in various frameworks and professional areas. Reflective simulation exercises show barriers and paths to improvement among staff providers. When facing EOL situations, physicians and nurses use cognitive language far more often than emotions related expressions, active listening, or presence in silence. Training a critical mass of staff providers may be valuable to induce a cultural shift in EOL care.

Opening end-of-life discussions: how to introduce Voicing My CHOiCES™, an advance care planning guide for adolescents and young adults.

PubMed

Zadeh, Sima; Pao, Maryland; Wiener, Lori

2015-06-01

Each year, more than 11,000 adolescents and young adults (AYAs), aged 15-34, die from cancer and other life-threatening conditions. In order to facilitate the transition from curative to end-of-life (EoL) care, it is recommended that EoL discussions be routine, begin close to the time of diagnosis, and continue throughout the illness trajectory. However, due largely to discomfort with the topic of EoL and how to approach the conversation, healthcare providers have largely avoided these discussions. We conducted a two-phase study through the National Cancer Institute with AYAs living with cancer or pediatric HIV to assess AYA interest in EoL planning and to determine in which aspects of EoL planning AYAs wanted to participate. These results provided insight regarding what EoL concepts were important to AYAs, as well as preferences in terms of content, design, format, and style. The findings from this research led to the development of an age-appropriate advance care planning guide, Voicing My CHOiCES™. Voicing My CHOiCES™: An Advanced Care Planning Guide for AYA became available in November 2012. This manuscript provides guidelines on how to introduce and utilize an advance care planning guide for AYAs and discusses potential barriers. Successful use of Voicing My CHOiCES™ will depend on the comfort and skills of the healthcare provider. The present paper is intended to introduce the guide to providers who may utilize it as a resource in their practice, including physicians, nurses, social workers, chaplains, psychiatrists, and psychologists. We suggest guidelines on how to: incorporate EoL planning into the practice setting, identify timepoints at which a patient's goals of care are discussed, and address how to empower the patient and incorporate the family in EoL planning. Recommendations for introducing Voicing My CHOiCES™ and on how to work through each section alongside the patient are provided.

Palliative and End-of-Life Care Education Needs of Nurses Across Inpatient Care Settings.

PubMed

Price, Deborah M; Strodtman, Linda; Montagnini, Marcos; Smith, Heather M; Miller, Jillian; Zybert, Jennifer; Oldfield, Justin; Policht, Tyler; Ghosh, Bidisha

2017-07-01

Educating nurses about palliative and end-of-life (EOL) care is a high priority in health care settings. The purpose of this study was to assess nurses' perceived competency regarding the provision of palliative and EOL care to hospitalized patients. This study surveyed nurses from 25 pediatric and adult acute and intensive care units (ICU; N = 583) Quantitative data analysis was descriptive and correlational. Qualitative data analysis identified themes of participant concerns. Data analysis revealed that perceived competency in palliative and EOL care is significantly higher in the ICU nurses (p <.0001). Mean scores were significantly higher when nurses had more than 10 years of experience (p <.0001). Open-ended responses indicated concerns regarding improved communication behaviors, decision making, and facilitation of continuity of care. The results provide guidance for development of palliative and EOL care nursing education programs tailored to address specific unit needs according to staff characteristics, patient population focus of care, and acuity level of care. J Contin Educ Nurs. 2017;48(7):329-336. Copyright 2017, SLACK Incorporated.

An end-of-life practice survey among clinical nephrologists associated with a single nephrology fellowship training program

PubMed Central

Ceckowski, Kevin A.; Little, Dustin J.; Merighi, Joseph R.; Browne, Teri

2017-01-01

Abstract Background Our nephrology fellowship requires specific training in recognition and referral of end-stage renal disease patients likely to benefit from palliative and hospice care. Methods To identify end-of-life (EOL) referral barriers that require greater training emphasis, we performed a cross-sectional, 17-item anonymous online survey (August–October 2015) of 93 nephrologists associated with the program since 1987. Results There was a 61% response rate (57/93 surveys). Ninety-five percent practiced clinical nephrology (54/57). Of these, 51 completed the survey (55% completion rate), and their responses were analyzed. Sixty-four percent were in practice >10 years; 65% resided in the Southern USA. Ninety-two percent felt comfortable discussing EOL care, with no significant difference between those with ≤10 versus  >10 years of practice experience (P = 0.28). Thirty-one percent reported referring patients to EOL care ‘somewhat’ or ‘much less often’ than indicated. The most frequent referral barriers were: time-consuming nature of EOL discussions (27%); difficulty in accurately determining prognosis for <6-month survival (35%); patient (63%) and family (71%) unwillingness; and patient (69%) and family (73%) misconceptions. Fifty-seven percent would refer more patients if dialysis or ultrafiltration could be performed in hospice. Some reported that local palliative care resources (12%) and hospice resources (6%) were insufficient. Conclusions The clinical nephrologists surveyed were comfortable with EOL care discussion and referral. Patient, family, prognostic and system barriers exist, and many reported lower than indicated referral rates. Additional efforts, including, but not limited to, EOL training during fellowship, are needed to overcome familial and structural barriers to facilitate nephrologist referral for EOL care. PMID:28852478

Advance care planning in patients with incurable cancer: study protocol for a randomised controlled trial

PubMed Central

Clayton, Josephine; Butow, Phyllis N; Silvester, William; Detering, Karen; Hall, Jane; Kiely, Belinda E; Cebon, Jonathon; Clarke, Stephen; Bell, Melanie L; Stockler, Martin; Beale, Phillip; Tattersall, Martin H N

2016-01-01

Introduction There is limited evidence documenting the effectiveness of Advance Care Planning (ACP) in cancer care. The present randomised trial is designed to evaluate whether the administration of formal ACP improves compliance with patients' end-of-life (EOL) wishes and patient and family satisfaction with care. Methods and analysis A randomised control trial in eight oncology centres across New South Wales and Victoria, Australia, is designed to assess the efficacy of a formal ACP intervention for patients with cancer. Patients with incurable cancer and an expected survival of 3–12 months, plus a nominated family member or friend will be randomised to receive either standard care or standard care plus a formal ACP intervention. The project sample size is 210 patient–family/friend dyads. The primary outcome measure is family/friend-reported: (1) discussion with the patient about their EOL wishes and (2) perception that the patient's EOL wishes were met. Secondary outcome measures include: documentation of and compliance with patient preferences for medical intervention at the EOL; the family/friend's perception of the quality of the patient's EOL care; the impact of death on surviving family; patient–family and patient–healthcare provider communication about EOL care; patient and family/friend satisfaction with care; quality of life of patient and family/friend subsequent to trial entry, the patient's strength of preferences for quality of life and length of life; the costs of care subsequent to trial entry and place of death. Ethics and dissemination Ethical approval was received from the Sydney Local Health District (RPA Zone) Human Research Ethical Committee, Australia (Protocol number X13-0064). Study results will be submitted for publication in peer-reviewed journals and presented at national and international conferences. Trial registration number Pre-results; ACTRN12613001288718. PMID:27909034

Interprofessional communication between oncologic specialists and general practitioners on end-of-life issues needs improvement.

PubMed

Oosterink, John J; Oosterveld-Vlug, Mariska G; Glaudemans, Jolien J; Pasman, H Roeline W; Willems, Dick L; Onwuteaka-Philipsen, Bregje D

2016-12-01

Timely end-of-life (EOL) discussions between patients and physicians are considered essential for high-quality EOL care, but research shows that these discussions frequently do not occur or occur late. In oncology, one barrier for timely EOL discussions is poor collaboration between oncologic specialists and GPs. To explore interprofessional communication and coordination between oncologic specialists and GPs on EOL discussions. We conducted in-depth interviews with 16 GPs and 14 oncologic specialists. Interviews were recorded, transcribed verbatim and analysed using qualitative content analysis. EOL discussions were primarily considered the role of the GP, but oncologists' perceptions of their own roles in discussing EOL issues varied. Interprofessional coordination on who discusses what and when was mostly absent. Interprofessional communication of EOL issues usually proceeded using the patient as intermediary. This functioned well but only if three essential conditions were met: the specialist being realistic to patients about limits of treatment, informing the GP adequately and the GP being proactive in initiating EOL issues in time. However, when these conditions were absent, timely EOL discussions did not seem to occur. EOL discussions are rarely a subject of direct interprofessional communication and mainly proceed through the patient as intermediary. For implementation of EOL discussions into regular care, earlier interprofessional communication and coordination is needed, particularly if barriers for such discussions occur. © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

2016 AAHA/IAAHPC End-of-Life Care Guidelines.

PubMed

Bishop, Gail; Cooney, Kathleen; Cox, Shea; Downing, Robin; Mitchener, Kathy; Shanan, Amir; Soares, Nancy; Stevens, Brenda; Wynn, Tammy

End-of-life (EOL) care and decisionmaking embody the critical final stage in a pet's life and are as important and meaningful as the sum of the clinical care provided for all prior life stages. EOL care should focus on maximizing patient comfort and minimizing suffering while providing a collaborative and supportive partnership with the caregiver client. Timely, empathetic, and nonjudgmental communication is the hallmark of effective client support. Veterinarians should not allow an EOL patient to succumb to a natural death without considering the option of euthanasia and ensuring that other measures to alleviate discomfort and distress are in place. Animal hospice care addresses the patient's unique emotional and social needs as well as the physical needs traditionally treated in clinical practice. An EOL treatment plan should consist of client education; evaluating the caregiver's needs and goals for the pet; and a collaborative, personalized, written treatment plan involving the clinical staff and client. Primary care practices should have a dedicated team to implement palliative and hospice care for EOL patients. How the healthcare team responds to a client's grief after the loss of a pet can be a key factor in the client's continued loyalty to the practice. Referral to professional grief-support counseling can be a helpful option in this regard.

Medical students as hospice volunteers: reflections on an early experiential training program in end-of-life care education.

PubMed

Mott, Melissa L; Gorawara-Bhat, Rita; Marschke, Michael; Levine, Stacie

2014-06-01

Despite an increase in the content of palliative medicine curricula in medical schools, students are rarely exposed to end-of-life (EOL) care through real-patient experiences during their preclinical education. To evaluate the utility and impact of exposure to EOL care for first year medical students (MS-1s) through a hospice volunteer experience. Patients and Families First (PFF), a hospice volunteer training program in EOL care, was piloted on three cohorts of MS-1s as an elective. Fifty-five students received 3 hours of volunteer training, and were then required to conduct at least two consecutive hospice visits on assigned patients to obtain course credit. Students' reflective essays on their experiences were analyzed using qualitative methodology and salient themes were extracted by two investigators independently and then collaboratively. The following five themes were identified from students' reflective essays: perceptions regarding hospice patients; reactions regarding self; normalcy of EOL care at home; impact of witnessing death and dying; and suggestions for improving EOL care education for medical students. Hospice volunteering during preclinical years may provide valuable experiential training for MS-1s in caring for seriously ill patients and their families by fostering personal reflection and empathic skills, thereby providing a foundation for future patient encounters during clinical training.

How Older Adults and Their Families Perceive Family Talk about Aging-Related EOL Issues: A Dialectical Analysis.

PubMed

Egbert, Nichole; Child, Jeffrey T; Lin, Mei-Chen; Savery, Carol; Bosley, Tammy

2017-04-17

For older adults, approaching end-of-life (EOL) brings unique transitions related to family relationships. Unfortunately, most families greatly underestimate the need to discuss these difficult issues. For example, parents approaching EOL issues often struggle with receiving assistance from others, avoiding family conflict, and maintaining their sense of personhood. In addition, discussions of EOL issues force family members to face their parents' mortality, which can be particularly difficult for adult children to process emotionally. This study explored aging issues identified by aging parents and their families as they traverse these impending EOL changes. Ten focus groups of seniors ( n = 65) were conducted. Focus groups were organized according to race (African-American/European-American), gender, and whether the older adult was living independently or in an assisted care facility. When asked open-ended questions about discussing aging and EOL issues with family members, participants revealed tensions that led us to consider Relational Dialectics Theory as a framework for analysis. The predominant tension highlighted in this report was certainty versus uncertainty, with the two sub-themes of sustained life versus sustained personhood and confronting versus avoiding EOL issues. For these data, there were more similarities than differences as a result of gender, race, or living situation than one might expect, although culture and financial status were found to be influential in the avoidance of EOL discussions. The results of this study help to provide additional insight into relational dialectics related to aging, EOL, and the importance of communication in facilitating family coping.

Evaluation of a Video-Based Seminar to Raise Health Care Professionals' Awareness of Culturally Sensitive End-of-Life Care.

PubMed

Cruz-Oliver, Dulce M; Malmstrom, Theodore K; Roegner, Michael; Yeo, Gwen

2017-10-01

Health care workers serve diverse communities and face challenges in delivering culturally responsive EOL care, especially when caring for Latino elders. The objective of this study was to investigate the effect of a newly developed telenovela, or video soap opera, on health care professionals (HCPs)' awareness of caregivers' stress and patients' cultural approaches to end-of-life (EOL) care decisions. A multicenter cross-sectional study among three communities in New York, Miami, and Missouri. Participants from a convenience sample of multidisciplinary HCPs were randomly assigned to view power point presentation with either a control video or an intervention-telenovela about caregiving as part of a one-hour audiovisual seminar and completed a pre- and post-test questionnaire to evaluate reaction and learning. Participants (N = 142) were mostly female (80%) nurses (54%) with a mean age of 44.5 ± 12.4 years and from non-Hispanic white (41%) or Hispanics (37%) ethnicity. In both control and intervention groups, post-test responses demonstrated a high level (87%) of satisfaction with seminar and an increase in openness to discuss EOL issues with culturally diverse patients (P < 0.001). Although both groups reported post-test improvement in awareness of health literacy, cultural competency skills, cultural differences about EOL attitudes, family caregiver stress, and possible interventions, this improvement was significantly higher in the intervention group (P < 0.05) compared with the control group. The telenovela was effective in increasing health care workers' awareness of caregivers stress and cultural approach to EOL decisions. There is need for ongoing efforts to educate HCPs on cultural sensitivity to help ethnically diverse caregivers and their patients benefit from EOL care. Copyright © 2017. Published by Elsevier Inc.

Impact of End-of-Life Discussions on the Reduction of Latino/non-Latino Disparities in DNR Order Completion

PubMed Central

Shen, Megan Johnson; Prigerson, Holly G.; Paulk, Elizabeth; Trevino, Kelly M.; Penedo, Frank J.; Tergas, Ana I.; Epstein, Andrew S.; Neugut, Alfred I.; Maciejewski, Paul K.

2016-01-01

Background Latino, as compared to non-Latino, white advanced cancer patients are less likely to sign do-not-resuscitate (DNR) orders, which is a form of advance care planning associated with better quality of life at the end of life. Latinos’ completion of DNR orders may be more sensitive to clinical discussions about end-of-life (EOL) care. The present study examines differences between Latino and white terminally ill cancer patients in the association between EOL discussions and DNR order completion. Methods Participants (N=117) were Latino (n=61) and non-Latino, white (n=56) patients with advanced cancers recruited between 2002 and 2008 from Parkland Hospital, which is a public hospital in Dallas, TX, as part of the Coping with Cancer study, which is a large, multi-institutional, prospective cohort study of advanced cancer patients designed to examine social and psychological influences on EOL care. In structured interviews, patients reported if they had EOL discussions with their physicians, and if they completed DNR orders. Results The association between EOL discussions and DNR order completion was significantly greater in Latino than white patients, adjusting for potential confounds (interaction AOR=6.64, p=0.041). Latino patients who had an EOL discussion were over 10 times more likely (AOR=10.91, p=0.001) to complete a DNR order than those who had not, and equally as likely to complete a DNR order as white patients. Conclusions Differences in the impact of EOL discussions on DNR order completion may explain Latino/non-Latino ethnic disparities in DNR order completion in EOL care and point to a means to eliminate those disparities. PMID:26992109

Cultural and ethical considerations for cardiopulmonary resuscitation in chinese patients with cancer at the end of life.

PubMed

Zhang, Zhe; Chen, Meng-Lei; Gu, Xiao-Li; Liu, Ming-Hui; Cheng, Wen-Wu

2015-03-01

End-of-life (EOL) decision making is based on the values and wishes of terminally ill patients. However, little is known on the extent to which cultural factors affect personal attitudes toward life-sustaining treatments (LSTs) such as cardiopulmonary resuscitation (CPR) in China. This study evaluated the cultural and ethical considerations during EOL decisions and assessed the factors that affect pursuing LSTs in China. We used a case-control study design and compared their baseline characteristics with the provided EOL care and treatments. The CPR treatment among patients with cancer at EOL was affected by Chinese family traditions and Western influences. Our results reflect the need to improve EOL care and treatment in China. © The Author(s) 2014.

Family communication and decision making at the end of life: a literature review.

PubMed

Wallace, Cara L

2015-06-01

Patients and families coping with a terminal illness are faced with a number of decisions over the course of their disease. The role that family communication plays in the process of decision making is an important one. The objectives for this review are to examine the current state of empirical literature on the relationship between family communication and decision making about end-of-life care, to identify gaps, and to discuss implications for policy, practice, and future research. Articles were identified using systematic keyword searches within the following relevant databases: Academic Search Complete, CINAHL Plus, Communications and Mass Media Complete, ERIC, PsychINFO, MEDLINE, SocINDEX, and ProQuest. The three bodies of relevant literature that emerged during this review include: (1) the importance of family communication at the end of life (EoL); (2) family decision making at the EoL; and (3) the interrelationship of communication (both within the family and with healthcare professionals) and decision making at the EoL. While the literature highlights the role of communication between medical professionals and the patient or family members, there is very little focus on the process of how family communication among the family members themselves contributes to decision making at the end of life. Barriers to end-of-life care are important considerations for helping patients to access timely and appropriate services. Understanding the pertinent role of family communication as it relates to the decision for EoL care is the first step in working to provide another avenue for overcoming these barriers.

Impact of end-of-life discussions on the reduction of Latino/non-Latino disparities in do-not-resuscitate order completion.

PubMed

Shen, Megan Johnson; Prigerson, Holly G; Paulk, Elizabeth; Trevino, Kelly M; Penedo, Frank J; Tergas, Ana I; Epstein, Andrew S; Neugut, Alfred I; Maciejewski, Paul K

2016-06-01

Compared with non-Latino, white patients with advanced cancer, Latino patients with advanced cancer are less likely to sign do-not-resuscitate (DNR) orders, which is a form of advance care planning associated with better quality of life at the end of life (EOL). Latinos' completion of DNR orders may be more sensitive to clinical discussions regarding EOL care. The current study examined differences between Latino and white terminally ill patients with cancer with regard to the association between EOL discussions and DNR order completion. A total of 117 participants with advanced cancer (61 of whom were Latino and 56 of whom were non-Latino white individuals) were recruited between 2002 and 2008 from Parkland Hospital (a public hospital in Dallas, Texas) as part of the Coping with Cancer study, which is a large, multiinstitutional, prospective cohort study of patients with advanced cancer that is designed to examine social and psychological influences on EOL care. In structured interviews, patients reported if they had EOL discussions with their physicians, and if they completed DNR orders. The association between EOL discussions and DNR order completion was significantly greater in Latino compared with white patients, adjusting for potential confounds (interaction adjusted odds ratio, 6.64; P = .041). Latino patients who had an EOL discussion were >10 times more likely (adjusted odds ratio, 10.91; P = .001) to complete a DNR order than those who had not, and were found to be equally as likely to complete a DNR order as white patients. Differences in the impact of EOL discussions on DNR order completion may explain Latino/non-Latino ethnic disparities in DNR order completion in EOL care, and point to a means to eliminate those disparities. Cancer 2016;122:1749-56. © 2016 American Cancer Society. © 2016 American Cancer Society.

Inuit interpreters engaged in end-of-life care in Nunavik, Northern Quebec.

PubMed

Hordyk, Shawn Renee; Macdonald, Mary Ellen; Brassard, Paul

2017-01-01

Inuit interpreters are key players in end-of-life (EOL) care for Nunavik patients and families. This emotionally intensive work requires expertise in French, English and Inuit dialects to negotiate linguistic and cultural challenges. Cultural differences among medical institutions and Inuit communities can lead to value conflicts and moral dilemmas as interpreters navigate how best to transmit messages of care at EOL. Our goal was to understand the experience of Inuit interpreters in the context of EOL care in Nunavik in order to identify training needs. In the context of a larger ethnographic project on EOL care in Nunavik, we met with 24 current and former interpreters from local health centres and Montreal tertiary care contexts. Data included informal and formal interviews focusing on linguistic resources, experiences concerning EOL care, and suggestions for the development of interpretation training. Inuit working as interpreters in Nunavik are hired to provide multiple services of which interpretation plays only a part. Many have no formal training and have few resources (e.g. visual aids, dictionaries) to draw upon during medical consultations. Given the small size of communities, many interpreters personally know their clients and often feel overwhelmed by moral dilemmas when translating EOL information for patients and families. The concept of moral distress is a helpful lens to make sense of their experience, including personal and professional repercussions. Inuit interpreters in Nunavik are working with little training yet in context with multiple linguistic and cultural challenges. Linguistic and cultural resources and focused training on moral dilemmas unique to circumpolar contexts could contribute to improved work conditions and ultimately to patient care.​​​​.

Teaching End-of-Life Care Using Interprofessional Simulation.

PubMed

Gannon, Jane; Motycka, Carol; Egelund, Eric; Kraemer, Dale F; Smith, W Thomas; Solomon, Kathleen

2017-04-01

Competency in end-of-life (EOL) care is a growing expectation for health professions students. This study assessed the impact of four EOL care scenarios, using high-fidelity simulation, on the perceived learning needs and attitudes of pharmacy and nursing students. On three campuses, pharmacy students (N = 158) were exposed to standard paper EOL case scenarios, while a fourth campus exposed eight graduate nursing and 37 graduate pharmacy students to simulated versions of the same cases. The paper-based groups produced similar pre-post changes on the End of Life Professional Caregiver Survey. Results were pooled and compared with the simulation-only group, revealing significantly higher changes in pre-post scores for the simulation group. Students participating in the simulation group showed some significant differences in attitudes toward EOL care, compared with students in the classroom setting. [J Nurs Educ. 2017;56(4):205-210.]. Copyright 2017, SLACK Incorporated.

Exploring Health Care Providers' Views About Initiating End-of-Life Care Communication.

PubMed

Nedjat-Haiem, Frances R; Carrion, Iraida V; Gonzalez, Krystana; Ell, Kathleen; Thompson, Beti; Mishra, Shiraz I

2017-05-01

Numerous factors impede effective and timely end-of-life (EOL) care communication. These factors include delays in communication until patients are seriously ill and/or close to death. Gaps in patient-provider communication negatively affect advance care planning and limit referrals to palliative and hospice care. Confusion about the roles of various health care providers also limits communication, especially when providers do not coordinate care with other health care providers in various disciplines. Although providers receive education regarding EOL communication and care coordination, little is known about the roles of all health care providers, including nonphysician support staff working with physicians to discuss the possibility of dying and help patients prepare for death. This study explores the perspectives of physicians, nurses, social workers, and chaplains on engaging seriously ill patients and families in EOL care communication. Qualitative data were from 79 (medical and nonmedical) providers practicing at 2 medical centers in Central Los Angeles. Three themes that describe providers' perceptions of their roles and responsibility in talking with seriously ill patients emerged: (1) providers' roles for engaging in EOL discussions, (2) responsibility of physicians for initiating and leading discussions, and (3) need for team co-management patient care. Providers highlighted the importance of beginning discussions early by having physicians lead them, specifically due to their medical training and need to clarify medical information regarding patients' prognosis. Although physicians are a vital part of leading EOL communication, and are at the center of communication of medical information, an interdisciplinary approach that involves nurses, social workers, and chaplains could significantly improve patient care.

Residential aged care residents and components of end of life care in an Australian hospital.

PubMed

Leong, Laurence Jee Peng; Crawford, Gregory Brian

2018-06-09

With ageing of Australians, the numbers of residential aged care (RAC) residents is rising. This places a spotlight on decisions about appropriate care for this population, including hospitalisation and end-of-life (EOL) care. The aim was to study a sample of RAC residents who attended and died in hospital, to quantify measurable components of EOL care so as to describe the extent of palliative care required. A retrospective case-note review of hospital records was conducted in Adelaide, Australia. Participants were 109 RAC residents who attended from July 2013 to June 2014 and died in hospital. Measurements were advance care planning, health care input from the RAC facilities to hospital and components of EOL care. Residents with and without advanced dementia were compared. Advance care directives (ACDs) were present from 11 to 50%, and advance care plans (ACPs) at 60%. There were more ACPs, resuscitation orders (for/against) and do-not-hospitalise orders in residents with advanced dementia than those without. General practitioner (GP) and extended care paramedic (ECP) input on decisions for hospital transfer were 30% and 1 %. Mean hospital stay to death was 5.2 days. For residents admitted under non-palliative care teams, specialist palliative care (SPC) was needed for phone advice in 5%, consultation in 45%, transfer to palliative care unit in 37%, and takeover by SPC team in 19%. Mean number of documented goals-of-care discussions with family/caregiver was 1.7. In the last 3 days of life, the mean daily number of doses of EOL medications was 4.2. Continuous subcutaneous infusion was commenced in 35%. Staff in RAC need to be adequately resourced to make complex decisions about whether to transfer to hospital. RAC nurses are mainly making these decisions as GP and ECP input were suboptimal. Ways to support nurses and optimise decision-making are needed. Advance care planning can be improved, especially documentation of EOL wishes and hospitalisation orders. By describing the components of EOL care, it is hoped providers and policy makers have more information to assist with making decisions about what is the most appropriate care for this population.

The end-of-life phase of high-grade glioma patients: dying with dignity?

PubMed

Sizoo, Eefje M; Taphoorn, Martin J B; Uitdehaag, Bernard; Heimans, Jan J; Deliens, Luc; Reijneveld, Jaap C; Pasman, H Roeline W

2013-01-01

In the end-of-life (EOL) phase, high-grade glioma (HGG) patients have a high symptom burden and often lose independence because of physical and cognitive dysfunction. This might affect the patient's personal dignity. We aimed to (a) assess the proportion of HGG patients dying with dignity as perceived by their relatives and (b) identify disease and care factors correlated with dying with dignity in HGG patients. We approached relatives of a cohort of 155 deceased HGG patients for the study. Participants completed a questionnaire concerning the EOL phase of the patient, covering several subthemes: (a) symptoms and signs, (b) health-related quality of life, (c) decision making, (d) place and quality of EOL care, and (e) dying with dignity. Relatives of 81 patients participated and 75% indicated that the patient died with dignity. These patients had fewer communication deficits, experienced fewer transitions between health care settings in the EOL phase, and more frequently died at their preferred place of death. Relatives were more satisfied with the physician providing EOL care and reported that the physician adequately explained treatment options. Multivariate analysis identified satisfaction with the physician, the ability to communicate, and the absence of transitions between settings as most predictive of a dignified death. Physicians caring for HGG patients in the EOL phase should timely focus on explaining possible treatment options, because patients experience communication deficits toward death. Physicians should strive to allow patients to die at their preferred place and avoid transitions during the last month of life.

Survey of neonatologists' attitudes toward limiting life-sustaining treatments in the neonatal intensive care unit.

PubMed

Feltman, D M; Du, H; Leuthner, S R

2012-11-01

To understand neonatologists' attitudes toward end-of-life (EOL) management in clinical scenarios, EOL ethical concepts and resource utilization. American Academy of Pediatrics (AAP) Perinatal section members completed an anonymous online survey. Respondents indicated preferences in limiting life-sustaining treatments in four clinical scenarios, ranked agreement with EOL-care ethics statements, indicated outside resources previously used and provided demographic information. In all, 451 surveys were analyzed. Across clinical scenarios and as general ethical concepts, withdrawal of mechanical ventilation in severely affected patients was most accepted by respondents; withdrawal of artificial nutrition and hydration was least accepted. One-third of neonatologists did not agree that non-initiation of treatment is ethically equivalent to withdrawal. Around 20% of neonatologists would not defer care if uncomfortable with a parent's request. Respondents' resources included ethics committees, AAP guidelines and legal counsel/courts. Challenges to providing just, unified EOL care strategies are discussed, including deferring care, limiting artificial nutrition/hydration and conditions surrounding ventilator withdrawal.

Engaging Physician Learners Through a Web-Based Platform: Individualized End-of-Life Education.

PubMed

Bergman, Jonathan; Ballon-Landa, Eric; Lerman, Steven E; Kwan, Lorna; Bennett, Carol J; Litwin, Mark S

2016-09-01

Web-based modules provide a convenient and low-cost education platform, yet should be carefully designed to ensure that learners are actively engaged. In order to improve attitudes and knowledge in end-of-life (EOL) care, we developed a web-based educational module that employed hyperlinks to allow users access to auxiliary resources: clinical guidelines and seminal research papers. Participants took pre-test evaluations of attitudes and knowledge regarding EOL care prior to accessing the educational module, and a post-test evaluation following the module intervention. We recorded the type of hyperlinks (guideline or paper) accessed by learners, and stratified participants into groups based on link type accessed (none, either, or both). We used demographic and educational data to develop a multivariate mixed-effects regression analysis to develop adjusted predictions of attitudes and knowledge. 114 individuals participated. The majority had some professional exposure to EOL care (prior instruction 62%; EOL referral 53%; EOL discussion 56%), though most had no family (68%) or personal experience (51%). On bivariate analysis, non-partnered (p = .04), medical student training level (p = .03), prior palliative care referral (p = .02), having a family member (p = .02) and personal experience of EOL care (p < .01) were all associated with linking to auxiliary resources via hyperlinks. When adjusting for confounders, β coefficient estimates and least squares estimation demonstrated that participants clicking on both hyperlink types were more likely to score higher on all knowledge and attitude items, and demonstrate increased score improvements. Auxiliary resources accessible by hyperlink are an effective adjunct to web-based learning in end-of-life care. © The Author(s) 2015.

Advance care planning in patients with incurable cancer: study protocol for a randomised controlled trial.

PubMed

Johnson, Stephanie; Clayton, Josephine; Butow, Phyllis N; Silvester, William; Detering, Karen; Hall, Jane; Kiely, Belinda E; Cebon, Jonathon; Clarke, Stephen; Bell, Melanie L; Stockler, Martin; Beale, Phillip; Tattersall, Martin H N

2016-12-01

There is limited evidence documenting the effectiveness of Advance Care Planning (ACP) in cancer care. The present randomised trial is designed to evaluate whether the administration of formal ACP improves compliance with patients' end-of-life (EOL) wishes and patient and family satisfaction with care. A randomised control trial in eight oncology centres across New South Wales and Victoria, Australia, is designed to assess the efficacy of a formal ACP intervention for patients with cancer. Patients with incurable cancer and an expected survival of 3-12 months, plus a nominated family member or friend will be randomised to receive either standard care or standard care plus a formal ACP intervention. The project sample size is 210 patient-family/friend dyads. The primary outcome measure is family/friend-reported: (1) discussion with the patient about their EOL wishes and (2) perception that the patient's EOL wishes were met. Secondary outcome measures include: documentation of and compliance with patient preferences for medical intervention at the EOL; the family/friend's perception of the quality of the patient's EOL care; the impact of death on surviving family; patient-family and patient-healthcare provider communication about EOL care; patient and family/friend satisfaction with care; quality of life of patient and family/friend subsequent to trial entry, the patient's strength of preferences for quality of life and length of life; the costs of care subsequent to trial entry and place of death. Ethical approval was received from the Sydney Local Health District (RPA Zone) Human Research Ethical Committee, Australia (Protocol number X13-0064). Study results will be submitted for publication in peer-reviewed journals and presented at national and international conferences. Pre-results; ACTRN12613001288718. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Overcoming barriers in care for the dying: Theoretical analysis of an innovative program model.

PubMed

Wallace, Cara L

2016-08-01

This article explores barriers to end-of-life (EOL) care (including development of a death denying culture, ongoing perceptions about EOL care, poor communication, delayed access, and benefit restrictions) through the theoretical lens of symbolic interactionism (SI), and applies general systems theory (GST) to a promising practice model appropriate for addressing these barriers. The Compassionate Care program is a practice model designed to bridge gaps in care for the dying and is one example of a program offering concurrent care, a recent focus of evaluation though the Affordable Care Act. Concurrent care involves offering curative care alongside palliative or hospice care. Additionally, the program offers comprehensive case management and online resources to enrollees in a national health plan (Spettell et al., 2009).SI and GST are compatible and interrelated theories that provide a relevant picture of barriers to end-of-life care and a practice model that might evoke change among multiple levels of systems. These theories promote insight into current challenges in EOL care, as well as point to areas of needed research and interventions to address them. The article concludes with implications for policy and practice, and discusses the important role of social work in impacting change within EOL care.

NNP education in neonatal end-of-life care: a needs assessment.

PubMed

Botwinski, Carol

2010-01-01

To determine from practicing neonatal nurse practitioners (NNPs) their perceived end-of-life (EOL) care learning needs. A needs assessment-based evaluation methodology was used to answer the research questions. A neonatal EOL needs assessment survey was developed, pilot tested, and then mailed to 260 NNPs across the United States. NNPs in clinical practice regarded their education on EOL for neonates and their families as inadequate. Twenty-three percent ranked "delivery room decisions to resuscitate infants considered at edge of viability" as the item for which they most wanted more training. The other top-ranked EOL items included balance between giving parents false hopes and removing all hopes, and communicating and giving bad news to families. Based on these findings, specific neonatal EOL education and communication skill workshops are warranted for graduate nursing core and advance practice continuing education courses. Additionally, there needs to be a mechanism to provide EOL content and support for the NNP already in clinical practice; it is suggested that learning about EOL issues can be integrated into existing (continuing nursing education CNE) educational activities. Further research is needed on what issues, tools, and methods in CNE programs make a difference in the experience of NNPs.

End of Life: An Overview

ERIC Educational Resources Information Center

Toner, Mary Ann; Shadden, Barbara B.

2012-01-01

Speech-language pathologists (SLPs) provide services to patients confronting the end of life (EOL) in a variety of settings. Instead of targeting improvement of health or sustaining life, EOL services focus primarily on quality of life. Although SLPs may not consider themselves core members of the health care team providing EOL services, the…

End-of-life care research in Hong Kong: A systematic review of peer-reviewed publications.

PubMed

Wang, Chong-Wen; Chan, Cecilia L W

2015-12-01

This systematic review aimed to examine end-of-life (EoL) care research undertaken in an Eastern cultural context--Hong Kong--with the hope of better informing EoL care professionals and policy makers and providing lessons for other countries or areas that share similar EoL care challenges. Eight databases were searched from their respective inception through to August of 2014. All of the resulting studies conducted in Hong Kong and relevant to EoL care or palliative care were examined. The included studies were assessed with respect to study design, care settings, participants, research themes, and major findings. Some 107 publications published between 1991 and 2014 were identified. These studies were undertaken at a range of places by different professionals. Of the total, 44 were led by physicians, 36 by nurses, 17 by social workers, and 10 by other professionals. Participants included both inpatients and outpatients with different illnesses, nursing home residents, older community-dwelling adults, deceased individuals, care staff, and informal caregivers. A total of 13 research themes were identified: (1) attitudes to or perceptions of death and dying; (2) utilization of healthcare services, (3) physical symptoms or medical problems; (4) death anxiety or mental health issues; (5) quality of life; (6) advance directives or advance care planning; (7) supportive care needs, (8) decision making; (9) spirituality; (10) cost-effectiveness or utility studies; (11) care professionals' education and training; (12) informal caregivers' perceptions and experience; and (13) scale development or validation. While there has been a wide and diverse range of research activities in Hong Kong, EoL care services at primary care settings should be strengthened. Some priority areas for further research are recommended.

Administrators' perspectives on end-of-life care for cancer patients in Japanese long-term care facilities.

PubMed

Fukahori, Hiroki; Miyashita, Mitsunori; Morita, Tatsuya; Ichikawa, Takayuki; Akizuki, Nobuya; Akiyama, Miki; Shirahige, Yutaka; Eguchi, Kenji

2009-10-01

The purpose of this study was to clarify administrators' perspectives on availability of recommended strategies for end-of-life (EOL) care for cancer patients at long-term care (LTC) facilities in Japan. A cross-sectional survey was conducted with administrators at Japanese LTC facilities. Participants were surveyed about their facilities, reasons for hospitalization of cancer patients, and their perspectives on availability of and strategies for EOL care. The 97 responses were divided into medical facility (n = 24) and non-medical facility (n = 73) groups according to physician availability. The most frequent reasons for hospitalization were a sudden change in patient's condition (49.4%), lack of around-the-clock care (43.0%), and inability to palliate symptoms (41.0%). About 50% of administrators believed their facilities could provide EOL care if supported by palliative care experts. There was no significant difference between facility types (P = 0.635). Most administrators (81.2%) regarded unstable cancer patients as difficult to care for. However, many (68.4%) regarded opioids given orally as easy to administer, but regarded continuous subcutaneous infusion/central venous nutrition as difficult. Almost all administrators believed the most useful strategy was transferring patients to hospitals at the request of patients or family members (96.9%), followed by consultation with palliative care experts (88.5%). Although LTC facilities in Japan currently do not provide adequate EOL care for cancer patients, improvement might be possible with support by palliative care teams. Appropriate models are necessary for achieving a good death for cancer patients. Interventions based on these models are necessary for EOL care for cancer patients in LTC facilities.

Providing grief resolution as an oncology nurse retention strategy: a literature review.

PubMed

Hildebrandt, Lori

2012-12-01

Oncology nurses play a pivotal role in optimizing care provided to patients at the end of life (EOL). Although oncology nurses commonly provide EOL care and witness deaths of patients that they have maintained long-standing relationships with, they are frequently excluded from grief resolution endeavors. With a worldwide shortage of oncology nurses, retention is paramount to ensuring that the care patients with cancer receive is not jeopardized. Various strategies were identified to resolve grief and increase nurse retention, including creating supportive work environments, debriefing with colleagues, providing EOL and grief education, and altering patient care assignments. Future research on emerging technologies and their effects on oncology nurse coping and retention strategies also was suggested.

Family factors affect clinician attitudes in pediatric end-of-life decision making: a randomized vignette study.

PubMed

Ruppe, Michael D; Feudtner, Chris; Hexem, Kari R; Morrison, Wynne E

2013-05-01

Conflicts between families and clinicians in pediatric end-of-life (EOL) care cause distress for providers, dissatisfaction for patients' families, and potential suffering for terminally ill children. We hypothesized that family factors might influence clinician decision making in these circumstances. We presented vignettes concerning difficult EOL decision making, randomized for religious objection to therapy withdrawal and perceived level of family involvement, to clinicians working in three Children's Hospital intensive care units. Additionally, attitudes about EOL care were assessed. Three hundred sixty-four respondents completed the questionnaire, for an overall response rate of 54%. Respondents receiving the "involved family" vignette were more likely to agree to continue medical care indefinitely (P<0.0005). Respondents were marginally more likely to pursue a court-appointed guardian for those patients whose families had nonreligious objections to withdrawal (P=0.05). Respondents who thought that a fear of being sued affected decisions were less likely to pursue unilateral withdrawal (odds ratio 0.8, 95% CI=0.6-0.9). Those who felt personal distress as a result of difficult EOL decision making, thought they often provided "futile" care, or those who felt EOL care was effectively addressed at the institution were less likely to want to defer to the parents' wishes (range of odds ratios 0.7-1). In this randomized vignette study, we have shown that family factors, particularly how involved a family seems to be in a child's life, affect what clinicians think is ethically appropriate in challenging EOL cases. Knowledge of how a family's degree of involvement may affect clinicians should be helpful to the clinical ethics consultants and offer some degree of insight to the clinicians themselves. Copyright © 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

The End-of-Life Phase of High-Grade Glioma Patients: Dying With Dignity?

PubMed Central

Taphoorn, Martin J.B.; Uitdehaag, Bernard; Heimans, Jan J.; Deliens, Luc; Reijneveld, Jaap C.; Pasman, H. Roeline W.

2013-01-01

Background. In the end-of-life (EOL) phase, high-grade glioma (HGG) patients have a high symptom burden and often lose independence because of physical and cognitive dysfunction. This might affect the patient's personal dignity. We aimed to (a) assess the proportion of HGG patients dying with dignity as perceived by their relatives and (b) identify disease and care factors correlated with dying with dignity in HGG patients. Methods. We approached relatives of a cohort of 155 deceased HGG patients for the study. Participants completed a questionnaire concerning the EOL phase of the patient, covering several subthemes: (a) symptoms and signs, (b) health-related quality of life, (c) decision making, (d) place and quality of EOL care, and (e) dying with dignity. Results. Relatives of 81 patients participated and 75% indicated that the patient died with dignity. These patients had fewer communication deficits, experienced fewer transitions between health care settings in the EOL phase, and more frequently died at their preferred place of death. Relatives were more satisfied with the physician providing EOL care and reported that the physician adequately explained treatment options. Multivariate analysis identified satisfaction with the physician, the ability to communicate, and the absence of transitions between settings as most predictive of a dignified death. Conclusions. Physicians caring for HGG patients in the EOL phase should timely focus on explaining possible treatment options, because patients experience communication deficits toward death. Physicians should strive to allow patients to die at their preferred place and avoid transitions during the last month of life. PMID:23335620

Improving the quality of end-of-life discussions.

PubMed

Myers, Jeff

2015-03-01

This article provides an update on the recent research and evidence regarding quality in end-of-life (EOL) discussions with a focus on the care of a person with cancer. Clinicians have the challenging task of customizing the information exchange that occurs during an EOL discussion. Patients identify important stipulations that accompany a desire for frank EOL discussions. These include timing of the discussion, ensuring evaluation of readiness to engage in the EOL discussion, and being invited to participate. The timing of an EOL discussion is likely to be more important than the setting in which an EOL discussion occurs. Less than 1 month prior to a person's death is likely to be an inadequate amount of time to allow a patient to consider and reflect on his or her EOL preferences. Among those admitted to the hospital, delay in the timing of EOL discussions carries the risk of losing decision-making capacity. There is greater use of quality metrics as patient outcomes among studies examining EOL discussions. System-wide approaches to improving EOL discussions should include standardized documentation templates that are widely accessible in electronic medical records.

Hospice in Assisted Living: Promoting Good Quality Care at End of Life

ERIC Educational Resources Information Center

Cartwright, Juliana C.; Miller, Lois; Volpin, Miriam

2009-01-01

Purpose: The purpose of this study was to describe good quality care at the end of life (EOL) for hospice-enrolled residents in assisted living facilities (ALFs). Design and Methods: A qualitative descriptive design was used to obtain detailed descriptions of EOL care provided by ALF medication aides, caregivers, nurses, and hospice nurses in…

Strengthening Nursing Education To Improve End-of-life Care.

ERIC Educational Resources Information Center

Ferrell, Betty R.; Virani, Rose; Grant, Marcia

1999-01-01

As the members of the health care team who spend the most time with patients who are facing death, nurses are aware of the need for improved end-of-life (EOL) care and have identified resources to achieve that goal by improving education. A survey of 725 nursing faculty and state boards indicates an awareness of the need for improved EOL care and…

Communication During Palliative Care and End of Life: Perceptions of Experienced Pediatric Oncology Nurses.

PubMed

Montgomery, Kathleen E; Sawin, Kathleen J; Hendricks-Ferguson, Verna

Communication between patients, families, and healthcare providers is a central component of end-of-life care. Nurse communication during palliative care (PC) and end of life (EOL) is a phenomenon with limited research. It is unclear how the level of nursing experience influences the perspectives of nurses communicating during EOL. The aim of this study is to describe the commonalities of experienced nurses' perceptions of communicating during PC and EOL and perceptions of barriers and facilitators to effective communication. This study was part of a larger multisite study that used a qualitative, empirical phenomenology design and represents focus group data gathered from pediatric oncology nurses with more than 5 years of experience or who were advanced practice nurses not involved in the direct evaluation of other nurses. Five core themes with corresponding themes and subthemes were identified. The core themes included (a) Evolution of PC/EOL, (b) Skill of Knowing, (c) Expanded Essence of Caring, (d) Experienced Nurse as Committed Advocate, and (e) Valuing Individual Response to Grief. Findings reflect how the concept of experience transcended the 5 core themes and captured how experience provided nurses the know-how to fulfill the roles of communication, caring, and advocacy for children and families. Enhancing nurse communication skills during EOL requires opportunities to gain experience coupled with clinical strategies, such as standardized curricula, simulation, competency-based orientation programs, mentorship, and peer support.

Measuring End-of-Life Care Processes in Nursing Homes

ERIC Educational Resources Information Center

Temkin-Greener, Helena; Zheng, Nan; Norton, Sally A.; Quill, Timothy; Ladwig, Susan; Veazie, Peter

2009-01-01

Purpose: The objectives of this study were to develop measures of end-of-life (EOL) care processes in nursing homes and to validate the instrument for measuring them. Design and Methods: A survey of directors of nursing was conducted in 608 eligible nursing homes in New York State. Responses were obtained from 313 (51.5% response rate) facilities.…

The economic burden of end-of-life care in metastatic breast cancer.

PubMed

Bramley, Thomas; Antao, Vincent; Lunacsek, Orsolya; Hennenfent, Kristin; Masaquel, Anthony

2016-11-01

To assess end-of-life (EOL) total healthcare costs and resource utilization during the last 6 months of claims follow-up among patients with metastatic breast cancer (MBC) who received systemic anti-neoplastic therapy. Newly diagnosed females with MBC initiating treatment January 1, 2003-June 30, 2011 were identified in a large commercial claims database. Two cohorts were defined based on a proxy measure for EOL 1 month prior to the end of last recorded follow-up within the study period: patients who were assumed dead at end of claims follow-up (EOL cohort) and patients who were alive (no-end-of-life [NEOL] cohort). Proxy measures for EOL were obtained from published literature and clinical expert opinion. Cost and resource utilization were evaluated for the 6 months prior to end of claims follow-up. Baseline variables, resource utilization, and costs were compared between cohorts with univariate statistical tests. Adjusted relative risks were calculated for resource utilization measures. A covariate-adjusted generalized linear model evaluated 6-month total healthcare costs. Of the 3,878 females included, 18.5% (n = 718) met the criteria for EOL. Mean observational time (MBC onset to end of claims follow-up) was shorter for the EOL cohort (EOL, 32 months vs NEOL, 35 months; p < 0.001). In adjusted analyses, the EOL cohort had 4.15 times higher 6-month total healthcare costs (EOL, $72,112 vs NEOL, $17,137; p < 0.001). NEOL month-to-month mean total healthcare costs fluctuated between $2336-$3145, while EOL costs increased steadily from $8,956 in the sixth month prior to death to $19,326 in the last month of life. The adjusted relative risk of inpatient, hospice and emergency department utilization was >2 times higher in the EOL cohort (p < 0.001). Potential EOL presented a greater economic burden in the 6 months prior to death. EOL month-to-month costs increased precipitously in the last 2 months of life and were driven by acute inpatient care.

Peace, Equanimity, and Acceptance in the Cancer Experience (PEACE): Validation of a scale to assess acceptance and struggle with terminal illness

PubMed Central

Mack, Jennifer W.; Nilsson, Matthew; Balboni, Tracy; Friedlander, Robert J.; Block, Susan D.; Trice, Elizabeth; Prigerson, Holly G.

2013-01-01

Objectives The role of emotional acceptance of a terminal illness in end-of-life (EOL) care is not known. We developed a measure of peaceful acceptance at the EOL, and evaluated the role of peaceful acceptance in EOL decision-making and care. Methods We developed the Peace, Equanimity, and Acceptance in the Cancer Experience (PEACE) questionnaire to measure the extent to which patients with advanced cancer feel a sense of peaceful acceptance of their terminal illness. The scale was administered to 160 advanced cancer patients along with measures of other attributes hypothesized to be related to acceptance, including cognitive acceptance of terminal illness. EOL outcomes in 56 patients who died during the study were also examined. Results The 12-item PEACE questionnaire had two subscales: a 7-item Struggle with Illness (Cronbach's α =.81) and a 5-item Peaceful Acceptance (α = .78) subscale. Both subscales were associated with patients’ self-reported peacefulness (r=.66 for acceptance, P<.0001; r=−.37 for struggle, P<.0001.) Struggle with Illness scores were associated with cognitive terminal illness acknowledgement (mean scores 14.9 versus 12.4, P=.001) and some aspects of advance care planning (living will or health care proxy, mean scores 13.9 versus 11.5, P=.02). In addition, among patients who had died, use of a feeding tube at the EOL was inversely associated with Peaceful Acceptance (P=.015). Conclusion The PEACE questionnaire is a valid and reliable measure of Peaceful Acceptance and Struggle with Illness. Scores are associated with some choices for EOL care among patients with advanced cancer. PMID:18429006

A Qualitative Examination of Physician Gender and Parental Status in Pediatric End-of-Life Communication.

PubMed

Bateman, Lori Brand; White, Marjorie Lee; Tofil, Nancy M; Clair, Jeffrey Michael; Needham, Belinda L

2017-07-01

In this study we utilized the framework of patient-centered communication to explore the influence of physician gender and physician parental status on (1) physician-parent communication and (2) care of pediatric patients at the end of life (EOL). The findings presented here emerged from a larger qualitative study that explored physician narratives surrounding pediatric EOL communication. The current study includes 17 pediatric critical care and pediatric emergency medicine physician participants who completed narrative interviews between March and October 2012 to discuss how their backgrounds influenced their approaches to pediatric EOL communication. Between April and June of 2013, participants completed a second round of narrative interviews to discuss topics generated out of the first round of interviews. We used grounded theory to inform the design and analysis of the study. Findings indicated that physician gender is related to pediatric EOL communication and care in two primary ways: (1) the level of physician emotional distress and (2) the way physicians perceive the influence of gender on communication. Additionally, parental status emerged as an important theme as it related to EOL decision-making and communication, emotional distress, and empathy. Although physicians reported experiencing more emotional distress related to interacting with patients at the EOL after they became parents, they also felt that they were better able to show empathy to parents of their patients.

Preparation for frontline end-of-life care: exploring the perspectives of paramedics and emergency medical technicians.

PubMed

Waldrop, Deborah P; Clemency, Brian; Maguin, Eugene; Lindstrom, Heather

2014-03-01

Prehospital emergency providers (emergency medical technicians [EMTs] and paramedics) who respond to emergency calls for patients near the end of life (EOL) make critical decisions in the field about initiating care and transport to an emergency department. To identify how a sample of prehospital providers learned about EOL care, their perceived confidence with and perspectives on improved preparation for such calls. This descriptive study used a cross-sectional survey design with mixed methods. One hundred seventy-eight prehospital providers (76 EMT-basics and 102 paramedics) from an emergency medical services agency participated. Multiple choice and open-ended survey questions addressed how they learned about EOL calls, their confidence with advance directives, and perspectives on improving care in the field. The response rate was 86%. Education about do-not-resuscitate (DNR) orders was formal (92%), experiential (77%), and self-directed (38%). Education about medical orders for life-sustaining treatment (MOLST) was formal (72%), experiential (67%), and self-directed (25%). Ninety-three percent were confident in upholding a DNR order, 87% were confident interpreting MOLST, and 87% were confident sorting out conflict between differing patient and family wishes. Qualitative data analysis yielded six themes on improving preparation of prehospital providers for EOL calls: (1) prehospital provider education; (2) public education; (3) educating health care providers on scope of practice; (4) conflict resolution skills; (5) handling emotional families; and (6) clarification of transfer protocols. These study results suggest the need for addressing the potential interrelationship between prehospital and EOL care through improved education and protocols for care in the field.

Experiences and Opinions Related to End-of-Life Discussion: From Oncologists' and Resident Physicians' Perspectives.

PubMed

Koh, Su-Jin; Kim, Shinmi; Kim, JinShil; Keam, Bhumsuk; Heo, Dae Seog; Lee, Kyung Hee; Kim, Bong-Seog; Kim, Jee Hyun; Chang, Hye Jung; Baek, Sun Kyung

2018-04-01

The aims of this study were to explore how oncologists and resident physicians practice end-of-life (EOL) discussions and to solicit their opinions on EOL discussions as a means to improve the quality of EOL care. A survey questionnaire was developed to explore the experiences and opinions about EOL discussions among oncologists and residents. Descriptive statistics, the t test, and the chisquare test were performed for the analyses. A total of 147 oncologists and 229 residents participated in this study. The study respondents reported diverse definitions of "terminal state," and mostrespondents tried to disclose the patient's condition to the patient and/or family members. Both groups were involved in EOL care discussions, with a rather low satisfaction level (57.82/100). The best timing to initiate discussionwas consideredwhen metastasis or disease recurrence occurred orwhen withdrawal of chemotherapy was anticipated. Furthermore, the study respondents suggested that patients and their family members should be included in the EOL discussion. Medical, legal, and ethical knowledge and communication difficulties along with practical issues were revealed as barriers and facilitators for EOL discussion. This study explored various perspectives of oncologists and resident physicians for EOL discussion. Since the Life-Sustaining-Treatment Decision-Making Act will be implemented shortly in Korea, now is the time for oncologists and residents to prepare themselves by acquiring legal knowledge and communication skills. To achieve this, education, training, and clinical tools for healthcare professionals are required.

Experiences and Opinions Related to End-of-Life Discussion: From Oncologists' and Resident Physicians' Perspectives

PubMed Central

Koh, Su-Jin; Kim, Shinmi; Kim, JinShil; Keam, Bhumsuk; Heo, Dae Seog; Lee, Kyung Hee; Kim, Bong-Seog; Kim, Jee Hyun; Chang, Hye Jung; Baek, Sun Kyung

2018-01-01

Purpose The aims of this study were to explore how oncologists and resident physicians practice end-of-life (EOL) discussions and to solicit their opinions on EOL discussions as a means to improve the quality of EOL care. Materials and Methods A survey questionnaire was developed to explore the experiences and opinions about EOL discussions among oncologists and residents. Descriptive statistics, the t test, and the chisquare test were performed for the analyses. Results A total of 147 oncologists and 229 residents participated in this study. The study respondents reported diverse definitions of “terminal state,” and mostrespondents tried to disclose the patient’s condition to the patient and/or family members. Both groups were involved in EOL care discussions, with a rather low satisfaction level (57.82/100). The best timing to initiate discussionwas consideredwhen metastasis or disease recurrence occurred orwhen withdrawal of chemotherapy was anticipated. Furthermore, the study respondents suggested that patients and their family members should be included in the EOL discussion. Medical, legal, and ethical knowledge and communication difficulties along with practical issues were revealed as barriers and facilitators for EOL discussion. Conclusion This study explored various perspectives of oncologists and resident physicians for EOL discussion. Since the Life-Sustaining-Treatment Decision-Making Act will be implemented shortly in Korea, now is the time for oncologists and residents to prepare themselves by acquiring legal knowledge and communication skills. To achieve this, education, training, and clinical tools for healthcare professionals are required. PMID:28675025

Exploring Advance Care Planning in Taiwanese Indigenous Cancer Survivors: Proposal for a Pilot Case-Control Study.

PubMed

Li, In-Fun; Hsiung, Yvonne

2017-12-21

Research on Taiwanese indigenous cancer survivors' end-of-life (EOL) planning is still in its infancy, despite recent government and societal efforts to promote quality EOL care. Previous national studies in Taiwan have characterized indigenous peoples as a socioeconomically disadvantaged minority group. Compared with their mainstream cohorts, these remote residents are vulnerable to multiple social welfare problems, receiving and accessing little in the way of health care in rural mountain areas. Although advance care planning (ACP) has been shown to help patients achieve better quality of dying, very little is known about indigenous intentions for such interventions. Relevant studies are scarce in Taiwan, and programs for cancer survivors have been based almost entirely on nonindigenous populations. Since there has been no research on Taiwanese indigenous people's aims for ACP, there is a need to understand the impact of survivorship on ACP readiness among those who are currently living with, through, and beyond cancer. We aim to identify differences in ACP intent and readiness among indigenous peoples with and without cancer diagnoses. We will identify the impact of factors such as tribal cultural beliefs and quality of life along with cancer exposure on the outcome of ACP readiness differences. In particular, we will examine the effects of ACP knowledge from previous ACP participation, EOL care experiences, and personal registry status of Do-Not-Resuscitate (DNR) in the national database. A secondary objective is to describe indigenous people's intent to participate in public education related to EOL planning. A descriptive case-control study (N=200) is proposed where controls are matched to cases' attributes of age, gender, and cancer diagnosis. This matching analysis allows assessment of cancer as an exposure while taking into account age and gender as confounding variables. We are currently in the process of training personnel and extracting clinical and administrative information from the health care system of collaborating facilities. This carefully designed study provides a unique opportunity because for the first time in Taiwan, cancer survivorship and ACP readiness for EOL planning will be examined among difficult-to-reach indigenous peoples. We plan to complete this study in approximately 3 years. In this study, we expect to survey palliative care usage in the remote indigenous group, understand factors that influence ACP readiness, and later foster culturally appropriate ACP public participation and policies in order to facilitate collaboration between cancer health care providers in various Taiwanese subcultures. ©In-Fun Li, Yvonne Hsiung. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 21.12.2017.

A pan-European survey of research in end-of-life cancer care.

PubMed

Sigurdardottir, Katrin Ruth; Haugen, Dagny Faksvåg; Bausewein, Claudia; Higginson, Irene J; Harding, Richard; Rosland, Jan Henrik; Kaasa, Stein

2012-01-01

To date, there is no coordinated strategy for end-of-life (EOL) cancer care research in Europe. The PRISMA (Reflecting the Positive Diversities of European Priorities for Research and Measurement in End-of-life Care) project is aiming to develop a programme integrating research and measurement in EOL care. This survey aimed to map and describe present EOL cancer care research in Europe and to identify priorities and barriers. A questionnaire of 62 questions was developed and 201 researchers in 41 European countries were invited to complete it online in May 2009. An open invitation to participate was posted on the internet. Invited contacts in 36 countries sent 127 replies; eight additional responses came through websites. A total of 127 responses were eligible for analysis. Respondents were 69 male and 58 female, mean age 49 (28-74) years; 85% of the scientific team leaders were physicians. Seventy-one of 127 research groups were located in a teaching hospital or cancer centre. Forty-five percent of the groups had only one to five members and 28% six to ten members. Sixty-three of 92 groups reported specific funding for EOL care research. Seventy-five percent of the groups had published papers in journals with impact factor ≤ 5 in the last 3 years; 8% had published in journals with impact factor >10. Forty-four out of 90 groups reported at least one completed Ph.D. in the last 3 years. The most frequently reported active research areas were pain, assessment and measurement tools, and last days of life and quality of death. Very similar areas--last days of life and quality of death, pain, fatigue and cachexia, and assessment and measurement tools--were ranked as the most important research priorities. The most important research barriers were lack of funding, lack of time, and insufficient knowledge/expertise. Most research groups in EOL care are small. The few large groups (14%) had almost half of the reported publications, and more than half of the current Ph.D. students. There is a lack of a common strategy and coordination in EOL cancer care research and a great need for international collaboration.

Engaging Terminally Ill Patients in End of Life Talk: How Experienced Palliative Medicine Doctors Navigate the Dilemma of Promoting Discussions about Dying.

PubMed

Pino, Marco; Parry, Ruth; Land, Victoria; Faull, Christina; Feathers, Luke; Seymour, Jane

2016-01-01

To examine how palliative medicine doctors engage patients in end-of-life (hereon, EoL) talk. To examine whether the practice of "eliciting and responding to cues", which has been widely advocated in the EoL care literature, promotes EoL talk. Conversation analysis of video- and audio-recorded consultations. Unselected terminally ill patients and their companions in consultation with experienced palliative medicine doctors. Outpatient clinic, day therapy clinic, and inpatient unit of a single English hospice. Doctors most commonly promoted EoL talk through open elaboration solicitations; these created opportunities for patients to introduce-then later further articulate-EoL considerations in such a way that doctors did not overtly ask about EoL matters. Importantly, the wording of elaboration solicitations avoided assuming that patients had EoL concerns. If a patient responded to open elaboration solicitations without introducing EoL considerations, doctors sometimes pursued EoL talk by switching to a less participatory and more presumptive type of solicitation, which suggested the patient might have EoL concerns. These more overt solicitations were used only later in consultations, which indicates that doctors give precedence to patients volunteering EoL considerations, and offer them opportunities to take the lead in initiating EoL talk. There is evidence that doctors treat elaboration of patients' talk as a resource for engaging them in EoL conversations. However, there are limitations associated with labelling that talk as "cues" as is common in EoL communication contexts. We examine these limitations and propose "possible EoL considerations" as a descriptively more accurate term. Through communicating-via open elaboration solicitations-in ways that create opportunities for patients to volunteer EoL considerations, doctors navigate a core dilemma in promoting EoL talk: giving patients opportunities to choose whether to engage in conversations about EoL whilst being sensitive to their communication needs, preferences and state of readiness for such dialogue.

Peace, Equanimity, and Acceptance in the Cancer Experience (PEACE): validation of a scale to assess acceptance and struggle with terminal illness.

PubMed

Mack, Jennifer W; Nilsson, Matthew; Balboni, Tracy; Friedlander, Robert J; Block, Susan D; Trice, Elizabeth; Prigerson, Holly G

2008-06-01

The role of emotional acceptance of a terminal illness in end-of-life (EOL) care is not known. The authors developed a measure of peaceful acceptance at the EOL, and evaluated the role of peaceful acceptance in EOL decision-making and care. The authors developed the Peace, Equanimity, and Acceptance in the Cancer Experience (PEACE) questionnaire to measure the extent to which patients with advanced cancer have a sense of peaceful acceptance of their terminal illness. The scale was administered to 160 patients with advanced cancer along with measures of other attributes that hypothetically are related to acceptance, including cognitive acceptance of terminal illness. EOL outcomes in 56 patients who died during the study also were examined. The 12-item PEACE questionnaire had 2 subscales: a 7-item Struggle With Illness subscale (Cronbach alpha = .81) and a 5-item Peaceful Acceptance subscale (alpha = .78). Both subscales were associated with patients' self-reported peacefulness (correlation coefficient [r] = 0.66 for acceptance [P <.0001]; r = -0.37 for struggle [P < .0001]). Struggle With Illness scores were associated with cognitive terminal illness acknowledgment (mean scores, 14.9 vs 12.4 for patients who were not aware that their illness was terminal; P = .001) and with some aspects of advance care planning (living will or healthcare proxy: mean scores, 13.9 vs 11.5; P = .02). In addition, among patients who had died, the use of a feeding tube at the EOL was associated inversely with Peaceful Acceptance (P = .015). The current study indicated that the PEACE questionnaire is a valid and reliable measure of peaceful acceptance and struggle with illness. Scores were associated with some choices for EOL care among patients with advanced cancer. (c) 2008 American Cancer Society.

“It is not the fading candle that one expects”: general practitioners’ perspectives on life-preserving versus “letting go” decision-making in end-of-life home care

PubMed Central

Renterghem, Veerle Van; Pype, Peter; Aelbrecht, Karolien; Derese, Anselme; Deveugele, Myriam

2015-01-01

Background Many general practitioners (GPs) are willing to provide end-of-life (EoL) home care for their patients. International research on GPs’ approach to care in patients’ final weeks of life showed a combination of palliative measures with life-preserving actions. Aim To explore the GP’s perspective on life-preserving versus “letting go” decision-making in EoL home care. Design Qualitative analysis of semi-structured interviews with 52 Belgian GPs involved in EoL home care. Results Nearly all GPs adopted a palliative approach and an accepting attitude towards death. The erratic course of terminal illness can challenge this approach. Disruptive medical events threaten the prospect of a peaceful end-phase and death at home and force the GP either to maintain the patient’s (quality of) life for the time being or to recognize the event as a step to life closure and “letting the patient go”. Making the “right” decision was very difficult. Influencing factors included: the nature and time of the crisis, a patient’s clinical condition at the event itself, a GP’s level of determination in deciding and negotiating “letting go” and the patient’s/family’s wishes and preparedness regarding this death. Hospitalization was often a way out. Conclusions GPs regard alternation between palliation and life-preservation as part of palliative care. They feel uncertain about their mandate in deciding and negotiating the final step to life closure. A shortage of knowledge of (acute) palliative medicine as one cause of difficulties in letting-go decisions may be underestimated. Sharing all these professional responsibilities with the specialist palliative home care teams would lighten a GP’s burden considerably.Key PointsA late transition from a life-preserving mindset to one of “letting go” has been reported as a reason why physicians resort to life-preserving actions in an end-of-life (EoL) context. We investigated GPs’ perspectives on this matter.Not all GPs involved in EoL home care adopt a “letting go” mindset. For those who do, this mindset is challenged by the erratic course of terminal illness.GPs prioritize the quality of the remaining life and the serenity of the dying process, which is threatened by disruptive medical events.Making the “right” decision is difficult. GPs feel uncertain about their own role and responsibility in deciding and negotiating the final step to life closure. PMID:26654583

"It is not the fading candle that one expects": general practitioners' perspectives on life-preserving versus "letting go" decision-making in end-of-life home care.

PubMed

Sercu, Maria; Renterghem, Veerle Van; Pype, Peter; Aelbrecht, Karolien; Derese, Anselme; Deveugele, Myriam

2015-01-01

Many general practitioners (GPs) are willing to provide end-of-life (EoL) home care for their patients. International research on GPs' approach to care in patients' final weeks of life showed a combination of palliative measures with life-preserving actions. To explore the GP's perspective on life-preserving versus "letting go" decision-making in EoL home care. Qualitative analysis of semi-structured interviews with 52 Belgian GPs involved in EoL home care. Nearly all GPs adopted a palliative approach and an accepting attitude towards death. The erratic course of terminal illness can challenge this approach. Disruptive medical events threaten the prospect of a peaceful end-phase and death at home and force the GP either to maintain the patient's (quality of) life for the time being or to recognize the event as a step to life closure and "letting the patient go". Making the "right" decision was very difficult. Influencing factors included: the nature and time of the crisis, a patient's clinical condition at the event itself, a GP's level of determination in deciding and negotiating "letting go" and the patient's/family's wishes and preparedness regarding this death. Hospitalization was often a way out. GPs regard alternation between palliation and life-preservation as part of palliative care. They feel uncertain about their mandate in deciding and negotiating the final step to life closure. A shortage of knowledge of (acute) palliative medicine as one cause of difficulties in letting-go decisions may be underestimated. Sharing all these professional responsibilities with the specialist palliative home care teams would lighten a GP's burden considerably. Key Points A late transition from a life-preserving mindset to one of "letting go" has been reported as a reason why physicians resort to life-preserving actions in an end-of-life (EoL) context. We investigated GPs' perspectives on this matter. Not all GPs involved in EoL home care adopt a "letting go" mindset. For those who do, this mindset is challenged by the erratic course of terminal illness. GPs prioritize the quality of the remaining life and the serenity of the dying process, which is threatened by disruptive medical events. Making the "right" decision is difficult. GPs feel uncertain about their own role and responsibility in deciding and negotiating the final step to life closure.

Perspectives of an Interdisciplinaryg Research Team to Engage Practice: Lessons from a Knowledge Exchange Trainee Experience

PubMed Central

Urquhart, Robin L.; Johnston, Grace M.; McVorran, Shauna M.; Burge, Fred I.

2010-01-01

End-of-life (EOL) care is an area of health services that will ultimately affect us all. To share the knowledge emerging from EOL research and to address inequities in the quality of EOL care in Nova Scotia, a knowledge exchange (KE) trainee was hired to translate research and surveillance into a Surveillance Report. The purpose of this paper is to reflect upon this initiative and share the research team's perspectives on their KE experiences. We describe four key competencies of the KE trainee selected, and discuss lessons learned from this KE trainee experience, to expand our understanding of KE. PMID:21532769

Canada's Compassionate Care Benefit: is it an adequate public health response to addressing the issue of caregiver burden in end-of-life care?

PubMed

Williams, Allison M; Eby, Jeanette A; Crooks, Valorie A; Stajduhar, Kelli; Giesbrecht, Melissa; Vuksan, Mirjana; Cohen, S Robin; Brazil, Kevin; Allan, Diane

2011-05-18

An increasingly significant public health issue in Canada, and elsewhere throughout the developed world, pertains to the provision of adequate palliative/end-of-life (P/EOL) care. Informal caregivers who take on the responsibility of providing P/EOL care often experience negative physical, mental, emotional, social and economic consequences. In this article, we specifically examine how Canada's Compassionate Care Benefit (CCB)--a contributory benefits social program aimed at informal P/EOL caregivers--operates as a public health response in sustaining informal caregivers providing P/EOL care, and whether or not it adequately addresses known aspects of caregiver burden that are addressed within the population health promotion (PHP) model. As part of a national evaluation of Canada's Compassionate Care Benefit, 57 telephone interviews were conducted with Canadian informal P/EOL caregivers in 5 different provinces, pertaining to the strengths and weaknesses of the CCB and the general caregiving experience. Interview data was coded with Nvivo software and emerging themes were identified by the research team, with such findings published elsewhere. The purpose of the present analysis was identified after comparing the findings to the literature specific to caregiver burden and public health, after which data was analyzed using the PHP model as a guiding framework. Informal caregivers spoke to several of the determinants of health outlined in the PHP model that are implicated in their burden experience: gender, income and social status, working conditions, health and social services, social support network, and personal health practises and coping strategies. They recognized the need for improving the CCB to better address these determinants. This study, from the perspective of family caregivers, demonstrates that the CCB is not living up to its full potential in sustaining informal P/EOL caregivers. Effort is required to transform the CCB so that it may fulfill the potential it holds for serving as one public health response to caregiver burden that forms part of a healthy public policy that addresses the determinants of this burden.

Canada's Compassionate Care Benefit: Is it an adequate public health response to addressing the issue of caregiver burden in end-of-life care?

PubMed Central

2011-01-01

Background An increasingly significant public health issue in Canada, and elsewhere throughout the developed world, pertains to the provision of adequate palliative/end-of-life (P/EOL) care. Informal caregivers who take on the responsibility of providing P/EOL care often experience negative physical, mental, emotional, social and economic consequences. In this article, we specifically examine how Canada's Compassionate Care Benefit (CCB) - a contributory benefits social program aimed at informal P/EOL caregivers - operates as a public health response in sustaining informal caregivers providing P/EOL care, and whether or not it adequately addresses known aspects of caregiver burden that are addressed within the population health promotion (PHP) model. Methods As part of a national evaluation of Canada's Compassionate Care Benefit, 57 telephone interviews were conducted with Canadian informal P/EOL caregivers in 5 different provinces, pertaining to the strengths and weaknesses of the CCB and the general caregiving experience. Interview data was coded with Nvivo software and emerging themes were identified by the research team, with such findings published elsewhere. The purpose of the present analysis was identified after comparing the findings to the literature specific to caregiver burden and public health, after which data was analyzed using the PHP model as a guiding framework. Results Informal caregivers spoke to several of the determinants of health outlined in the PHP model that are implicated in their burden experience: gender, income and social status, working conditions, health and social services, social support network, and personal health practises and coping strategies. They recognized the need for improving the CCB to better address these determinants. Conclusions This study, from the perspective of family caregivers, demonstrates that the CCB is not living up to its full potential in sustaining informal P/EOL caregivers. Effort is required to transform the CCB so that it may fulfill the potential it holds for serving as one public health response to caregiver burden that forms part of a healthy public policy that addresses the determinants of this burden. PMID:21592383

Knowledge of advance directive and perceptions of end-of-life care in Chinese-American elders: The role of acculturation.

PubMed

Gao, Xiang; Sun, Fei; Ko, Eunjeong; Kwak, Jung; Shen, Huei-Wern

2015-12-01

This study aimed to describe knowledge of an advance directive (AD) and preferences regarding end-of-life (EoL) care communication, decision making, and designation of surrogates in Chinese-American elders and to examine the role of acculturation variables in AD awareness. Survey data were collected through face-to-face interviews on a sample of 385 Chinese-American elders aged 55 or above living in the Phoenix metropolitan area. The choice of language (Mandarin, Cantonese, or English) and place of interview (senior apartments, Chinese senior centers, or homes) was at the respondent's preference. Hierarchical logistic regression analysis was employed to examine the influence of acculturation variables on AD awareness. Some 21% of participants had heard about ADs, and only 10% had completed one. Elders with higher acculturation levels (OR = 1.04, p < 0.10) and those residing more than 20 years in the United States (OR = 6.87, p < 0.01) were more likely to be aware of ADs after controlling for the effects of demographics, health, and experiences of EoL care. The majority preferred physicians to initiate AD discussions (84.9%) and identified burdens on families as the most important factor in making EoL decisions (89.3%). About 55.1 % considered daughters as the preferred healthcare surrogate. Acculturation levels influence awareness of an AD, and family values are crucial in EoL care decision making. Cultural factors should be considered in designing and delivering appropriate programs to promote knowledge of EoL care among Chinese-American elders and their families.

Environmental Design for End-of-Life Care: An Integrative Review on Improving the Quality of Life and Managing Symptoms for Patients in Institutional Settings.

PubMed

Sagha Zadeh, Rana; Eshelman, Paul; Setla, Judith; Kennedy, Laura; Hon, Emily; Basara, Aleksa

2018-03-01

The environment in which end-of-life (EOL) care is delivered can support or detract from the physical, psychological, social, and spiritual needs of patients, their families, and their caretakers. This review aims to organize and analyze the existing evidence related to environmental design factors that improve the quality of life and total well-being of people involved in EOL care and to clarify directions for future research. This integrated literature review synthesized and summarized research evidence from the fields of medicine, environmental psychology, nursing, palliative care, architecture, interior design, and evidence-based design. This synthesis analyzed 225 documents, including nine systematic literature reviews, 40 integrative reviews, three randomized controlled trials, 118 empirical research studies, and 55 anecdotal evidence. Of the documents, 192 were peer-reviewed, whereas 33 were not. The key environmental factors shown to affect EOL care were those that improved 1) social interaction, 2) positive distractions, 3) privacy, 4) personalization and creation of a home-like environment, and 5) the ambient environment. Possible design interventions relating to these topics are discussed. Examples include improvement of visibility and line of sight, view of nature, hidden medical equipment, and optimization of light and temperature. Studies indicate several critical components of the physical environment that can reduce total suffering and improve quality of life for EOL patients, their families, and their caregivers. These factors should be considered when making design decisions for care facilities to improve physical, psychological, social, and spiritual needs at EOL. Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Rural-Urban Differences in End-of-Life Nursing Home Care: Facility and Environmental Factors

ERIC Educational Resources Information Center

Temkin-Greener, Helena; Zheng, Nan Tracy; Mukamel, Dana B.

2012-01-01

Purpose of the study: This study examines urban-rural differences in end-of-life (EOL) quality of care provided to nursing home (NH) residents. Data and Methods: We constructed 3 risk-adjusted EOL quality measures (QMs) for long-term decedent residents: in-hospital death, hospice referral before death, and presence of severe pain. We used…

[End-of-Life Care in Intensive Care Units: Nursing strategies of family involvement at the end of life].

PubMed

Cyrol, Katharina; Fröhlich, Martin R; Piatti, Francesca; Imhof, Lorenz

2018-06-01

Background: Family members of people dying in the intensive care unit (ICU) are exposed to many stress factors and they often do not experience involvement in End-of-Life (EoL) situations. For example, they criticize a low degree of participation in patients care, delayed or incomplete information and lack of privacy. Even nursing staff is facing various obstacles in EoL situations in ICUs. Aim: This study investigates strategies used by ICU nursing staff in German-speaking Switzerland to increase family members participation in situations at the end of life. Method: Data was collected by conducting 12 semi-structured interviews using an approach based on Grounded Theory. A model was developed to explain nursing strategies for family involvement in EoL situations in the ICU. Conclusions: Nurses provide personal space and tranquillity for family members and allow them to be present at any time. Against this background, they support family members and enable them to say goodbye consciously to a loved one. Subsequent work should examine the effectiveness of the strategies described, particularly in terms of stress reactions displayed by family members in the aftermath of EoL situations. In practice, family members should be provided space for privacy. The entire healthcare team is recommended to identify and pursue common values and objectives. Moreover, intradisciplinary exchange and mentoring need to be encouraged. In order to prepare future nursing staff for EoL situations in the ICU, recognizing and promoting their educational skills is mandatory.

Costs of care at the end of life among elderly patients with chronic kidney disease: patterns and predictors in a nationwide cohort study.

PubMed

Chen, Bradley; Fan, Victoria Y; Chou, Yiing-Jenq; Kuo, Chin-Chi

2017-01-26

Despite the urgent need for evidence to guide the end-of-life (EOL) care for patients with chronic kidney disease (CKD), we have limited knowledge of the costs and intensity of EOL care in this population. The present study examined patterns and predictors for EOL care intensity among elderly patients with CKD. We conducted a retrospective nationwide cohort study utilizing the Taiwan National Health Insurance (NHI) Research Database. A total of 65,124 CKD patients aged ≥ 60 years, who died in hospitals or shortly after discharge between 2002 and 2012 were analyzed. The primary outcomes were inpatient expenses and use of surgical interventions in the last 30 days of life. Utilization of intensive care unit (ICU), mechanical ventilation, resuscitation, and dialysis was also examined in a sub-sample of 2072 patients with detailed prescription data. Multivariate log-linear and logistic regression analyses were performed to assess patient-, physician-, and facility-specific predictors and the potential impact of a 2009 payment policy to reimburse hospice care for non-cancer patients. During the last 30 days of life, average inpatients costs for elderly CKD patients were approximately US$10,260, with 40.9% receiving surgical interventions, 40.2% experiencing ICU admission, 45.3% undergoing mechanical ventilation, 14.7% receiving resuscitation and 42.0% receiving dialysis. Significant variability was observed in the inpatient costs and use of intensive services. Costs were lower among individuals with the following characteristics: advanced age; high income; high Charlson Comorbidity Index scores; treatment by older physicians, nephrologists, and family medicine physicians; and treatment at local hospitals. Similar findings were obtained for the use of surgical interventions and other intensive services. A declining trend was detected in the costs of EOL care, use of surgical interventions and resuscitation between 2009 and 2012, which is consistent with the impact of a 2009 NHI payment policy to reimburse non-cancer hospice care. Overall EOL costs and rates of intensive service use among older patients with CKD were high, with significant variability across various patient and provider characteristics. Several opportunities exist for providers and policy makers to reduce costs and enhance the value of EOL care for this population.

The Comfort Measures Order Set at a Tertiary Care Academic Hospital: Is There a Comparable Difference in End-of-Life Care Between Patients Dying in Acute Care When CMOS Is Utilized?

PubMed

Lau, Christine; Stilos, Kalli; Nowell, Allyson; Lau, Fanchea; Moore, Jennifer; Wynnychuk, Lesia

2018-04-01

Standardized protocols have been previously shown to be helpful in managing end-of-life (EOL) care in hospital. The comfort measures order set (CMOS), a standardized framework for assessing imminently dying patients' symptoms and needs, was implemented at a tertiary academic hospital. We assessed whether there were comparable differences in the care of a dying patient when the CMOS was utilized and when it was not. A retrospective chart review was completed on patients admitted under oncology and general internal medicine, who were referred to the inpatient palliative care team for "EOL care" between February 2015 and March 2016. Of 83 patients, 56 (67%) received intiation of the CMOS and 27 (33%) did not for EOL care. There was significant involvement of spiritual care with the CMOS (66%), as compared to the group without CMOS (19%), P < .05. The use of CMOS resulted in 1.7 adjustments to symptom management per patient by palliative care, which was significantly less than the number of symptom management adjustments per patient when CMOS was not used (3.3), P < .05. However, initiating CMOS did not result in a signficant difference in patient distress around the time of death ( P = .11). Dyspnea was the most frequently identified symptom causing distress in actively dying patients. Implementation of the CMOS is helpful in providing a foundation to a comfort approach in imminently dying patients. However, more education on its utility as a framework for EOL care and assessment across the organization is still required.

Maintaining family life balance while facing a child's imminent death-A mixed methods study.

PubMed

Eskola, Katri; Bergstraesser, Eva; Zimmermann, Karin; Cignacco, Eva

2017-10-01

To understand parents' experiences and needs during a child's end-of-life care at home and to identify systemic factors that influence its provision. A child's end-of-life phase is an extremely difficult time for the whole family. Parents have specific needs, especially when they care for a dying child at home. Concurrent embedded mixed methods design. This sub-study of the nationwide survey, 'Paediatric End-of-Life Care Needs in Switzerland' (2012-2015) included 47 children who received EOL care at home from 2011-2012. We extracted quantitative data from patients' medical charts and obtained information via parental questionnaire and then compared parents whose child died at home or in hospital by computing generalized estimation equations. We thematically analysed interviews with parents who provided EOL care at home. Parents created an intimate lifeworld and a sense of normality for the child at home. They constantly balanced the family's lifeworld with the requirements and challenges posed by the outside world. This work exhausted parents. Parental 'readiness' and social support drove EOL care for children at home. Parents needed practical help with housekeeping and had negative experiences when dealing with insurance. In only 34.8% of cases was a child's EOL home care supported by paediatric palliative care team. Paediatric end-of-life care at home is only feasible if parents make extraordinary efforts. If family-centred end-of-life home care is provided by a hospital-based paediatric palliative home care team, which includes paid housekeeping help and psychological support, parents' needs could be better met. © 2017 John Wiley & Sons Ltd.

Engaging Terminally Ill Patients in End of Life Talk: How Experienced Palliative Medicine Doctors Navigate the Dilemma of Promoting Discussions about Dying

PubMed Central

Parry, Ruth; Land, Victoria; Faull, Christina; Feathers, Luke; Seymour, Jane

2016-01-01

Objective To examine how palliative medicine doctors engage patients in end-of-life (hereon, EoL) talk. To examine whether the practice of “eliciting and responding to cues”, which has been widely advocated in the EoL care literature, promotes EoL talk. Design Conversation analysis of video- and audio-recorded consultations. Participants Unselected terminally ill patients and their companions in consultation with experienced palliative medicine doctors. Setting Outpatient clinic, day therapy clinic, and inpatient unit of a single English hospice. Results Doctors most commonly promoted EoL talk through open elaboration solicitations; these created opportunities for patients to introduce–then later further articulate–EoL considerations in such a way that doctors did not overtly ask about EoL matters. Importantly, the wording of elaboration solicitations avoided assuming that patients had EoL concerns. If a patient responded to open elaboration solicitations without introducing EoL considerations, doctors sometimes pursued EoL talk by switching to a less participatory and more presumptive type of solicitation, which suggested the patient might have EoL concerns. These more overt solicitations were used only later in consultations, which indicates that doctors give precedence to patients volunteering EoL considerations, and offer them opportunities to take the lead in initiating EoL talk. There is evidence that doctors treat elaboration of patients’ talk as a resource for engaging them in EoL conversations. However, there are limitations associated with labelling that talk as “cues” as is common in EoL communication contexts. We examine these limitations and propose “possible EoL considerations” as a descriptively more accurate term. Conclusions Through communicating–via open elaboration solicitations–in ways that create opportunities for patients to volunteer EoL considerations, doctors navigate a core dilemma in promoting EoL talk: giving patients opportunities to choose whether to engage in conversations about EoL whilst being sensitive to their communication needs, preferences and state of readiness for such dialogue. PMID:27243630

Increasing Receipt of High-Tech/High-Cost Imaging and Its Determinants in the Last Month of Taiwanese Patients With Metastatic Cancer, 2001-2010: A Retrospective Cohort Study.

PubMed

Liu, Tsang-Wu; Hung, Yen-Ni; Soong, Thomas C; Tang, Siew Tzuh

2015-08-01

One strategy for controlling the skyrocketing costs of cancer care may be to target high-tech/high-cost imaging at the end of life (EOL). This population-based study investigated receipt of high-tech/high-cost imaging and its determinants for Taiwanese patients with metastatic cancer in their last month of life.Individual patient-level data were linked with encrypted identification numbers from computerized administrative data in Taiwan, that is, the National Register of Deaths Database, Cancer Registration System database, and National Health Insurance claims datasets, Database of Medical Care Institutions Status, and national census statistics (population/household income). We identified receipt of computerized tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and radionuclide bone scans (BSs) for 236,911 Taiwanese cancer decedents with metastatic disease, 2001 to 2010. Associations of patient, physician, hospital, and regional factors with receiving CT, MRI, and bone scan in the last month of life were evaluated by multilevel generalized linear-mixed models.Over one-third (average [range]: 36.11% [33.07%-37.31%]) of patients with metastatic cancer received at least 1 high-tech/high-cost imaging modality in their last month (usage rates for CT, MRI, PET, and BS were 31.05%, 5.81%, 0.25%, and 8.15%, respectively). In 2001 to 2010, trends of receipt increased for CT (27.96-32.22%), MRI (4.34-6.70%), and PET (0.00-0.62%), but decreased for BS (9.47-6.57%). Facilitative determinants with consistent trends for at least 2 high-tech/high-cost imaging modalities were male gender, younger age, married, rural residence, lung cancer diagnosis, dying within 1 to 2 years of diagnosis, not under medical oncology care, and receiving care at a teaching hospital with a larger volume of terminally ill cancer patients and greater EOL care intensity. Undergoing high-tech/high-cost imaging at EOL generally was not associated with regional characteristics, healthcare resources, and EOL care intensity.To more effectively use high-tech/high-cost imaging at EOL, clinical and financial interventions should target nonmedical oncologists/hematologists affiliated with teaching hospitals that tend to aggressively treat high volumes of terminally ill cancer patients, thereby avoiding unnecessary EOL care spending and transforming healthcare systems into affordable high-quality cancer care delivery systems.

Conceptualizing Surrogate Decision-Making at End of Life in the Intensive Care Unit using Cognitive Task Analysis

PubMed Central

Dionne-Odom, J. Nicholas; Willis, Danny G.; Bakitas, Marie; Crandall, Beth; Grace, Pamela J.

2014-01-01

Background Surrogate decision-makers (SDMs) face difficult decisions at end of life (EOL) for decisionally incapacitated intensive care unit (ICU) patients. Purpose Identify and describe the underlying psychological processes of surrogate decision-making for adults at EOL in the ICU. Method Qualitative case study design using a cognitive task analysis (CTA) interviewing approach. Participants were recruited from October 2012 to June 2013 from an academic tertiary medical center’s ICU located in the rural Northeastern United States. Nineteen SDMs for patients who had died in the ICU completed in-depth semi-structured CTA interviews. Discussion The conceptual framework formulated from data analysis reveals that three underlying, iterative, psychological dimensions: gist impressions, distressing emotions, and moral intuitions impact a SDM’s judgment about the acceptability of either the patient’s medical treatments or his or her condition. Conclusion The framework offers initial insights about the underlying psychological processes of surrogate decision-making and may facilitate enhanced decision support for SDMs. PMID:25982772

Conceptualizing surrogate decision making at end of life in the intensive care unit using cognitive task analysis.

PubMed

Dionne-Odom, J Nicholas; Willis, Danny G; Bakitas, Marie; Crandall, Beth; Grace, Pamela J

2015-01-01

Surrogate decision makers (SDMs) face difficult decisions at end of life (EOL) for decisionally incapacitated intensive care unit (ICU) patients. To identify and describe the underlying psychological processes of surrogate decision making for adults at EOL in the ICU. Qualitative case study design using a cognitive task analysis interviewing approach. Participants were recruited from October 2012 to June 2013 from an academic tertiary medical center's ICU located in the rural Northeastern United States. Nineteen SDMs for patients who had died in the ICU completed in-depth semistructured cognitive task analysis interviews. The conceptual framework formulated from data analysis reveals that three underlying, iterative, psychological dimensions (gist impressions, distressing emotions, and moral intuitions) impact an SDM's judgment about the acceptability of either the patient's medical treatments or his or her condition. The framework offers initial insights about the underlying psychological processes of surrogate decision making and may facilitate enhanced decision support for SDMs. Copyright © 2015 Elsevier Inc. All rights reserved.

Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment

PubMed Central

Wright, Alexi A.; Zhang, Baohui; Ray, Alaka; Mack, Jennifer W.; Trice, Elizabeth; Balboni, Tracy; Mitchell, Susan L.; Jackson, Vicki A.; Block, Susan D.; Maciejewski, Paul K.; Prigerson, Holly G.

2010-01-01

Context Talking about death can be difficult. Without evidence that end-of-life (EOL) discussions improve patient outcomes, physicians must balance their desire to honor patient autonomy against a concern that EOL discussions may inflict psychological harm. Objective To determine whether EOL discussions with physicians are associated with fewer aggressive interventions. Design, Setting, Participants A United States multi-site, prospective, longitudinal cohort study of advanced cancer patients and their informal caregivers (n=332 dyads), September 2002-February 2008. Patients were followed from enrollment to death a median of 4.4 months later. Bereaved caregivers’ psychiatric illness and quality of life (QoL) was assessed a median 6.5 months later. Main Outcome Measures The primary outcome were aggressive medical care (e.g., ventilation, resuscitation) and hospice in the final week of life. Secondary outcomes included patients’ mental health and caregivers’ bereavement adjustment. Results 123 of 332 (37.0%) patients reported EOL discussions before baseline. EOL discussions were not associated with higher rates of Major Depressive Disorder (8.3% vs. 5.8; AOR 1.33, 95% CI 0.54-3.32), or more “worry” (6.5 vs. 7.0; p=0.19)). After propensity-score weighted adjustment, EOL discussions were associated with lower rates of ventilation (1.6% vs. 11.0%; AOR 0.26, 95% CI 0.08-0.83), resuscitation (0.8% vs. 6.7%; AOR 0.16, 95% CI 0.03-0.80), ICU admission (4.1 vs. 12.4%; AOR 0.35, 95% CI 0.14-0.90), and earlier hospice enrollment (65.6% vs. 44.5%; AOR 1.58, 95% CI 1.04-2.63). In adjusted analyses, more aggressive medical care was associated with worse patient QoL (6.4 vs. 4.6; F=3.60, p=0.01) and higher risk for Major Depressive Disorder in bereaved caregivers (AOR 3.37, 95% CI 1.12-10.13), while longer hospice stays were associated with better patient QoL (5.6 vs. 6.9; F=3.70, p=0.01). Better patient QoL was associated with better caregiver QoL at follow-up (β=0.20; p=0.001). Conclusion EOL discussions are associated with less aggressive medical care near death and earlier hospice referrals. Aggressive care is associated with worse patient QoL and worse bereavement adjustment. PMID:18840840

Training Community Clergy in Serious Illness: Balancing Faith and Medicine.

PubMed

Koss, Sarah E; Weissman, Ross; Chow, Vinca; Smith, Patrick T; Slack, Bethany; Voytenko, Vitaliy; Balboni, Tracy A; Balboni, Michael J

2018-06-06

Community-based clergy are highly engaged in helping seriously ill patients address spiritual concerns at the end of life (EOL). While they desire EOL training, no data exist in guiding how to conceptualize a clergy-training program. The objective of this study was used to identify best practices in an EOL training program for community clergy. As part of the National Clergy Project on End-of-Life Care, the project conducted key informant interviews and focus groups with active clergy in five US states (California, Illinois, Massachusetts, New York, and Texas). A diverse purposive sample of 35 active clergy representing pre-identified racial, educational, theological, and denominational categories hypothesized to be associated with more intensive utilization of medical care at the EOL. We assessed suggested curriculum structure and content for clergy EOL training through interviews and focus groups for the purpose of qualitative analysis. Thematic analysis identified key themes around curriculum structure, curriculum content, and issues of tension. Curriculum structure included ideas for targeting clergy as well as lay congregational leaders and found that clergy were open to combining resources from both religious and health-based institutions. Curriculum content included clergy desires for educational topics such as increasing their medical literacy and reviewing pastoral counseling approaches. Finally, clergy identified challenging barriers to EOL training needing to be openly discussed, including difficulties in collaborating with medical teams, surrounding issues of trust, the role of miracles, and caution of prognostication. Future EOL training is desired and needed for community-based clergy. In partnering together, religious-medical training programs should consider curricula sensitive toward structure, desired content, and perceived clergy tensions.

What Is the End of Life Period? Trajectories and Characterization Based on Primary Caregiver Reports.

PubMed

Cohen-Mansfield, Jiska; Cohen, Rinat; Skornick-Bouchbinder, Michal; Brill, Shai

2018-04-17

As the population lives longer, end of life (EOL) is emerging as a distinct life phase, about which there is still limited understanding. Characterizing this important period is vital for clarifying issues regarding trajectory and decline at EOL and for health service planning on an institutional, communal, and societal level. In this article, we aim to characterize the EOL period, examining the duration and number of EOL stages, as well as functional, attitudinal, and emotional trajectories. In this cross-sectional study, 70 primary caregivers of deceased persons were interviewed. Standardized rates of functional, attitudinal, and emotional change across the EOL period were calculated. Frequencies were compared using the McNemar statistical test. EOL period was found to have a median length of 3.25 years, and an average of approximately three progressive stages. The duration of EOL stages tended to decrease as death approached. Unexpected events (eg new medical diagnosis/accident) served as the precipitating event for the EOL period for approximately half of the deceased persons, and changes in existing conditions (eg health status/cognitive state) were also reported to precipitate EOL for a similar proportion. Reports of functionality across stages found the steepest decline in the "physical" domain and the most moderate decline in the "social" domain. With each stage, positive indicators, such as "will to live," showed a progressive decline, whereas negative indicators, including "suffering" and "dependence level," progressively increased. Results help characterize EOL trajectories and should inform care planning and decision making at various levels. In addition, they suggest a methodology for better understanding EOL.

Caring for dying cancer patients in the Chinese cultural context: A qualitative study from the perspectives of physicians and nurses.

PubMed

Dong, Fengqi; Zheng, Ruishuang; Chen, Xuelei; Wang, Yanhui; Zhou, Hongyuan; Sun, Rong

2016-04-01

To explore the experiences of Chinese physicians and nurses who care for dying cancer patients in their practical work. This was a qualitative study using semi-structured face-to-face interviews. Fifteen physicians and 22 nurses were recruited from a cancer center in mainland China. The data were analyzed by qualitative thematic analysis. Disclosure of information on death and cancer to dying cancer patients is taboo in traditional Chinese culture, which greatly decreases the physicians' and nurses' effective communication with dying patients in end-of-life (EOL) care. Both physicians and nurses described strong ambitions to give dying cancer patients high-quality care, and they emphasized the importance of maintaining dying patients' hopes in the death-denying cultural context. However, the nurses were more concerned with dying patients' physical comfort and wish fulfillment, while the physicians placed greatest emphasis on patients' rights and symptom management. Both physicians and nurses suffered whilst also benefitting from taking care of dying patients which helped with their personal growth and allowed greater insight into themselves and their clinical practice. Our results also indicated that Chinese physicians and nurses require improved methods of communication on EOL care, as well as needing more support to provide quality EOL care. Chinese physicians and nurses experience a challenge when caring for dying cancer patients in the Chinese cultural context. Flexible and specific education and training in EOL cancer care are required to meet the needs of Chinese physicians and nurses at the cancer center studied. Copyright © 2015 Elsevier Ltd. All rights reserved.

Thoughts about Dying in America: Enhancing the impact of one's life journey and legacy by also planning for the end of life.

PubMed

Pizzo, Philip A

2016-11-15

This Perspective offers a summary of the recommendations in the Institute of Medicine report Dying in America How we die is a deeply personal issue that each of us will face. However, the approach to end-of-life (EOL) care in the United States needs improvement. Too frequently, healthcare delivery is uncoordinated and has many providers who are not adequately prepared to have meaningful conversations about EOL planning. This is amplified by payment systems and policies that create impediments, misunderstanding, and sometimes misinformation. Dying in America made five recommendations to improve quality and honor individual preferences near the EOL beginning with making conversations with providers and families something that occurs during various phases of the life cycle and not just when one is facing serious illness or possible EOL. It was recommended (i) that public and private payers and care delivery organizations cover the provision of comprehensive care that is accessible and available to individuals on a 24/7 schedule; (ii) that professional societies and other entities establish standards for clinician patient communication and advance care planning and that payers and care delivery organizations adopt them; (iii) that educational institutions, credentialing bodies, accrediting boards, state regulatory agencies, and care delivery organizations establish palliative care training, certification, and/or licensure requirements; (iv) that public and private payers and care delivery organizations integrate the financing of health and social services; and (v) that public and private organizations should engage their constituents and provide fact-based information to encourage advance care planning and informed choice.

Last Days of Life (PDQ®)—Health Professional Version

Cancer.gov

The last days of life in cancer involves managing end-of-life (EOL) care issues for a wide range of possible symptoms and ethical dilemmas. Get detailed information about EOL issues and the role of the oncologist in this clinician summary.

Is death our business? Philosophical conflicts over the end-of-life in old age psychiatry.

PubMed

McKellar, Duncan; Ng, Felicity; Chur-Hansen, Anna

2016-01-01

Old age psychiatrists work with end-of-life (EOL) issues and encounter patient deaths, but death and dying have received limited focus in old age psychiatry training and research. This qualitative study explores old age psychiatrists' experience of and approach to working with patients at the EOL. Australian old age psychiatrists were purposively sampled and interviewed in-depth. Data saturation was achieved after nine participant interviews. Verbatim transcripts were analysed for themes, which were independently verified. Two dichotomous overarching themes were identified. Death is not our business reflected participants' experience of working in a mental health framework and incorporated four themes: death should not occur in psychiatry; working in a psychiatric treatment model; keeping a distance from death and unexpected death is a negative experience. Death is our business reflected participants' experience of working in an aged care context and incorporated four themes: death is part of life; encountering the EOL through dementia care; doing EOL work and expected death is a positive experience. Participants reported conflict because of the contradictory domains in which they work. They were comfortable working with patients at the EOL when death was expected, particularly in dementia. By contrast, they struggled with death as an adverse outcome in circumstances influenced by mental health culture, which was characterised by risk management, suicide prevention and a focus on recovery. This study has implications for models of care underpinning old age psychiatry. An integrated person-centred model of care may provide a contextually appropriate approach for practice.

Caregiving Youth Knowledge and Perceptions of Parental End-of-Life Wishes in Huntington's Disease.

PubMed

Kavanaugh, Melinda S; Noh, Hyunjin; Zhang, Lixia

2016-01-01

Knowledge of patient end-of-life (EOL) wishes and discussions are vital for family caregivers, including children and youth who may be in caregiving roles ("young carers" or "caregiving youth"). However, little is known about caregiving youth awareness and perceptions of EOL issues. This study sought to explore caregiving youth knowledge of EOL wishes and their willingness for EOL discussions. Face-to-face interviews with 40 caregiving youth ages 10-20, who have a parent with Huntington's disease (HD), provided information about their knowledge of the presence of their ill parent's living will (LW) and durable power of attorney for health care (DPAHC), and willingness to talk with the parent about EOL choices and possibility of death. Less than one-half of the participants were aware of the parent's LW or DPAHC. Content analysis revealed themes in reasons to want or not want EOL discussion with the parent: respect for the parent's wishes, caregiving youths' opinion not valued, and avoidance of EOL issues. Themes also included reasons to not want discussion with the parent about possibility of death: protecting the parent, parent in denial, parent not ready, and realization of the terminal outcome. Findings suggest HD patients and their caregiving youth need support for open EOL discussions, and could benefit from educational programs and support groups around EOL issues.

Aircraft Measurements for Understanding Air-Sea Coupling and Improving Coupled Model Predictions Over the Indian Ocean

DTIC Science & Technology

2012-09-30

briefing for aircraft operations in Diego Garcia, reports posted on EOL field catalog in realtime (http://catalog.eol.ucar.edu/cgi- bin/dynamo/report...index); • Dropsonde data processing on all P3 flights and realtime QC/reporting to GTS; and • Science summary of aircraft missions posted on EOL ...data analysis, worked with EOL on data quality control (QC), participated in the DYNAMO Sounding Workshop at EOL /NCAR from 6-7 February 2012

The Impact of Faith Beliefs on Perceptions of End-of-Life Care and Decision Making among African American Church Members.

PubMed

Johnson, Jerry; Hayden, Tara; True, Jennifer; Simkin, Daren; Colbert, Louis; Thompson, Beverly; Stewart, Denise; Martin, Latoya

2016-02-01

African Americans underuse palliative care and hospice services because of a combination of factors including faith beliefs. As the spiritual family for many African Americans, the church presents an opportunity to improve communication about palliative care and hospice and end-of-life (EOL) decision making. We conducted a focus group study to understand the cultural and spiritual perspectives that influence decisions about palliative care and hospice among African American church members who visit and support persons with life-limiting illnesses. Our specific aims were to elicit their perceptions, beliefs, and attitudes about: (1) the relation between faith beliefs and EOL care; (2) emotional and family influences on EOL decision making; (3) palliative care and hospice resources; and (4) opportunities to improve communication among lay persons and health professionals and within families. Seven focus groups using purposeful sampling. We partnered with two African American churches. Of 51 persons, 27 were deacons or deaconesses, 17 were members of health or bereavement ministries, and 7 were other members of the congregations. We found that faith beliefs of African Americans can support discussions about palliative care and hospice. Participants perceived that many of their congregants harbor beliefs, perceptions, and feelings about death and dying that were often not communicated to family members or to health providers. Among African Americans, faith beliefs, emotional issues, family dynamics, and insufficient knowledge of palliative care and hospice are intertwined and influence decision making about palliative care and hospice. Our findings confirm the influence of faith beliefs of African Americans on decisions about palliative care and hospice and demonstrate the opportunity to improve communication about palliative care and hospice and EOL through collaborations with the African American church.

Experiences with and attitudes toward death and dying among homeless persons.

PubMed

Song, John; Ratner, Edward R; Bartels, Dianne M; Alderton, Lucy; Hudson, Brenda; Ahluwalia, Jasjit S

2007-04-01

Homeless persons face many barriers to health care, have few resources, and experience high death rates. They live lives of disenfranchisement and neglect. Few studies have explored their experiences and attitudes toward death and dying. Unfortunately, studies done in other populations may not apply to homeless persons. Exploring these experiences and attitudes may provide insight into life, health care, and end-of-life (EOL) concerns of this population. To explore the experiences and attitudes toward death and dying among homeless persons. Qualitative study utilizing focus groups. Fifty-three homeless persons recruited from homeless service agencies. In-depth interviews, which were audiotaped and transcribed. We present seven themes, some of which are previously unreported. Homeless persons described many significant experiences with death and dying, and many participants suffered losses while very young. These encounters influenced participants' attitudes toward risks and risky behavior: e.g., for some, these experiences provided justification for high-risk behaviors and influenced their behaviors while living on the streets. For others, they may be associated with their homelessness. Finally, these experiences informed their attitudes toward death and dying as well as EOL care; homeless persons believe that care will be poor at the EOL. Findings from this study have implications for addressing social services, health promotion, prevention, and EOL care for homeless persons, as well as for others who are poor and disenfranchised.

Experiences With and Attitudes Toward Death and Dying Among Homeless Persons

PubMed Central

Ratner, Edward R; Bartels, Dianne M.; Alderton, Lucy; Hudson, Brenda; Ahluwalia, Jasjit S.

2007-01-01

Background Homeless persons face many barriers to health care, have few resources, and experience high death rates. They live lives of disenfranchisement and neglect. Few studies have explored their experiences and attitudes toward death and dying. Unfortunately, studies done in other populations may not apply to homeless persons. Exploring these experiences and attitudes may provide insight into life, health care, and end-of-life (EOL) concerns of this population. Objective To explore the experiences and attitudes toward death and dying among homeless persons. Design Qualitative study utilizing focus groups. Participants Fifty-three homeless persons recruited from homeless service agencies. Measurements In-depth interviews, which were audiotaped and transcribed. Results We present seven themes, some of which are previously unreported. Homeless persons described many significant experiences with death and dying, and many participants suffered losses while very young. These encounters influenced participants’ attitudes toward risks and risky behavior: e.g., for some, these experiences provided justification for high-risk behaviors and influenced their behaviors while living on the streets. For others, they may be associated with their homelessness. Finally, these experiences informed their attitudes toward death and dying as well as EOL care; homeless persons believe that care will be poor at the EOL. Conclusions Findings from this study have implications for addressing social services, health promotion, prevention, and EOL care for homeless persons, as well as for others who are poor and disenfranchised. PMID:17372788

Multicultural long-term care nurses’ perceptions of factors influencing patient dignity at the end of life.

PubMed

Periyakoil, Vyjeyanthi S; Stevens, Marguerite; Kraemer, Helena

2013-03-01

The goal of this mixed-methods study was to characterize the perceptions of multicultural long-term care nurses about patient dignity at the end-of-life (EOL). The study was conducted in a large, urban, long-term care (LTC) facility. Participants were 45 long-term care nurses and 26 terminally ill nursing home residents. Nurses completed an openended interview about their perceptions of the concept of dying with dignity, and the data were analyzed using grounded theory methods. Main themes identified as promoting resident dignity at the EOL included treating them with respect, helping them prepare for the EOL, promoting shared decision-making, and providing high-quality care. The nurses’ cultural and religious backgrounds influenced their perceptions of what constitutes dignity-conserving care. Foreign-born nurses stressed the need for EOL rituals, but this was strikingly absent in the statements of U.S.-born nurses. Foreign-born Catholic nurses stated that the dying experience should not be altered using analgesics to relieve suffering or by attempts to hasten death by forgoing curative therapy or by other means. Nurses and terminally ill individuals completed the Dignity Card-sort Tool (DCT). A comparison of the DCT responses of the LTC nurses cohort with those of the terminally ill participants revealed that the nurses felt patient dignity was eroded when patient wishes were not followed and when they were treated without respect. In contrast, dying LTC residents felt that poor medical care and loss of ability to choose care options were the most important factors leading to erosion of dignity.

A 40-Year History of End-of-Life Offerings in US Medical Schools: 1975-2015.

PubMed

Dickinson, George E

2017-07-01

The purpose of this longitudinal study of US medical schools over a 40-year period was to ascertain their offerings on end-of-life (EOL) issues. At 5-year intervals, beginning in 1975, US medical schools were surveyed via a questionnaire to determine their EOL offerings. Data were reported with frequency distributions. The Institute of Medicine has encouraged more emphasis on EOL issues over the past 2 decades. Findings revealed that undergraduate medical students in the United States are now exposed to death and dying, palliative care, and geriatric medicine. The inclusion of EOL topics has definitely expanded over the 40-year period as findings reveal that US undergraduate medical students are currently exposed in over 90% of programs to death and dying, palliative care, and geriatric medicine, with the emphasis on these topics varying with the medical programs. Such inclusion should produce future favorable outcomes for undergraduate medical students, patients, and their families.

Case-Mix Adjustment of the Bereaved Family Survey.

PubMed

Kutney-Lee, Ann; Carpenter, Joan; Smith, Dawn; Thorpe, Joshua; Tudose, Alina; Ersek, Mary

2018-01-01

Surveys of bereaved family members are increasingly being used to evaluate end-of-life (EOL) care and to measure organizational performance in EOL care quality. The Bereaved Family Survey (BFS) is used to monitor EOL care quality and benchmark performance in the Veterans Affairs (VA) health-care system. The objective of this study was to develop a case-mix adjustment model for the BFS and to examine changes in facility-level scores following adjustment, in order to provide fair comparisons across facilities. We conducted a cross-sectional secondary analysis of medical record and survey data from veterans and their family members across 146 VA medical centers. Following adjustment using model-based propensity weighting, the mean change in the BFS-Performance Measure score across facilities was -0.6 with a range of -2.6 to 0.6. Fifty-five (38%) facilities changed within ±0.5 percentage points of their unadjusted score. On average, facilities that benefited most from adjustment cared for patients with greater comorbidity burden and were located in urban areas in the Northwest and Midwestern regions of the country. Case-mix adjustment results in minor changes to facility-level BFS scores but allows for fairer comparisons of EOL care quality. Case-mix adjustment of the BFS positions this National Quality Forum-endorsed measure for use in public reporting and internal quality dashboards for VA leadership and may inform the development and refinement of case-mix adjustment models for other surveys of bereaved family members.

A team approach in palliative care: enhancing outcomes.

PubMed

Schrader, Susan L; Horner, Arlene; Eidsness, LuAnn; Young, Sandy; Wright, Chris; Robinson, Michael

2002-07-01

While most Americans envision a "good death" as one occurring quickly and painlessly at home surrounded by loved ones, many people do not die in this fashion. Palliative care focuses on holistic treatment of patients whose disease is not responsive to curative treatment, and strives to improve quality of life for patients and families at end-of-life (EOL). This hospital-based study examines the extent to which a palliative care consultant team makes a difference in EOL for patients and families. Data were collected from a convenience sample of 50 hospitalized patients referred to an interdisciplinary palliative care consulting team at a South Dakota tertiary hospital during 2001. Various palliative care interventions were introduced during the course of hospitalization, and data were collected two days later to see if quality of life had improved. Statistically significant improvements were found in pain levels, non-pain symptom management, numerous psychosocial measures of quality of life, change in code status, and perceptions of communication and treatment during hospitalization. The study demonstrates that consultations with a palliative care team are beneficial and enhance the EOL experience for patients and families.

Experiences of Slovene ICU physicians with end-of-life decision making: a nation-wide survey.

PubMed

Groselj, Urh; Orazem, Miha; Kanic, Maja; Vidmar, Gaj; Grosek, Stefan

2014-10-21

Advances in intensive care medicine have enormously improved ability to successfully treat seriously ill patients. However, intensive treatment and prolongation of life is not always in the patient's best interest, and many ethical dilemmas arise in end-of-life (EOL) situations. We aimed to assess intensive care unit (ICU) physicians' experiences with EOL decision making and to compare the responses according to ICU type. A cross-sectional survey was performed in all 35 Slovene ICUs, using a questionnaire designed to assess ICU physician experiences with EOL decision making, focusing on limitations of life-sustaining treatments (LST). We distributed 370 questionnaires (approximating the number of Slovene ICU physicians) and 267 were returned (72% response rate). The great majority of ICU physicians reported using do-not-resuscitate (DNR) orders (97%), withholding LST (94%), and withdrawing antibiotics (86%) or inotropes (95%). Fewer ICU physicians reported withdrawing mechanical ventilation (52%) or extubating patients (27%). Hydration was reported to be only rarely terminated (76% of participants reported never terminating it). In addition, 63% of participants had never encountered advance directives, and 39% reported to "never" or "rarely" participating in decision making with relatives of patients. Nurses were reported to be "never" or "rarely" involved in the EOL decision making process by 84% of participants. Limitation of LST was regularly used by Slovene ICU physicians. DNR orders and withholding of LST were the most commonly used measures. Hydration was only rarely terminated. In addition, use of advance directives was almost non-existent in practice, and the patients' relatives and nurses only infrequently participated in the decision making.

Social Work Practice with LGBT Elders at End of Life: Developing Practice Evaluation and Clinical Skills Through a Cultural Perspective.

PubMed

Arthur, Darren P

2015-01-01

This article focuses on culturally sensitive clinical issues related to best practices with lesbian, gay, bisexual, transgender (LGBT) elder patients at end-of-life (EOL) at key points in the therapeutic relationship. Vital concepts, including practice evaluation and clinical skills, are presented through a cultural and oncology lens. There is a paucity of LGBT research and literature as well as a shortfall of MSW graduate school education specific to social work palliative and end-of-life care (PELC) practice with LGBT elders. The content of this article is designed to be adapted and used as an educational tool for institutions, agencies, graduate programs, medical professions, social work, and students. Learning the unique elements of LGBT cultural history and their implications on EOL care can improve social work practice. This article provides an examination from assessment and engagement basics to advance care planning incorporating specific LGBT EOL issues.

Homeless Individuals Approaching the End of Life: Symptoms and Attitudes.

PubMed

Tobey, Matthew; Manasson, Julia; Decarlo, Kristen; Ciraldo-Maryniuk, Katrina; Gaeta, Jessie M; Wilson, Erica

2017-04-01

Over a million individuals in the United States experience homelessness annually and homeless individuals die at a higher rate than domiciled peers. Homeless individuals often have unique experiences at the end of life (EOL). This study examined the symptoms experienced by homeless individuals nearing the EOL and explored social background, attitudes, and experiences. Investigators conducted surveys of homeless individuals approaching the EOL at a medical respite home. Eligibility required a serious medical condition and for the patient's medical provider to answer "no" to the question "Would you be surprised if this patient were not alive in one year?" Interviews explored symptoms using the Memorial Symptom Assessment Survey. Symptoms were compared with those of relevant comparator groups in other studies. Participants (n = 20) were young to face the EOL (median age = 58) and suffered high rates of substance use disorders (n = 18; 90%) and psychiatric diagnoses (n = 16; 80%). Symptom frequency was high, especially as regarded pain and psychological symptoms. Previous experience with death among family and peers was universal (n = 20; 100%). Mistrust of others' decisions about the EOL was common, as was concern about receiving too little (n = 11; 55%) or too much (n = 8; 40%) care at the EOL. The frequency of symptoms was higher than in three comparator studies and those studies' subgroups (P < 0.01 for each comparison). Homeless individuals may experience a high frequency of pain and other symptoms as they approach the EOL. Care for such individuals may require a tailored approach. Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Engaging Patients With Advance Directives Using an Information Visualization Approach.

PubMed

Woollen, Janet; Bakken, Suzanne

2016-01-01

Despite the benefits of advance directives (AD) to patients and care providers, they are often not completed due to lack of patient awareness. The purpose of the current article is to advocate for creation and use of an innovative information visualization (infovisual) as a health communication tool aimed at improving AD dissemination and engagement. The infovisual would promote AD awareness by encouraging patients to learn about their options and inspire contemplation and conversation regarding their end-of-life (EOL) journey. An infovisual may be able to communicate insights that are often communicated in words, but are much more powerfully communicated by example. Furthermore, an infovisual could facilitate vivid understanding of options and inspire the beginning of often difficult conversations among care providers, patients, and loved ones. It may also save clinicians time, as care providers may be able to spend less time explaining details of EOL care options. Use of an infovisual could assist in ensuring a well-planned EOL journey. Copyright 2016, SLACK Incorporated.

Development and Pilot Evaluation of a Novel Dignity-Conserving End-of-Life (EoL) Care Model for Nursing Homes in Chinese Societies.

PubMed

Ho, Andy H Y; Dai, Annie A N; Lam, Shu-Hang; Wong, Sandy W P; Tsui, Amy L M; Tang, Jervis C S; Lou, Vivian W Q

2016-06-01

The provision of end-of-life (EoL) care in long-term-care settings remains largely underdeveloped in most Chinese societies, and nursing home residents often fail to obtain good care as they approach death. This paper systematically describes the development and implementation mechanisms of a novel Dignity-Conserving EoL Care model that has been successfully adopted by three nursing homes in Hong Kong and presents preliminary evidence of its effectiveness on enhancing dignity and quality of life (QoL) of terminally ill residents. Nine terminally ill nursing home residents completed the McGill Quality of Life Questionnaire and the Nursing Facilities Quality of Life Questionnaire at baseline and 6 months post-EoL program enrollment. Wilcoxon signed rank test was used to detect significance changes in each QoL domains across time. Although significant deterioration was recorded for physical QoL, significant improvement was observed for social QoL. Moreover, a clear trend toward significant improvements was identified for the QoL domains of individuality and relationships. A holistic and compassionate caring environment, together with the core principles of family-centered care, interagency and interdisciplinary teamwork, as well as cultural-specific psycho-socio-spiritual support, are all essential elements for optimizing QoL and promoting death with dignity for nursing home residents facing morality. This study provides a useful framework to facilitate the future development of EoL care in long-term-care settings in the Chinese context. © The Author 2015. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Increasing Receipt of High-Tech/High-Cost Imaging and Its Determinants in the Last Month of Taiwanese Patients With Metastatic Cancer, 2001–2010

PubMed Central

Liu, Tsang-Wu; Hung, Yen-Ni; Soong, Thomas C.; Tang, Siew Tzuh

2015-01-01

Abstract One strategy for controlling the skyrocketing costs of cancer care may be to target high-tech/high-cost imaging at the end of life (EOL). This population-based study investigated receipt of high-tech/high-cost imaging and its determinants for Taiwanese patients with metastatic cancer in their last month of life. Individual patient-level data were linked with encrypted identification numbers from computerized administrative data in Taiwan, that is, the National Register of Deaths Database, Cancer Registration System database, and National Health Insurance claims datasets, Database of Medical Care Institutions Status, and national census statistics (population/household income). We identified receipt of computerized tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and radionuclide bone scans (BSs) for 236,911 Taiwanese cancer decedents with metastatic disease, 2001 to 2010. Associations of patient, physician, hospital, and regional factors with receiving CT, MRI, and bone scan in the last month of life were evaluated by multilevel generalized linear-mixed models. Over one-third (average [range]: 36.11% [33.07%–37.31%]) of patients with metastatic cancer received at least 1 high-tech/high-cost imaging modality in their last month (usage rates for CT, MRI, PET, and BS were 31.05%, 5.81%, 0.25%, and 8.15%, respectively). In 2001 to 2010, trends of receipt increased for CT (27.96–32.22%), MRI (4.34–6.70%), and PET (0.00–0.62%), but decreased for BS (9.47–6.57%). Facilitative determinants with consistent trends for at least 2 high-tech/high-cost imaging modalities were male gender, younger age, married, rural residence, lung cancer diagnosis, dying within 1 to 2 years of diagnosis, not under medical oncology care, and receiving care at a teaching hospital with a larger volume of terminally ill cancer patients and greater EOL care intensity. Undergoing high-tech/high-cost imaging at EOL generally was not associated with regional characteristics, healthcare resources, and EOL care intensity. To more effectively use high-tech/high-cost imaging at EOL, clinical and financial interventions should target nonmedical oncologists/hematologists affiliated with teaching hospitals that tend to aggressively treat high volumes of terminally ill cancer patients, thereby avoiding unnecessary EOL care spending and transforming healthcare systems into affordable high-quality cancer care delivery systems. PMID:26266390

Living with a Crucial Decision: A Qualitative Study of Parental Narratives Three Years after the Loss of Their Newborn in the NICU

PubMed Central

Caeymaex, Laurence; Speranza, Mario; Vasilescu, Caroline; Danan, Claude; Bourrat, Marie-Michèle

2011-01-01

Background The importance of involving parents in the end-of-life decision-making-process (EOL DMP) for their child in the neonatal intensive care unit (NICU) is recognised by ethical guidelines in numerous countries. However, studies exploring parents' opinions on the type of involvement report conflicting results. This study sought to explore parents' experience of the EOL DMP for their child in the NICU. Methods The study used a retrospective longitudinal design with a qualitative analysis of parental experience 3 years after the death of their child in four NICUs in France. 53 face-to-face interviews and 80 telephone interviews were conducted with 164 individuals. Semi-structured interviews were conducted to explore how parents perceived their role in the decision process, what they valued about physicians' attitudes in this situation and whether their long-term emotional well being varied according to their perceived role in the EOL DMP. Findings Qualitative analysis identified four types of perceived role in the DMP: shared, medical, informed parental decision, and no decision. Shared DM was the most appreciated by parents. Medical DM was experienced as positive only when it was associated with communication. Informed parental DM was associated with feelings of anxiousness and abandonment. The physicians' attitudes that were perceived as helpful in the long term were explicit sharing of responsibility, clear expression of staff preferences, and respectful care and language toward the child. Interpretation Parents find it valuable to express their opinion in the EOL DMP of their child. Nonetheless, they do need continuous emotional support and an explicit share of the responsibility for the decision. As involvement preferences and associated feelings can vary, parents should be able to decide what role they want to play. However, our study suggests that fully autonomous decisions should be misadvised in these types of tragic choices. PMID:22194873

End-of-life parental communication priorities among bereaved fathers due to cancer.

PubMed

Park, Eliza M; Deal, Allison M; Yopp, Justin M; Edwards, Teresa; Stephenson, Elise M; Hailey, Claire E; Nakamura, Zev M; Rosenstein, Donald L

2017-05-01

To elicit widowed fathers' perspectives on which domains of parenting-related communication they consider most important for dying parents to discuss at the end of life (EOL). Two hundred seventy nine fathers widowed by cancer completed a survey about their own depression and bereavement symptoms, their wife's illness, and EOL parental communication priorities. Chi square and Fisher's exact tests and logistic regression were used to evaluate relationships between maternal EOL characteristics and fathers' responses to parenting-related EOL communication priorities. Fathers identified raising children in a manner that reflected maternal wishes, whether/how to talk with children about their mother's death, and how the mother wanted to be remembered as the most important EOL communication domains. Fathers who reported that their dying wives were worried about the children were more likely to prioritize raising children in ways that reflect her wishes (p=0.01). Other EOL characteristics were not associated with communication domains. Communicating with children and maintaining emotional connection with the deceased parent are important priorities for bereaved fathers who lost a spouse to cancer. Health care providers working with seriously ill parents may improve family outcomes by supporting communication at the EOL between co-parents. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

End-of-life care in residential care homes: a retrospective study of the perspectives of family members using the VOICES questionnaire.

PubMed

Andersson, Sofia; Lindqvist, Olav; Fürst, Carl-Johan; Brännström, Margareta

2017-03-01

In Europe, residential care homes (RCHs) are replacing hospitals as the place where death occurs, and they play an important role in end-of-life (EOL) care. The aim was to describe the quality of care during the last 3 months and last 3 days of life of those who died in RCHs as reported by family members. We also investigated whether there were differences in the EOL care of younger patients (<85 years) vs. the oldest old patients (≥85 years) as reported by family members. A retrospective survey design. Deaths (n = 189) at 19 RCHs in one municipality in Sweden were included. Family members were sent the VOICES questionnaire 1 month after their elderly relative had died. Descriptive statistics were used. In the last 3 days before death, most family members reported there was enough help with nursing (93%) and personal care (78.5%). Among the family members, 86% were told that the resident was likely to die shortly. Most (94.1%) of residents were reported to have died at their preferred place. No significant difference was found between age groups. Family members also reported that about half of the elderly had pain (46.5%) and 86.4% received treatment; 55.9% had breathlessness and 39.7% received treatment. Breathlessness was significantly (p = 0.01) more common in the younger group, and they were treated more often (p = 0.006) than the oldest old. This study revealed an overall positive picture of personal and nursing care and communication. These findings indicate that the quality of EOL care at RCHs is high. Inadequate management was found for symptom relief the last days of life. This suggests that this subject merits further attention by care professionals. To achieve better quality of EOL care at RCHs, we emphasise the importance of systematically working to improve symptom relief. © 2016 Nordic College of Caring Science.

Implementation and Impact of Patient Lay Navigator-Led Advance Care Planning Conversations.

PubMed

Rocque, Gabrielle B; Dionne-Odom, J Nicholas; Sylvia Huang, Chao-Hui; Niranjan, Soumya J; Williams, Courtney P; Jackson, Bradford E; Halilova, Karina I; Kenzik, Kelly M; Bevis, Kerri S; Wallace, Audrey S; Lisovicz, Nedra; Taylor, Richard A; Pisu, Maria; Partridge, Edward E; Butler, Thomas W; Briggs, Linda A; Kvale, Elizabeth A

2017-04-01

Advance care planning (ACP) improves alignment between patient preferences for life-sustaining treatment and care received at end of life (EOL). To evaluate implementation of lay navigator-led ACP. A convergent, parallel mixed-methods design was used to evaluate implementation of navigator-led ACP across 12 cancer centers. Data collection included 1) electronic navigation records, 2) navigator surveys (n = 45), 3) claims-based patient outcomes (n = 820), and 4) semistructured navigator interviews (n = 26). Outcomes of interest included 1) the number of ACP conversations completed, 2) navigator self-efficacy, 3) patient resource utilization, hospice use, and chemotherapy at EOL, and 4) navigator-perceived barriers and facilitators to ACP. From June 1, 2014 to December 31, 2015, 50 navigators completed Respecting Choices ® First Steps ACP Facilitator training. Navigators approached 18% of patients (1319/8704); 481 completed; 472 in process; 366 declined. Navigators were more likely to approach African American patients than Caucasian patients (20% vs. 14%, P < 0.001). Significant increases in ACP self-efficacy were observed after training. The mean score for feeling prepared to conduct ACP conversations increased from 5.6/10 to 7.5/10 (P < 0.001). In comparison with patients declining ACP participation (n = 171), decedents in their final 30 days of life who engaged in ACP (n = 437) had fewer hospitalizations (46% vs. 56%, P = 0.02). Key facilitators of successful implementation included physician buy-in, patient readiness, and prior ACP experience; barriers included space limitations, identifying the "right" time to start conversations, and personal discomfort discussing EOL. A navigator-led ACP program was feasible and may be associated with lower rates of resource utilization near EOL. Copyright © 2017 American Academy of Hospice and Palliative Medicine. All rights reserved.

Systematic review of the primary research on minority ethnic groups and end-of-life care from the United Kingdom.

PubMed

Evans, Natalie; Meñaca, Arantza; Andrew, Erin V W; Koffman, Jonathan; Harding, Richard; Higginson, Irene J; Pool, Robert; Gysels, Marjolein

2012-02-01

Patients from minority ethnic groups experience lower rates of referrals to end-of-life (EoL) care services, higher levels of dissatisfaction with services, and perceive some services as culturally inappropriate. To systematically review original studies of minority ethnic groups and EoL care in the U.K. and appraise their quality. Searches were carried out in 13 electronic databases, eight journals, reference lists, and the gray literature. Studies of minority ethnic groups and EoL care in the U.K. were included. Studies were graded for quality and key themes were identified. Forty-five studies met inclusion criteria. Study quality was good on average. Identified key themes included age structure; inequality by disease group; referrals; caregivers; place of care and death; awareness of services and communication; and cultural competency. Strategies described for the reduction of inequities were partial and reactive. The format of 10 studies prevented quality grading; these were, however, reviewed as they provided unique insights. Variations in terminology and sampling frames complicated comparison across studies. The results highlight the multiple and related factors that contribute to low service use and substandard quality of services experienced by minority ethnic groups, and the need for authors to clarify what they mean by "culturally competent" EoL care. The synthesis of diverse and disparate studies underpins a number of key recommendations for health care professionals and policymakers. Tackling these epidemiological, demographic, institutional, social, and cultural factors will require a systematic and organization-wide approach rather than the current piecemeal and reactive interventions. Copyright © 2012 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

NCAR Earth Observing Laboratory's Data Tracking System

NASA Astrophysics Data System (ADS)

Cully, L. E.; Williams, S. F.

2014-12-01

The NCAR Earth Observing Laboratory (EOL) maintains an extensive collection of complex, multi-disciplinary datasets from national and international, current and historical projects accessible through field project web pages (https://www.eol.ucar.edu/all-field-projects-and-deployments). Data orders are processed through the EOL Metadata Database and Cyberinfrastructure (EMDAC) system. Behind the scenes is the institutionally created EOL Computing, Data, and Software/Data Management Group (CDS/DMG) Data Tracking System (DTS) tool. The DTS is used to track the complete life cycle (from ingest to long term stewardship) of the data, metadata, and provenance for hundreds of projects and thousands of data sets. The DTS is an EOL internal only tool which consists of three subsystems: Data Loading Notes (DLN), Processing Inventory Tool (IVEN), and Project Metrics (STATS). The DLN is used to track and maintain every dataset that comes to the CDS/DMG. The DLN captures general information such as title, physical locations, responsible parties, high level issues, and correspondence. When the CDS/DMG processes a data set, IVEN is used to track the processing status while collecting sufficient information to ensure reproducibility. This includes detailed "How To" documentation, processing software (with direct links to the EOL Subversion software repository), and descriptions of issues and resolutions. The STATS subsystem generates current project metrics such as archive size, data set order counts, "Top 10" most ordered data sets, and general information on who has ordered these data. The DTS was developed over many years to meet the specific needs of the CDS/DMG, and it has been successfully used to coordinate field project data management efforts for the past 15 years. This paper will describe the EOL CDS/DMG Data Tracking System including its basic functionality, the provenance maintained within the system, lessons learned, potential improvements, and future developments.

Evaluation of Physician and Nurse Dyad Training Procedures to Deliver a Palliative and End-of-Life Communication Intervention to Parents of Children with a Brain Tumor

PubMed Central

Hendricks-Ferguson, Verna L.; Kane, Javier R.; Pradhan, Kamnesh R.; Shih, Chie-Schin; Gauvain, Karen M.; Baker, Justin N.; Haase, Joan E.

2017-01-01

When a child’s prognosis is poor, physicians and nurses (MDs/RNs) often struggle with initiating discussions about palliative and end-of-life care (PC/EOL) early in the course of illness trajectory. We describe evaluation of training procedures used to prepare MD/RN dyads to deliver an intervention entitled: Communication Plan: Early Through End of Life (COMPLETE) intervention. Our training was delivered to 5 pediatric neuro-oncologists and 8 pediatric nurses by a team of expert consultants (i.e., in medical ethics, communication, and PC/EOL) and parent advisors. Although half of the group received training in a 1-day program and half in a 2-day program, content for all participants included 4 modules: family assessment, goal-directed treatment planning, anticipatory guidance, and staff communication and follow-up. Evaluations included dichotomous ratings and qualitative comments on content, reflection, and skills practice for each module. Positive aspects of our training included parent advisers’ insights, emphasis on hope and non-abandonment messages, written materials to facilitate PC/EOL communication, and an MD/RN dyad approach. Lessons learned and challenges related to our training procedures will be described. Overall, the MDs and RNs reported that our PC/EOL communication-training procedures were helpful and useful. Future investigators should carefully plan training procedures for PC/EOL communication interventions. PMID:25623029

End-of-life care across Southern Europe: a critical review of cultural similarities and differences between Italy, Spain and Portugal.

PubMed

Meñaca, Arantza; Evans, Natalie; Andrew, Erin V W; Toscani, Franco; Finetti, Silvia; Gómez-Batiste, Xavier; Higginson, Irene J; Harding, Richard; Pool, Robert; Gysels, Marjolein

2012-06-01

Evidence from a range of sources demonstrates that end-of-life (EoL) care practices and preferences vary across countries; culture is consistently one of the main explanations given for this. In order to understand how cultural factors are used to explain similarities and differences in EoL care between Spain, Italy and Portugal, database and hand searches were performed and cross-cutting core themes identified. Similarities included higher proportions of people who wished to die at home than actually died at home, a persistent trend for partial disclosure in Italy and Spain, low use of advance directives, and low incidence of all medical EoL decisions (with the exception of terminal sedation) compared to northern European countries. The role of religion and the importance of family ties were the two main cultural factors used to explain the similarities. Further research is needed in order to interpret the important differences that were also found. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

UK quality statements on end of life care in dementia: a systematic review of research evidence.

PubMed

Candy, Bridget; Elliott, Margaret; Moore, Kirsten; Vickerstaff, Victoria; Sampson, Elizabeth; Jones, Louise

2015-10-19

Globally, the number of people who die with dementia is increasing. The importance of a palliative approach in the care of people with dementia is recognised and there are national polices to enhance current care. In the UK implementation of these polices is promoted by the National Institute for Health and Care Excellence (NICE) Dementia Quality Standards (QS). Since publication of the QS new care interventions have been developed. To explore critically the current international research evidence on effect available to inform NICE Dementia QS relevant to end of life (EOL) care. We used systematic review methods to seek the research evidence for three statements within the Dementia QS. These are those that recommend: (1) a case management approach, (2) discussing and consideration of making a statement about future care (SFC) and (3) a palliative care assessment (PCA). We included evaluative studies of relevant interventions that used a comparative design, such as trials and cohort studies, and measured EOL care outcomes for persons dying with moderate to severe dementia. Our primary outcome of interest was whether the intervention led to a measurable impact on wellbeing for the person with dementia and their family. We assessed included studies for quality using a scale by Higginson and colleagues (2002) for assessment of quality of studies in palliative care, and two authors undertook key review processes. Data sources included Cinahl, Embase, and PsychINFO from 2001 to August 2014. Our search strategy included free text and medical subject headings relevant to population and recommended care. We found seven studies evaluating a care intervention; four assessed SFC, three PCA. None assessed case management. Studies were of weak design; all used retrospective data and relied on others for precise record keeping and for accurate recall of events. There was limited overlap in outcome measurements. Overall reported benefits were mixed. Quality statements relevant to EOL care are useful to advance practice however they have a limited evidence base. High quality empirical work is needed to establish that the recommendations in these statements are best practice.

Increased resource use in men with metastatic prostate cancer does not result in improved survival or quality of care at the end of life.

PubMed

Golan, Ron; Bernstein, Adrien N; Gu, Xiangmei; Dinerman, Brian F; Sedrakyan, Art; Hu, Jim C

2018-05-15

Cancer care and end-of-life (EOL) care contribute substantially to health care expenditures. Outside of clinical trials, to our knowledge there exists no standardized protocol to monitor disease progression in men with metastatic prostate cancer (mPCa). The objective of the current study was to evaluate the factors and outcomes associated with increased imaging and serum prostate-specific antigen use in men with mPCa. Using Surveillance, Epidemiology, and End Results-Medicare data from 2004 to 2012, the authors identified men diagnosed with mPCa with at least 6 months of follow-up. Extreme users were classified as those who had either received prostate-specific antigen testing greater than once per month, or who underwent cross-sectional imaging or bone scan more frequently than every 2 months over a 6-month period. Associations between extreme use and survival outcomes, costs, and quality of care at EOL, as measured by timing of hospice referral, frequency of emergency department visits, length of stay, and intensive care unit or hospital admissions, were examined. Overall, a total of 3026 men with mPCa were identified, 791 of whom (26%) were defined as extreme users. Extreme users were more commonly young, white/non-Hispanic, married, higher earning, and more educated (P<.001, respectively). Extreme use was not associated with improved quality of care at EOL. Yearly health care costs after diagnosis were 36.4% higher among extreme users (95% confidence interval, 27.4%-45.3%; P<.001). Increased monitoring among men with mPCa significantly increases health care costs, without a definitive improvement in survival nor quality of care at EOL noted. Monitoring for disease progression outside of clinical trials should be reserved for those in whom findings will change management. Cancer 2018;124:2212-9. © 2018 American Cancer Society. © 2018 American Cancer Society.

Cultural competence in end-of-life care: terms, definitions, and conceptual models from the British literature.

PubMed

Evans, Natalie; Meñaca, Arantza; Koffman, Jonathan; Harding, Richard; Higginson, Irene J; Pool, Robert; Gysels, Marjolein

2012-07-01

Cultural competency is increasingly recommended in policy and practice to improve end-of-life (EoL) care for minority ethnic groups in multicultural societies. It is imperative to critically analyze this approach to understand its underlying concepts. Our aim was to appraise cultural competency approaches described in the British literature on EoL care and minority ethnic groups. This is a critical review. Articles on cultural competency were identified from a systematic review of the literature on minority ethnic groups and EoL care in the United Kingdom. Terms, definitions, and conceptual models of cultural competency approaches were identified and situated according to purpose, components, and origin. Content analysis of definitions and models was carried out to identify key components. One-hundred thirteen articles on minority ethnic groups and EoL care in the United Kingdom were identified. Over half (n=60) contained a term, definition, or model for cultural competency. In all, 17 terms, 17 definitions, and 8 models were identified. The most frequently used term was "culturally sensitive," though "cultural competence" was defined more often. Definitions contained one or more of the components: "cognitive," "implementation," or "outcome." Models were categorized for teaching or use in patient assessment. Approaches were predominantly of American origin. The variety of terms, definitions, and models underpinning cultural competency approaches demonstrates a lack of conceptual clarity, and potentially complicates implementation. Further research is needed to compare the use of cultural competency approaches in diverse cultures and settings, and to assess the impact of such approaches on patient outcomes.

Rural-urban differences in end-of-life nursing home care: facility and environmental factors.

PubMed

Temkin-Greener, Helena; Zheng, Nan Tracy; Mukamel, Dana B

2012-06-01

This study examines urban-rural differences in end-of-life (EOL) quality of care provided to nursing home (NH) residents. We constructed 3 risk-adjusted EOL quality measures (QMs) for long-term decedent residents: in-hospital death, hospice referral before death, and presence of severe pain. We used CY2005-2007 100% Minimum Data Set, Medicare beneficiary file, and inpatient and hospice claims. Logistic regression models were estimated to predict the probability of each outcome conditional on decedents' risk factors. For each facility, QMs were calculated as the difference between the actual and the expected risk-adjusted outcome rates. We fit multivariate linear regression models, with fixed state effects, for each QM to assess the association with urban-rural location. We found urban-rural differences for in-hospital death and hospice QMs, but not for pain. Compared with NHs located in urban areas, facilities in smaller towns and in isolated rural areas have significantly (p < .001) worse EOL quality for in-hospital death and hospice use. Whereas the differences in these QMs are statistically significant between facilities located in large versus small towns, they are not statistically significant between facilities located in small towns and isolated rural areas. This study provides empirical evidence for urban-rural differences in EOL quality of care using a national sample of NHs. Identifying differences is a necessary first step toward improving care for dying NH residents and for bridging the urban-rural gap.

Impact of caregivers' unmet needs for supportive care on quality of terminal cancer care delivered and caregiver's workforce performance.

PubMed

Park, Sang Min; Kim, Young Jin; Kim, Samyong; Choi, Jong Soo; Lim, Ho-Yeong; Choi, Youn Seon; Hong, Young Seon; Kim, Si-Young; Heo, Dae Seog; Kang, Ki Moon; Jeong, Hyun Sik; Lee, Chang Geol; Moon, Do Ho; Choi, Jin-Young; Kong, In Sik; Yun, Young Ho

2010-06-01

Family caregivers play an important role in caring for cancer patients, but the impact of caregivers' unmet needs on the quality of end-of-life (EOL) care they deliver and on their workplace performance are less understood. We identified 1,662 family caregivers of cancer patients who had died at any of 17 hospitals in Korea during 2004. The caregivers answered a telephone questionnaire about needs that were not met when they delivered terminal cancer care and how those unmet their needs affected their workplace performance; they also answered the Quality Care Questionnaire-End of Life (QCQ-EOL). Compared with caregivers who did not have unmet needs, caregivers who had unmet needs for symptom management, financial support, or community support showed poorer QCQ-EOL scores (P < 0.01). Caregivers who had unmet needs for financial support (adjusted odds ratio (aOR) = 7.55; 95% confidential interval (CI) 3.80-15.00), psychosocial support (aOR = 6.24; 95% CI 2.95-13.05), symptom management (aOR = 3.21; 95% CI 2.26-4.54), community support (aOR = 3.82; 95% CI 2.38-6.11), or religious support (aOR = 4.55; 95% CI 1.84-11.26) were more likely to experience work limitations. Caregivers of patients receiving conventional hospital care were more likely to have unmet needs for symptom management (aOR = 1.21; 95% CI 1.00-1.47), psychosocial support (aOR = 1.99; 95% CI 1.37-2.88), and religious support (aOR = 1.73; 95% CI 1.08-2.78) than those of patients receiving palliative hospice care. Caregivers' unmet needs negatively affected both the quality of EOL care they delivered and their workplace performance. More investment in caregiver support and public policies that meet caregiver needs are needed, and hospice use should be encouraged.

Conversation Game Effectively Engages Groups of Individuals in Discussions about Death and Dying.

PubMed

Van Scoy, Lauren Jodi; Reading, Jean M; Scott, Allison M; Green, Michael J; Levi, Benjamin H

2016-06-01

Discussions about end-of-life (EOL) values, wishes, and beliefs are critical for effective advance care planning (ACP). New strategies are needed to engage individuals in EOL conversations. The study objective was to test the feasibility of using a conversation game to engage individuals in EOL discussions. This study used a mixed-methods approach. Participants played a conversation game that prompts players to answer and discuss 20 questions about death, dying, and EOL care. Participants completed pre- and postgame questionnaires and participated in postgame focus groups. Subjects were 70 healthy volunteers (18 groups of families, friends, or strangers). Demographics, emotional state, and perceived relational closeness were measured using preintervention questionnaires. Postintervention questionnaires measured conversation satisfaction, realism, self-rated quality, and emotional state. Postgame focus groups evaluated players' experiences playing the game. Using a seven-point Likert scale (1 = low score, 7 = high score), players rated game conversations as satisfying (mean [M] = 6.1, SD = 0.9), realistic (M = 5.6, SD = 0.8), and of high quality (M = 5.7, SD = 0.9). There were no negative effects on emotional state immediately postgame (M = 1.3, SD = 0.5). A thematic analysis of participants' experiences (n = 55) revealed that (1) playing the game was an enjoyable, positive experience; (2) a game is a good framing for EOL discussions; and (3) there were mixed opinions about ideal game group composition. This study established that healthy volunteers enjoyed engaging in a two-hour discussion about EOL issues when framed as a game. The game experience was a positive, satisfying, and enjoyable activity for participants. Further studies are needed to determine if health games can promote effective ACP.

Preparedness for End of Life-a Survey of Jerusalem District Nursing Homes.

PubMed

Shaulov, Adir; Frankel, Meir; Rubinow, Alan; Maaravi, Yoram; Brezis, Mayer

2015-10-01

To evaluate the quality of end-of-life (EOL) care in nursing homes. Survey and semistructured interviews. Jerusalem district nursing homes. Staff members of 28 long-term care and skilled nursing facilities in the Jerusalem area in Israel of various ethnic, religious, and administrative affiliations (N = 207). Qualitative analysis of semistructured interviews and statistical analysis of questionnaires. Most staff members reported that EOL preferences were unknown for more than 90% of residents and that fewer than 10% had a healthcare proxy. Most staff members recalled conducting fewer than five EOL conversations over the past year with residents or family members and could recall fewer than five cases in which a resident was allowed to die in the nursing home. According to staff opinions the prevalence of tube feeding was estimated at greater than 10%, initiated because of aspiration, malnutrition, and understaffing, often against family's preferences. More than 25% of staff members believed that pain management was inadequate. Knowledge about management of chronic pain was poor in half of nurses and nearly one-third of physicians. Most staff would rather not receive the treatments they administered to residents. Nursing homes in Jerusalem lack competency for quality EOL care, and there are multiple psychological, training, and policy challenges to improvement. © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.

End-of-Life Medical Costs of Medicaid Cancer Patients.

PubMed

Tangka, Florence K L; Subramanian, Sujha; Sabatino, Susan A; Howard, David H; Haber, Susan; Hoover, Sonja; Richardson, Lisa C

2015-06-01

To quantify end-of-life (EOL) medical costs for adult Medicaid beneficiaries diagnosed with cancer. We linked Medicaid administrative data with 2000-2003 cancer registry data to identify 3,512 adult Medicaid beneficiaries who died after a cancer diagnosis and matched them to a cohort of beneficiaries without cancer who died during the same period. We used multivariable regression analysis to estimate incremental per-person EOL cost after controlling for beneficiaries' age, race/ethnicity, sex, cancer site, and state of residence. End-of-life costs during the final 4 months of life were about $10,000 higher for Medicaid cancer patients than for those without cancer. Medicaid cancer patients are more intensive users of inpatient and ambulatory services than are Medicaid patients without cancer. Medicaid cancer patients who die soon after diagnosis have higher costs of care and use inpatient services more intensely than do Medicaid patients without cancer. Medicaid cancer patients incur substantially higher EOL costs than noncancer patients. This increased cost may reflect the cost of palliative care. Future studies should assess the types and timing of services provided to Medicaid cancer patients at the EOL. © Health Research and Educational Trust.

End-of-Life Medical Costs of Medicaid Cancer Patients

PubMed Central

Tangka, Florence KL; Subramanian, Sujha; Sabatino, Susan A; Howard, David H; Haber, Susan; Hoover, Sonja; Richardson, Lisa C

2015-01-01

Objectives To quantify end-of-life (EOL) medical costs for adult Medicaid beneficiaries diagnosed with cancer. Data Sources We linked Medicaid administrative data with 2000–2003 cancer registry data to identify 3,512 adult Medicaid beneficiaries who died after a cancer diagnosis and matched them to a cohort of beneficiaries without cancer who died during the same period. Study Design We used multivariable regression analysis to estimate incremental per-person EOL cost after controlling for beneficiaries' age, race/ethnicity, sex, cancer site, and state of residence. Principal Findings End-of-life costs during the final 4 months of life were about $10,000 higher for Medicaid cancer patients than for those without cancer. Medicaid cancer patients are more intensive users of inpatient and ambulatory services than are Medicaid patients without cancer. Medicaid cancer patients who die soon after diagnosis have higher costs of care and use inpatient services more intensely than do Medicaid patients without cancer. Conclusions Medicaid cancer patients incur substantially higher EOL costs than noncancer patients. This increased cost may reflect the cost of palliative care. Future studies should assess the types and timing of services provided to Medicaid cancer patients at the EOL. PMID:25424134

Advance care planning and end-of-life care in a network of rural Western Australian hospitals.

PubMed

Auret, Kirsten; Sinclair, Craig; Averill, Barbara; Evans, Sharon

2015-08-01

To provide a current perspective on end-of-life (EOL) care in regional Western Australia, with a particular focus on the final admission prior to death and the presence of documented advance care planning (ACP). Retrospective medical notes audit. One regional hospital (including colocated hospice) and four small rural hospitals in the Great Southern region of Western Australia. Ninety recently deceased patients, who died in hospitals in the region. Fifty consecutive patients from the regional hospital and 10 consecutive patients from each of the four rural hospitals were included in the audit. A retrospective medical notes audit was undertaken. A 94-item audit tool assessed patient demographics, primary diagnosis, family support, status on admission and presence of documented ACP. Detailed items described the clinical care delivered during the final admission, including communication with family, referral to palliative care, transfers, medical investigations, medical treatments and use of EOL care pathways. Fifty-two per cent were women; median age was 82 years old. Forty per cent died of malignancy. Median length of stay was 7 days. Thirty-nine per cent had formal or informal ACP documented. Rural hospitals performed comparably with the regional hospital on all measures. This study provides benchmarking information that can assist other rural hospitals and suggests ongoing work on optimal methods of measuring quality in EOL care. © 2015 National Rural Health Alliance Inc.

"Now I Don't Have to Guess": Using Pamphlets to Encourage Residents and Families/Friends to Engage in Advance Care Planning in Long-Term Care.

PubMed

Sussman, Tamara; Kaasalainen, Sharon; Bui, Matthew; Akhtar-Danesh, Noori; Mintzberg, Susan; Strachan, Patricia

2017-01-01

Objective: This article explores whether access to illness trajectory pamphlets for five conditions with high prevalence in long-term care (LTC) can encourage residents and families/friends to openly engage in advance care planning (ACP) discussions with one another and with health providers. Method: In all, 57 residents and families/friends in LTC completed surveys and 56 participated in seven focus groups that explored whether the pamphlets supported ACP engagement. Results: Survey results suggested that access to pamphlets encouraged residents and families/friends to reflect on future care (48/57, 84%), clarified what questions to ask (40/57, 70%), and increased comfort in talking about end of life (EOL) care (36/57, 63%). Discussions between relatives and friends/families (32/57, 56%) or with health providers (21/57, 37%) were less common. Focus group deliberations illuminated that while reading illness-specific information was validating, a tendency to protect one another from an emotional topic, prevented residents and families/friends from conversing with one another about EOL issues. Discussion: Having access to pamphlets with information about EOL care provides important and welcome opportunities for reflection for both residents in LTC and their families/friends. Moving residents and families/friends from reflecting on issues to discussing them together could require staff support through planned care conferences or staff initiated conversations at the bedside.

Evaluation of Physician and Nurse Dyad Training Procedures to Deliver a Palliative and End-of-Life Communication Intervention to Parents of Children with a Brain Tumor.

PubMed

Hendricks-Ferguson, Verna L; Kane, Javier R; Pradhan, Kamnesh R; Shih, Chie-Schin; Gauvain, Karen M; Baker, Justin N; Haase, Joan E

2015-01-01

When a child's prognosis is poor, physicians and nurses (MDs/RNs) often struggle with initiating discussions about palliative and end-of-life care (PC/EOL) early in the course of illness trajectory. We describe evaluation of training procedures used to prepare MD/RN dyads to deliver an intervention entitled: Communication Plan: Early Through End of Life (COMPLETE) intervention. Our training was delivered to 5 pediatric neuro-oncologists and 8 pediatric nurses by a team of expert consultants (i.e., in medical ethics, communication, and PC/EOL) and parent advisors. Although half of the group received training in a 1-day program and half in a 2-day program, content for all participants included 4 modules: family assessment, goal-directed treatment planning, anticipatory guidance, and staff communication and follow-up. Evaluations included dichotomous ratings and qualitative comments on content, reflection, and skills practice for each module. Positive aspects of our training included parent advisers' insights, emphasis on hope and non-abandonment messages, written materials to facilitate PC/EOL communication, and an MD/RN dyad approach. Lessons learned and challenges related to our training procedures will be described. Overall, the MDs and RNs reported that our PC/EOL communication-training procedures were helpful and useful. Future investigators should carefully plan training procedures for PC/EOL communication interventions. © 2015 by Association of Pediatric Hematology/Oncology Nurses.

Palliative Care in Critical Care Settings: A Systematic Review of Communication-Based Competencies Essential for Patient and Family Satisfaction.

PubMed

Schram, Andrew W; Hougham, Gavin W; Meltzer, David O; Ruhnke, Gregory W

2017-11-01

There is an emerging literature on the physician competencies most meaningful to patients and their families. However, there has been no systematic review on physician competency domains outside direct clinical care most important for patient- and family-centered outcomes in critical care settings at the end of life (EOL). Physician competencies are an essential component of palliative care (PC) provided at the EOL, but the literature on those competencies relevant for patient and family satisfaction is limited. A systematic review of this important topic can inform future research and assist in curricular development. Review of qualitative and quantitative empirical studies of the impact of physician competencies on patient- and family-reported outcomes conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for systematic reviews. The data sources used were PubMed, MEDLINE, Web of Science, and Google Scholar. Fifteen studies (5 qualitative and 10 quantitative) meeting inclusion and exclusion criteria were identified. The competencies identified as critical for the delivery of high-quality PC in critical care settings are prognostication, conflict mediation, empathic communication, and family-centered aspects of care, the latter being the competency most frequently acknowledged in the literature identified. Prognostication, conflict mediation, empathic communication, and family-centered aspects of care are the most important identified competencies for patient- and family-centered PC in critical care settings. Incorporation of education on these competencies is likely to improve patient and family satisfaction with EOL care.

Associations between United States Acculturation and the End-of-Life Experience of Caregivers of Patients with Advanced Cancer

PubMed Central

Nilsson, Matthew; Loggers, Elizabeth Trice; Paulk, Elizabeth; Stieglitz, Heather; Kupersztoch, Yankel M.; Prigerson, Holly G.

2009-01-01

Abstract Background Cultural beliefs and values influence treatment preferences for and experiences with end-of-life (EOL) care among racial and ethnic groups. Within-group variations, however, may exist based on level of acculturation. Objectives To examine the extent to which EOL treatment factors (EOL treatment preferences and physician–caregiver communication) and select psychosocial factors (mental health, complementary therapies, and internal and external social support) differ based on the level of acculturation of caregivers of patients with advanced cancer. Methods One hundred sixty-seven primary caregivers of patients with advanced cancer were interviewed as part of the multisite, prospective Coping with Cancer Study. Results Caregivers who were less acculturated were more positively predisposed to use of a feeding tube at EOL (odds ratio [OR] 0.99 [p = 0.05]), were more likely to perceive that they received too much information from their doctors (OR 0.95 [p = 0.05]), were less likely to use mental health services (OR 1.03 [p = 0.003] and OR 1.02 [p = 0.02]), and desire additional services (OR 1.03 [p = 0.10] to 1.05 [p = 0.009]) than their more acculturated counterparts. Additionally, caregivers who were less acculturated cared for patients who were less likely to report having a living will (OR 1.03 [p = 0.0003]) or durable power of attorney for health care (OR 1.02 [p = 0.007]) than more acculturated caregivers. Caregivers who were less acculturated felt their religious and spiritual needs were supported by both the community (β −0.28 [p = 0.0003]) and medical system (β −0.38 [p < 0.0001]), had higher degrees of self-efficacy (β −0.22 [p = 0.005]), and had stronger family relationships and support (β −0.27 [p = 0.0004]). Conclusions The level of acculturation of caregivers of patients with advanced cancer does contribute to differences in EOL preferences and EOL medical decision-making. PMID:19995291

Enhancing Care of Aged and Dying Prisoners: Is e-Learning a Feasible Approach?

PubMed

Loeb, Susan J; Penrod, Janice; Myers, Valerie H; Baney, Brenda L; Strickfaden, Sophia M; Kitt-Lewis, Erin; Wion, Rachel K

Prisons and jails are facing sharply increased demands in caring for aged and dying inmates. Our Toolkit for Enhancing End-of-life Care in Prisons effectively addressed end-of-life (EOL) care; however, geriatric content was limited, and the product was not formatted for broad dissemination. Prior research adapted best practices in EOL care and aging; but, delivery methods lacked emerging technology-focused learning and interactivity. Our purposes were to uncover current training approaches and preferences and to ascertain the technological capacity of correctional settings to deliver computer-based and other e-learning training. An environmental scan was conducted with 11 participants from U.S. prisons and jails to ensure proper fit, in terms of content and technology capacity, between an envisioned computer-based training product and correctional settings. Environmental scan findings focused on content of training, desirable qualities of training, prominence of "homegrown" products, and feasibility of commercial e-learning. This study identified qualities of training programs to adopt and pitfalls to avoid and revealed technology-related issues to be mindful of when designing computer-based training for correctional settings, and participants spontaneously expressed an interest in geriatrics and EOL training using this learning modality as long as training allowed for tailoring of materials.

Care and companionship in an isolating environment: Inmates attending to dying peers

PubMed Central

Hollenbeak, Christopher S.; Penrod, Janice; Smith, Carol A.; Kitt-Lewis, Erin; Crouse, Sarah B.

2013-01-01

The purpose of this study was to examine the values, beliefs, and perceptions of end-of-life (EOL) care held by inmates caring for peers approaching end of life. The study is part of a broader participatory action research project to infuse enhanced EOL care into state prisons. Face-to-face interviews using a semi-structured discussion guide were conducted with 17 male prisoners who were providing care for peers with advanced chronic illness and approaching end of life. Qualitative data were analyzed using content and thematic analyses. Key themes were: getting involved; living the role; and transforming self through caring for others. As well, contextual features at the organizational, peer, and personal levels were identified that either facilitated or impeded inmate caregiving. Provision of enhanced EOL care by inmate peers shows promise for improving prison community relations and morale, reducing suffering, and demonstrating care and compassion within the harsh prison environment. This study provides clear evidence that providing compassionate care for dying peers may result in transformative experiences for inmate caregivers. Implications for correctional nursing practice include providing training for inmate caregivers, including them in team meetings, and implementing grief support programs. Also, upholding nursing’s code of ethics and watching for predatory behavior are critical. “Prisons in the United States contain an ever growing number of aging men and women who…are incontinent, forgetful, suffering chronic illnesses, extremely ill, and dying” (Human Rights Watch, 2012, p. 4) PMID:24158099

Advance Care Planning in Patients with Primary Malignant Brain Tumors: A Systematic Review

PubMed Central

Song, Krystal; Amatya, Bhasker; Voutier, Catherine; Khan, Fary

2016-01-01

Advance care planning (ACP) is a process of reflection and communication of a person’s future health care preferences, and has been shown to improve end-of-life (EOL) care for patients. The aim of this systematic review is to present an evidence-based overview of ACP in patients with primary malignant brain tumors (pmBT). A comprehensive literature search was conducted using medical and health science electronic databases (PubMed, Cochrane, Embase, MEDLINE, ProQuest, Social Care Online, Scopus, and Web of Science) up to July 2016. Manual search of bibliographies of articles and gray literature search were also conducted. Two independent reviewers selected studies, extracted data, and assessed the methodologic quality of the studies using the Critical Appraisal Skills Program’s appraisal tools. All studies were included irrespective of the study design. A meta-analysis was not possible due to heterogeneity amongst included studies; therefore, a narrative analysis was performed for best evidence synthesis. Overall, 19 studies were included [1 randomized controlled trial (RCT), 17 cohort studies, 1 qualitative study] with 4686 participants. All studies scored “low to moderate” on the methodological quality assessment, implying high risk of bias. A single RCT evaluating a video decision support tool in facilitating ACP in pmBT patients showed a beneficial effect in promoting comfort care and gaining confidence in decision-making. However, the effect of the intervention on quality of life and care at the EOL were unclear. There was a low rate of use of ACP discussions at the EOL. Advance directive completion rates and place of death varied between different studies. Positive effects of ACP included lower hospital readmission rates, and intensive care unit utilization. None of the studies assessed mortality outcomes associated with ACP. In conclusion, this review found some beneficial effects of ACP in pmBT. The literature still remains limited in this area, with lack of intervention studies, making it difficult to identify superiority of ACP interventions in pmBT. More robust studies, with appropriate study design, outcome measures, and defined interventions are required to inform policy and practice. PMID:27822458

Experiential learning to increase palliative care competence among the Indigenous workforce: an Australian experience.

PubMed

Shahid, Shaouli; Ekberg, Stuart; Holloway, Michele; Jacka, Catherine; Yates, Patsy; Garvey, Gail; Thompson, Sandra C

2018-01-20

Improving Indigenous people's access to palliative care requires a health workforce with appropriate knowledge and skills to respond to end-of-life (EOL) issues. The Indigenous component of the Program of Experience in the Palliative Approach (PEPA) includes opportunities for Indigenous health practitioners to develop skills in the palliative approach by undertaking a supervised clinical placement of up to 5 days within specialist palliative care services. This paper presents the evaluative findings of the components of an experiential learning programme and considers the broader implications for delivery of successful palliative care education programme for Indigenous people. Semistructured interviews were conducted with PEPA staff and Indigenous PEPA participants. Interviews were recorded, transcribed and key themes identified. Participants reported that placements increased their confidence about engaging in conversations about EOL care and facilitated relationships and ongoing work collaboration with palliative care services. Management support was critical and placements undertaken in settings which had more experience caring for Indigenous people were preferred. Better engagement occurred where the programme included Indigenous staffing and leadership and where preplacement and postplacement preparation and mentoring were provided. Opportunities for programme improvement included building on existing postplacement and follow-up activities. A culturally respectful experiential learning education programme has the potential to upskill Indigenous health practitioners in EOL care. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

“Now I Don’t Have to Guess”: Using Pamphlets to Encourage Residents and Families/Friends to Engage in Advance Care Planning in Long-Term Care

PubMed Central

Sussman, Tamara; Kaasalainen, Sharon; Bui, Matthew; Akhtar-Danesh, Noori; Mintzberg, Susan; Strachan, Patricia

2017-01-01

Objective: This article explores whether access to illness trajectory pamphlets for five conditions with high prevalence in long-term care (LTC) can encourage residents and families/friends to openly engage in advance care planning (ACP) discussions with one another and with health providers. Method: In all, 57 residents and families/friends in LTC completed surveys and 56 participated in seven focus groups that explored whether the pamphlets supported ACP engagement. Results: Survey results suggested that access to pamphlets encouraged residents and families/friends to reflect on future care (48/57, 84%), clarified what questions to ask (40/57, 70%), and increased comfort in talking about end of life (EOL) care (36/57, 63%). Discussions between relatives and friends/families (32/57, 56%) or with health providers (21/57, 37%) were less common. Focus group deliberations illuminated that while reading illness-specific information was validating, a tendency to protect one another from an emotional topic, prevented residents and families/friends from conversing with one another about EOL issues. Discussion: Having access to pamphlets with information about EOL care provides important and welcome opportunities for reflection for both residents in LTC and their families/friends. Moving residents and families/friends from reflecting on issues to discussing them together could require staff support through planned care conferences or staff initiated conversations at the bedside. PMID:29308424

Patient autonomy and advance care planning: a qualitative study of oncologist and palliative care physicians' perspectives.

PubMed

Johnson, Stephanie B; Butow, Phyllis N; Kerridge, Ian; Tattersall, Martin H N

2018-02-01

Patients' are encouraged to participate in advance care planning (ACP) in order to enhance their autonomy. However, controversy exists as to what it means to be autonomous and there is limited understanding of how social and structural factors may influence cancer patients' ability to exercise their autonomy. The objective of this study is to explore oncologists' and palliative care physicians' understanding of patient autonomy, how this influences reported enactment of decision-making at the end of life (EOL), and the role of ACP in EOL care. Qualitative semi-structured interviews were conducted with consultant oncologists (n = 11) and palliative medicine doctors (n = 7) working in oncology centres and palliative care units across Australia. We found that doctors generally conceptualized autonomy in terms of freedom from interference but that there was a profound disconnect between this understanding of autonomy and clinical practice in EOL decision-making. The clinicians in our study privileged care, relationships and a 'good death' above patient autonomy, and in practice were reluctant to 'abandon' their patients to total non-interference in decision-making. Patient autonomy in healthcare is bounded, as while patients were generally encouraged to express their preferences for care, medical norms about the quality and 'reasonableness' of care, the availability of services and the patients' family relationships act to enhance or limit patients' capacity to realize their preferences. While for many, this disconnect between theory and practice did not diminish the rhetorical appeal of ACP; for others, this undermined the integrity of ACP, as well as its relevance to care. For some, ACP had little to do with patient autonomy and served numerous other ethical, practical and political functions. The ethical assumptions regarding patient autonomy embedded in academic literature and policy documents relating to ACP are disconnected from the realities of clinical care. Medical norms and professional boundaries surrounding 'good deaths' have a greater influence on care than patient preference. ACP programs, therefore, may be rejected by healthcare professionals as irrelevant to care or may have the unintended consequence of limiting patient autonomy when used as a professional tool to encourage a 'right' way to die. A singular focus on bureaucratic ACP programs, which reduce patient autonomy to a 'tick box' exercise, may fail to enhance EOL care in any meaningful way.

Physician and parent perceptions of prognosis and end-of-life experience in children with advanced heart disease.

PubMed

Balkin, Emily M; Wolfe, Joanne; Ziniel, Sonja I; Lang, Peter; Thiagarajan, Ravi; Dillis, Shay; Fynn-Thompson, Francis; Blume, Elizabeth D

2015-04-01

Little is known about how physician and parent perspectives compare regarding the prognosis and end-of-life (EOL) experience of children with advanced heart disease (AHD). The study's objective was to describe and compare parent and physician perceptions regarding prognosis and EOL experience in children with AHD. This was a cross-sectional survey study of cardiologists and bereaved parents. Study subjects were parents and cardiologists of children with primary cardiac diagnoses who died in a tertiary care pediatric hospital between January 2007 and December 2009. Inclusion required both physician and parent to have completed surveys respective to the same patient. A total of 31 parent/physician pairs formed the analytic sample. Perceptions were measured of cardiologists and bereaved parents regarding the EOL experience of children with AHD. Nearly half of parents and physicians felt that patients suffered 'a great deal,' 'a lot,' or 'somewhat' at EOL, but there was no agreement between them. At diagnosis, parents more often expected complete repair and normal lifespan while the majority of physicians expected shortened lifespan without normal quality of life. Parents who expected complete repair with normal life were more likely to report 'a lot' of suffering at EOL (p=0.002). In 43% of cases, physicians reported that the parents were prepared for the way in which their child died, while the parents reported feeling unprepared. Both parents and physicians perceive suffering at EOL in patients who die of AHD. Moreover, parent expectations at diagnosis may influence perceptions of suffering at EOL. Physicians overestimate the degree of parent preparedness for their child's death.

Closing the empathy gap in college students' judgments of end-of-life tradeoffs.

PubMed

Stephens, Joseph D W; Neal, Danielle S; Overman, Amy A

2014-08-01

When considering hypothetical end-of-life (EOL) scenarios involving 80-year-old intensive-care unit patients, young adults are more likely than older adults to judge that shorter lifespan would be a fair trade in exchange for a more pleasant death. This result has been interpreted in terms of an empathy gap, in which individuals fail to relate to the affective states of others. If so, the effect should be reduced when young adults consider scenarios involving patients similar to themselves. The present study examined college students' willingness to trade healthy lifespan for better death in EOL scenarios involving 80-year-old and 22-year-old cancer victims. Results indicated students under 30 were less likely to trade lifespan in the 22-year-old scenarios, and were less likely to trade lifespan in either set of scenarios when the 22-year-old scenarios were presented first. The findings are consistent with an empathy gap account of judgments concerning EOL care. © 2013 International Union of Psychological Science.

Negotiated reorienting: a grounded theory of nurses' end-of-life decision-making in the intensive care unit.

PubMed

Gallagher, Ann; Bousso, Regina Szylit; McCarthy, Joan; Kohlen, Helen; Andrews, Tom; Paganini, Maria Cristina; Abu-El-Noor, Nasser Ibrahim; Cox, Anna; Haas, Margit; Arber, Anne; Abu-El-Noor, Mysoon Khalil; Baliza, Michelle Freire; Padilha, Katia Grillo

2015-04-01

Intensive care units (ICUs) focus on treatment for those who are critically ill and interventions to prolong life. Ethical issues arise when decisions have to be made regarding the withdrawal and withholding of life-sustaining treatment and the shift to comfort and palliative care. These issues are particularly challenging for nurses when there are varying degrees of uncertainty regarding prognosis. Little is known about nurses' end-of-life (EoL) decision-making practice across cultures. To understand nurses' EoL decision-making practices in ICUs in different cultural contexts. We collected and analysed qualitative data using Grounded Theory. Interviews were conducted with experienced ICU nurses in university or hospital premises in five countries: Brazil, England, Germany, Ireland and Palestine. Semi-structured interviews were conducted with 51 nurses (10 in Brazil, 9 in England, 10 in Germany, 10 in Ireland and 12 nurses in Palestine). They were purposefully and theoretically selected to include nurses having a variety of characteristics and experiences concerning end-of-life (EoL) decision-making. The study used grounded theory to inform data collection and analysis. Interviews were facilitated by using key questions. The comparative analysis of the data within and across data generated by the different research teams enabled researchers to develop a deeper understanding of EoL decision-making practices in the ICU. Ethical approval was granted in each of the participating countries and voluntary informed consent obtained from each participant. The core category that emerged was 'negotiated reorienting'. Whilst nurses do not make the 'ultimate' EoL decisions, they engage in two core practices: consensus seeking (involving coaxing, information cuing and voice enabling); and emotional holding (creating time-space and comfort giving). There was consensus regarding the core concept and core practices employed by nurses in the ICUs in the five countries. However, there were some discernible differences regarding the power dynamics in nurse-doctor relationships, particularly in relation to the cultural perspectives on death and dying and in the development of palliative care. The research suggests the need for culturally sensitive ethics education and bereavement support in different cultural contexts. Copyright © 2015. Published by Elsevier Ltd.

End-of-Life Care Interventions: An Economic Analysis

PubMed Central

Pham, B; Krahn, M

2014-01-01

Background The annual cost of providing care for patients in their last year of life is estimated to account for approximately 9% of the Ontario health care budget. Access to integrated, comprehensive support and pain/symptom management appears to be inadequate and inequitable. Objective To evaluate the cost-effectiveness of end-of-life (EoL) care interventions included in the EoL care mega-analysis. Data Sources Multiple sources were used, including systematic reviews, linked health administration databases, survey data, planning documents, expert input, and additional literature searches. Review Methods We conducted a literature review of cost-effectiveness studies to inform the primary economic analysis. We conducted the primary economic analysis and budget impact analysis for an Ontario cohort of decedents and their families and included interventions pertaining to team-based models of care, patient care planning discussions, educational interventions for patients and caregivers, and supportive interventions for informal caregivers. The time horizon was the last year of life. Costs were in 2013 Canadian dollars. Effectiveness measures included days at home, percentage dying at home, and quality-adjusted life-days. We developed a Markov model; model inputs were obtained from a cohort of Ontario decedents assembled from Institute for Clinical Evaluative Sciences databases and published literature. Results In-home palliative team care was cost-effective; it increased the chance of dying at home by 10%, increased the average number of days at home (6 days) and quality-adjusted life-days (0.5 days), and it reduced costs by approximately $4,400 per patient. Expanding in-home palliative team care to those currently not receiving such services (approximately 45,000 per year, at an annual cost of $76–108 million) is likely to improve quality of life, reduce the use of acute care resources, and save $191–$385 million in health care costs. Results for the other interventions were uncertain. Limitations The cost-effectiveness analysis was based in part on the notion that resources allocated to EoL care interventions were designed to maximize quality-adjusted life-years (QALY) for patients and their family, but improving QALYs may not be the intended aim of EoL interventions. Conclusions In-home palliative team care was cost-effective, but firm conclusions about the cost-effectiveness of other interventions were not possible. PMID:26339303

End-of-Life Care Interventions: An Economic Analysis.

PubMed

Pham, B; Krahn, M

2014-01-01

The annual cost of providing care for patients in their last year of life is estimated to account for approximately 9% of the Ontario health care budget. Access to integrated, comprehensive support and pain/symptom management appears to be inadequate and inequitable. To evaluate the cost-effectiveness of end-of-life (EoL) care interventions included in the EoL care mega-analysis. Multiple sources were used, including systematic reviews, linked health administration databases, survey data, planning documents, expert input, and additional literature searches. We conducted a literature review of cost-effectiveness studies to inform the primary economic analysis. We conducted the primary economic analysis and budget impact analysis for an Ontario cohort of decedents and their families and included interventions pertaining to team-based models of care, patient care planning discussions, educational interventions for patients and caregivers, and supportive interventions for informal caregivers. The time horizon was the last year of life. Costs were in 2013 Canadian dollars. Effectiveness measures included days at home, percentage dying at home, and quality-adjusted life-days. We developed a Markov model; model inputs were obtained from a cohort of Ontario decedents assembled from Institute for Clinical Evaluative Sciences databases and published literature. In-home palliative team care was cost-effective; it increased the chance of dying at home by 10%, increased the average number of days at home (6 days) and quality-adjusted life-days (0.5 days), and it reduced costs by approximately $4,400 per patient. Expanding in-home palliative team care to those currently not receiving such services (approximately 45,000 per year, at an annual cost of $76-108 million) is likely to improve quality of life, reduce the use of acute care resources, and save $191-$385 million in health care costs. Results for the other interventions were uncertain. The cost-effectiveness analysis was based in part on the notion that resources allocated to EoL care interventions were designed to maximize quality-adjusted life-years (QALY) for patients and their family, but improving QALYs may not be the intended aim of EoL interventions. In-home palliative team care was cost-effective, but firm conclusions about the cost-effectiveness of other interventions were not possible.

Communicating With Dying Patients and Their Families: Multimedia Training in End-of-Life Care.

PubMed

Chappell, Phylliss M; Healy, Jennifer; Lee, Shuko; Medellin, Glen; Sanchez-Reilly, Sandra

2017-08-01

The need for end-of-life (EOL), high-impact education initiatives to prepare medical students to communicate with dying patients and their families and to cope with issues of death and dying, is well recognized. Third-year medical students (n = 224), during their ambulatory rotation, completed a multimedia EOL curriculum, which included pre-/posttests, an online case-based module, didactic presentation, and a tablet computer application designed to demonstrate the signs and symptoms seen in the last hours of life for families of dying patients. Pre- and posttests were compared using Pearson χ 2 or Fisher exact test, and improvement was measured by weighted κ coefficient. On preintervention surveys, the majority of students demonstrated positive attitudes toward the care of dying patients and their families. Despite this high pretest positive attitude, there was a statistically significant overall positive attitude change after the intervention. The lowest pretest positive attitudes and lowest posttest positive attitude shifts, although all statistically improved, involved addressing the thoughts and feelings of dying patients and in coping with their own emotional response. Medical students exposure to this multimedia EOL curriculum increases positive attitudes in caring for dying patients and their families.

Clergy Views on a Good Versus a Poor Death: Ministry to the Terminally Ill.

PubMed

LeBaron, Virginia T; Cooke, Amanda; Resmini, Jonathan; Garinther, Alexander; Chow, Vinca; Quiñones, Rebecca; Noveroske, Sarah; Baccari, Andrew; Smith, Patrick T; Peteet, John; Balboni, Tracy A; Balboni, Michael J

2015-12-01

Clergy are often important sources of guidance for patients and family members making medical decisions at the end-of-life (EOL). Previous research revealed spiritual support by religious communities led to more aggressive care at the EOL, particularly among minority patients. Understanding this phenomenon is important to help address disparities in EOL care. The study objective was to explore and describe clergy perspectives regarding "good" versus "poor" death within the participant's spiritual tradition. This was a qualitative, descriptive study. Community clergy from various spiritual backgrounds, geographical locations within the United States, and races/ethnicities were recruited. Participants included 35 clergy who participated in one-on-one interviews (N = 14) and two focus groups (N = 21). Semistructured interviews explored clergy viewpoints on factors related to a "good death." Principles of grounded theory were used to identify a final set of themes and subthemes. A good death was characterized by wholeness and certainty and emphasized being in relationship with God. Conversely, a "poor death" was characterized by separation, doubt, and isolation. Clergy identified four primary determinants of good versus poor death: dignity, preparedness, physical suffering, and community. Participants expressed appreciation for contextual factors that affect the death experience; some described a "middle death," or one that integrates both positive and negative elements. Location of death was not viewed as a significant contributing factor. Understanding clergy perspectives regarding quality of death can provide important insights to help improve EOL care, particularly for patients highly engaged with faith communities. These findings can inform initiatives to foster productive relationships between clergy, clinicians, and congregants and reduce health disparities.

A Nationwide Survey of Quality of End-of-Life Cancer Care in Designated Cancer Centers, Inpatient Palliative Care Units, and Home Hospices in Japan: The J-HOPE Study.

PubMed

Miyashita, Mitsunori; Morita, Tatsuya; Sato, Kazuki; Tsuneto, Satoru; Shima, Yasuo

2015-07-01

End-of-life (EOL) cancer care in general hospitals and home care has not previously been evaluated in Japan. This study aimed to evaluate EOL cancer care from the perspective of bereaved family members in nationwide designated cancer centers, inpatient palliative care units (PCUs), and home hospices in Japan. We conducted a cross-sectional, anonymous, self-report questionnaire survey for bereaved family members of cancer patients in March 2008 for 56 designated cancer centers and in June 2007 for 100 PCUs and 14 home hospices. Outcomes were overall care satisfaction, structure and process of care (Care Evaluation Scale), and achievement of a good death (Good Death Inventory). In designated cancer centers, PCUs, and home hospices, 2794 (response rate 59%), 5312 (response rate 69%), and 292 (response rate 67%) bereaved family members participated, respectively. Mean scores for overall care satisfaction were high for all places of death, at 4.3 ± 1.2 for designated cancer centers, 5.0 ± 1.2 for PCUs, and 5.0 ± 1.0 for home hospices. Designated cancer centers showed significantly lower ratings than PCUs and home hospices for structure and process of care and achievement of a good death (P = 0.0001 each). Home hospices were rated significantly higher than PCUs for achievement of a good death (P = 0.0001). The main findings of this study were: (1) overall, bereaved family members were satisfied with end-of-life care in all three places of death; (2) designated cancer centers were inferior to PCUs and home hospices and had more room for improvement; and 3) home hospices were rated higher than PCUs for achieving a good death, although home hospices remain uncommon in Japan. Copyright © 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

What do Japanese residents learn from treating dying patients? The implications for training in end-of-life care.

PubMed

Arai, Kazuko; Saiki, Takuya; Imafuku, Rintaro; Kawakami, Chihiro; Fujisaki, Kazuhiko; Suzuki, Yasuyuki

2017-11-13

How medical residents' experiences with care for dying patients affect their emotional well-being, their learning outcomes, and the formation of their professional identities is not fully understood. We examine residents' emotional states and learning occurring during the provision of care to dying patients and specifically discuss the impact of providing end-of-life (EOL) care on professional identity formation. Semi-structured interviews were conducted with 13 residents who had graduated in the last 3 to 5 years. Thematic theoretical analysis was applied, and key themes were developed based on Kolb's experiential learning cycle. Eight key themes emerged from the analysis. The residents experienced dilemmas in confronting the reality of medical uncertainty as well as a disruption of emotional state and self-efficacy. Although the residents felt a sense of helplessness and guilt, they were able to reflect on strategies for handling medical care that focused on patients and that required a truly sincere attitude. They also contemplated the importance of palliative care and communication with patients, patients' family members and medical staff. Building on these experiences, the residents rebuilt a sense of awareness that allowed them to directly engage with the type of medical care that they are likely to be called upon to perform in the future as the population continues to age. This study revealed Japanese residents' perceptions, emotions and learning processes in caring for dying patients by applying Kolb's experiential learning theory. The findings of this study may illuminate valuable pieces of knowledge for future education in EOL care.

Are life-extending treatments for terminal illnesses a special case? Exploring choices and societal viewpoints.

PubMed

McHugh, Neil; van Exel, Job; Mason, Helen; Godwin, Jon; Collins, Marissa; Donaldson, Cam; Baker, Rachel

2018-02-01

Criteria used by the National Institute for Health and Care Excellence (NICE) to assess life-extending, end-of-life (EoL) treatments imply that health gains from such treatments are valued more than other health gains. Despite claims that the policy is supported by societal values, evidence from preference elicitation studies is mixed and in-depth research has shown there are different societal viewpoints. Few studies elicit preferences for policies directly or combine different approaches to understand preferences. Survey questions were designed to investigate support for NICE EoL guidance at national and regional levels. These 'Decision Rule' and 'Treatment Choice' questions were administered to an online sample of 1496 UK respondents in May 2014. The same respondents answered questions designed to elicit their agreement with three viewpoints (previously identified and described) in relation to provision of EoL treatments for terminally ill patients. We report the findings of these choice questions and examine how they relate to each other and respondents' viewpoints. The Decision Rule questions described three policies: DA - a standard 'value for money' test, applied to all health technologies; DB - giving special consideration to all treatments for terminal illnesses; and DC - giving special consideration to specific categories of treatments for terminal illnesses e.g. life extension (as in NICE EoL guidance) or those that improve quality-of-life (QoL). Three Treatment Choices were presented: TA - improving QoL for patients with a non-terminal illness; TB - extending life for EoL patients; and TC - improving QoL at the EoL. DC received most support (45%) with most respondents giving special consideration to EoL only when treatments improved QoL. The most commonly preferred treatment choices were TA (51%) and TC (43%). Overall, this study challenges claims about public support for NICE's EoL guidance and the focus on life extension at EoL and substantiates existing evidence of plurality in societal values. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.

A management system for end-of-life tyres: a Portuguese case study.

PubMed

Ferrão, Paulo; Ribeiro, Paulo; Silva, Paulo

2008-01-01

The European Union introduced several policy instruments based in the extended producer responsibility (EPR) in order to improve the environmental performance of products and services through their life cycles. In this context, the Portuguese government decided to apply the EPR concept to tyres, and producers were obliged to constitute an end-of-life management system to promote the collection, recycling and reuse of end-of-life (EOL) tyres. This required producers, distributors, recyclers and retreaders to be identified and characterized, and local processing infrastructures to be analyzed. The information was used to design an economically optimised EOL tyre management system while promoting the activity of all EOL operators in order for the imposed collecting and recovery targets to be fulfilled. This paper discusses the interaction between the different governmental, private and academic institutions for the creation of the integrated management system for EOL tyres, the approach taken, the technical, political and legal aspects underneath them, as well as the environmental consequences induced by the creation of the management system. The results obtained during the first years of operation are reported and show an increase in the collection and recycling of EOL tyres and the consolidation of the collection and processing infrastructures.

The impact of inpatient palliative care on end of life care among older trauma patients who die after hospital discharge.

PubMed

Lilley, Elizabeth J; Lee, Katherine C; Scott, John W; Krumrei, Nicole J; Haider, Adil H; Salim, Ali; Gupta, Rajan; Cooper, Zara

2018-05-30

Palliative care is associated with lower intensity treatment and better outcomes at the end of life. Trauma surgeons play a critical role in end-of-life (EOL) care, however the impact of PC on healthcare utilization at the end of life has yet to be characterized in older trauma patients. This retrospective cohort study using 2006-2011 national Medicare claims included trauma patients ≥65 years who died within 180 days after discharge. The exposure of interest was inpatient palliative care during the trauma admission. A non-PC control group was developed by exact-matching for age, comorbidity, admission year, injury severity, length of stay, and post-discharge survival. We employed logistic regression to evaluate six EOL care outcomes: discharge to hospice, rehospitalization, skilled nursing facility (SNF) or long-term acute care hospital (LTACH) admission, death in an institutional setting, and intensive care unit (ICU) admission or receipt of life-sustaining treatments (LST) during a subsequent hospitalization. Of 294,665 patients who died within 180 days after discharge, 2.1% received inpatient PC. Among 5,693 matched pairs, inpatient PC was associated with increased odds of discharge to hospice (odds ratio [95% confidence interval] = 3.80 [3.54-4.09]) and reduced odds of rehospitalization (0.17[0.15-0.20]), SNF/LTACH admission (0.43[0.39-0.47]), death in an institutional setting (0.34[0.30-0.39]), subsequent ICU admission (0.51[0.36-0.72]), or receiving LST (0.56[0.39-0.80]). Inpatient palliative care is associated with lower intensity and less burdensome EOL care in the geriatric trauma population. Nonetheless, it remains underutilized among those who die within 6 months after discharge. Level III STUDY TYPE: Prognostic.

End-of-life care: Indian perspective

PubMed Central

Sharma, Himanshu; Jagdish, Vankar; Anusha, Prabhakaran; Bharti, Sharma

2013-01-01

According to Hinduism, the main religion of India, the end-of-life (EOL) deals with good and bad death. The WHO definition of palliative care stresses on improving not only the quality of life of patients facing incurable diseases but also their families by providing relief from the pain and suffering that includes the psychosocial and spiritual needs as well. The Indian Society of Palliative Care has been doing a commendable work and appreciable efforts are being done by the Kerala model of delivering the EOL care. The spiritual, ethical issues and ethical challenges raised when the patients are in terminal phase are also reviewed keeping in mind the socio-cultural norms. The Indian Penal Code (IPC) has lacunae, which hamper the physicians from taking proper decision in the EOL care. Some of the sections like IPC 309 are defunct and need to be changed. The Indian Society for Critical Care Medicine has developed a position statement on the patient management of the terminally ill patient in the Intensive Care Unit (ICU) which states that the society should move from the paternalistic model to the share based decision model of the West when deciding the fate of such patients. The literature review on the Indian research on palliative care shows very little emphatic results and the medical under graduates show illiteracy. To strengthen it Medical Council of India has included the palliative care in its curriculum by starting a PG course. Literature review revealed that more research from Indian perspective should be done in this area. This article studies the core issues of developing palliative care in Indian setting keeping in mind the ethical, spiritual and legal issues. PMID:23858271

Chemotherapy Near the End of Life for Chinese Patients with Solid Malignancies

PubMed Central

Sheng, Jin; Zhang, Ya‐Xiong; He, Xiao‐Bo; Fang, Wen‐Feng; Yang, Yun‐Peng; Lin, Gui‐Nan; Wu, Xuan; Li, Ning; Zhang, Jing; Zhai, Lin‐Zhu; Zhao, Yuan‐Yuan; Huang, Yan; Zhou, Ning‐Ning; Zhao, Hong‐Yun

2016-01-01

Abstract Introduction. There are increasing concerns about the negative impacts of chemotherapy near the end of life (EOL). There is discrepancy among different countries about its use, and little is known about the real‐world situation in China. Patients and Methods. This retrospective study was conducted at six representative hospitals across China. Adult decedents with a record of advanced solid cancer and palliative chemotherapy were consecutively screened from 2010 through 2014. The prevalence of EOL chemotherapy within the last 1 month of life was set as the primary outcome. The correlations among EOL chemotherapy, clinicopathological features, and overall survival (OS) were investigated. Results. A total of 3,350 decedents who had had cancer were consecutively included; 2,098 (62.6%) were male and the median age was 56 years (range, 20–88). There were 177 (5.3%), 387 (11.6%), and 837 (25.0%) patients who received EOL chemotherapy within the last 2 weeks, 1 month, and 2 months of life, respectively. We identified inferior OS (median OS, 7.1 vs. 14.2 months; hazard ratio, 1.37; 95% confidence interval [CI], 1.23–1.53; p < .001), more intensive treatments (e.g., admitted to intensive care unit [ICU] in the last month of life, received cardiopulmonary resuscitation and invasive ventilation support), and hospital death (odds ratio, 1.53; 95% CI, 1.14–2.06; p = .005) among patients who received continued chemotherapy within the last month compared with those who did not. However, subgroup analyses indicated that receiving oral agents correlated with fewer ICU admissions and lower rates of in‐hospital death. Conclusion. This study showed that EOL chemotherapy is commonly used in China. Intravenous chemotherapy at the EOL significantly correlated with poor outcomes and the role of oral anticancer agents warrants further investigation. Implications for Practice. The role of chemotherapy toward the end of life (EOL) in patients with solid cancers is debatable. This article is believed to be the first to report the current prevalence of EOL chemotherapy in China. This study found that, compared with oral anticancer agents, intravenous chemotherapy at the EOL was significantly associated with poor outcomes. Therefore, the role of oral anticancer agents at the EOL stage deserves further investigation. PMID:27789776

Chemotherapy Near the End of Life for Chinese Patients with Solid Malignancies.

PubMed

Sheng, Jin; Zhang, Ya-Xiong; He, Xiao-Bo; Fang, Wen-Feng; Yang, Yun-Peng; Lin, Gui-Nan; Wu, Xuan; Li, Ning; Zhang, Jing; Zhai, Lin-Zhu; Zhao, Yuan-Yuan; Huang, Yan; Zhou, Ning-Ning; Zhao, Hong-Yun; Zhang, Li

2017-01-01

There are increasing concerns about the negative impacts of chemotherapy near the end of life (EOL). There is discrepancy among different countries about its use, and little is known about the real-world situation in China. This retrospective study was conducted at six representative hospitals across China. Adult decedents with a record of advanced solid cancer and palliative chemotherapy were consecutively screened from 2010 through 2014. The prevalence of EOL chemotherapy within the last 1 month of life was set as the primary outcome. The correlations among EOL chemotherapy, clinicopathological features, and overall survival (OS) were investigated. A total of 3,350 decedents who had had cancer were consecutively included; 2,098 (62.6%) were male and the median age was 56 years (range, 20-88). There were 177 (5.3%), 387 (11.6%), and 837 (25.0%) patients who received EOL chemotherapy within the last 2 weeks, 1 month, and 2 months of life, respectively. We identified inferior OS (median OS, 7.1 vs. 14.2 months; hazard ratio, 1.37; 95% confidence interval [CI], 1.23-1.53; p < .001), more intensive treatments (e.g., admitted to intensive care unit [ICU] in the last month of life, received cardiopulmonary resuscitation and invasive ventilation support), and hospital death (odds ratio, 1.53; 95% CI, 1.14-2.06; p = .005) among patients who received continued chemotherapy within the last month compared with those who did not. However, subgroup analyses indicated that receiving oral agents correlated with fewer ICU admissions and lower rates of in-hospital death. This study showed that EOL chemotherapy is commonly used in China. Intravenous chemotherapy at the EOL significantly correlated with poor outcomes and the role of oral anticancer agents warrants further investigation. The Oncologist 2017;22:53-60Implications for Practice: The role of chemotherapy toward the end of life (EOL) in patients with solid cancers is debatable. This article is believed to be the first to report the current prevalence of EOL chemotherapy in China. This study found that, compared with oral anticancer agents, intravenous chemotherapy at the EOL was significantly associated with poor outcomes. Therefore, the role of oral anticancer agents at the EOL stage deserves further investigation. © AlphaMed Press 2016.

Exploring traditional end-of-life beliefs, values, expectations, and practices among Chinese women living in England: Informing culturally safe care.

PubMed

Fang, Mei Lan; Malcoe, Lorraine Halinka; Sixsmith, Judith; Wong, Louise Yuen Ming; Callender, Matthew

2015-10-01

This study explores the end-of-life (EoL) beliefs, values, practices, and expectations of a select group of harder-to-reach Chinese women living in England. A cultural safety approach was undertaken to interpret 11 in-depth, semistructured interviews. Interviews were conducted in Mandarin and Cantonese. Transcripts were translated and back-translated by two researchers. Findings were analyzed using the technical analytical principles of grounded theory. The key themes generated from our analysis include: acculturation; differential beliefs and norms in providing care: family versus health services; language and communication; Eastern versus Western spiritual practices and beliefs; and dying, death, and the hereafter. End-of-life discussions can be part of an arduous, painful, and uncomfortable process, particularly for migrants living on the margins of society in a new cultural setting. For some Chinese people living in the United Kingdom, end-of-life care requires attention to acculturation, particularly Western versus Eastern beliefs on religion, spirituality, burial practices, and provision of care, and the availability of culturally specific care, all of which encompass issues related to gender. Stories of a purposive sample of Chinese women were viewed through a cultural safety lens to gain a deeper understanding of how social and cultural norms and expectations, in addition to the pressures of acculturation, impact gendered roles and responsibilities. The analysis revealed variations between/within Eastern and Western culture that resulted in pronounced, and oftentimes gendered, differences in EoL care expectations.

NCAR Earth Observing Laboratory - An End-to-End Observational Science Enterprise

NASA Astrophysics Data System (ADS)

Rockwell, A.; Baeuerle, B.; Grubišić, V.; Hock, T. F.; Lee, W. C.; Ranson, J.; Stith, J. L.; Stossmeister, G.

2017-12-01

Researchers who want to understand and describe the Earth System require high-quality observations of the atmosphere, ocean, and biosphere. Making these observations not only requires capable research platforms and state-of-the-art instrumentation but also benefits from comprehensive in-field project management and data services. NCAR's Earth Observing Laboratory (EOL) is an end-to-end observational science enterprise that provides leadership in observational research to scientists from universities, U.S. government agencies, and NCAR. Deployment: EOL manages the majority of the NSF Lower Atmosphere Observing Facilities, which includes research aircraft, radars, lidars, profilers, and surface and sounding systems. This suite is designed to address a wide range of Earth system science - from microscale to climate process studies and from the planet's surface into the Upper Troposphere/Lower Stratosphere. EOL offers scientific, technical, operational, and logistics support to small and large field campaigns across the globe. Development: By working closely with the scientific community, EOL's engineering and scientific staff actively develop the next generation of observing facilities, staying abreast of emerging trends, technologies, and applications in order to improve our measurement capabilities. Through our Design and Fabrication Services, we also offer high-level engineering and technical expertise, mechanical design, and fabrication to the atmospheric research community. Data Services: EOL's platforms and instruments collect unique datasets that must be validated, archived, and made available to the research community. EOL's Data Management and Services deliver high-quality datasets and metadata in ways that are transparent, secure, and easily accessible. We are committed to the highest standard of data stewardship from collection to validation to archival. Discovery: EOL promotes curiosity about Earth science, and fosters advanced understanding of the processes involved in observational research. Through EOL's Education and Outreach Program, we strive to inspire and develop the next generation of observational scientists and engineers by offering a range of educational, experiential, and outreach opportunities, including engineering internships.

Study examines trends for Medicare patients at EOL.

PubMed

2011-08-01

Patients are more likely to be treated by 10 doctors or more. Researcher says that great intensity of care does not necessarily mean higher quality of care. Physicians must listen more carefully to wishes of patients at the end of life, researcher says.

Advance care planning and proxy decision making for patients with advanced Parkinson disease.

PubMed

Kwak, Jung; Wallendal, Maggie S; Fritsch, Thomas; Leo, Gary; Hyde, Trevor

2014-03-01

To examine advance care planning practices and proxy decision making by family healthcare proxies for patients with advanced Parkinson disease (PD). Sixty-four spouses and adult children, self-designated as a/the healthcare proxy for advanced patients with PD, participated in a cross-sectional survey study. Sixty patients with PD (95%) had completed a living will, but only 38% had shared the document with a physician. Among three life-support treatments--cardiopulmonary resuscitation (CPR), ventilator, and feeding tube--47% of patients opted for CPR, 16% for ventilator, and 20% for feeding tube. Forty-two percent of proxies did not know patients' preferences for one or more of the three life-support treatments. Only 28% of proxies reported that patients wanted hospice. Patients who shared advance directives with a physician were significantly less likely to choose CPR and a feeding tube and they were more likely to choose hospice. In a hypothetical end-of-life (EOL) scenario, the majority of proxies chose comfort care as the EOL goal of care (53%) and pain and symptom management only as the course of treatment option (72%); these proxy choices for patients, however, were not associated with patients' preferences for life support. Patients' proxies preferred a form of shared decision making with other family members and physicians. Advance care planning is effective when patients, families, and healthcare professionals together consider future needs for EOL care decisions. Further efforts are needed by healthcare professionals to provide evidence-based education about care options and facilitate advanced discussion and shared decision making by the patient and families.

Commentary on a participatory inquiry paradigm used to assess EOL simulation participant outcomes and design.

PubMed

Gannon, Jane M

2017-11-20

Care at the end-of-life has attracted global attention, as health care workers struggle with balancing cure based care with end-of-life care, and knowing when to transition from the former to the latter. Simulation is gaining in popularity as an education strategy to facilitate health care provider decision-making by improving communication skills with patients and family members. This commentary focuses on the authors' simulation evaluation process. When data were assessed using a participatory inquiry paradigm, the evaluation revealed far more than a formative or summative evaluation of participant knowledge and skills in this area of care. Consequently, this assessment strategy has ramifications for best practices for simulation design and evaluation.

76 FR 35221 - Proposed Collection; Comment Request; NINR End-of-Life and Palliative Care Science Needs...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-06-16

... Request; NINR End-of-Life and Palliative Care Science Needs Assessment: Funding Source Questionnaire... Collection: Title: NINR End-of-Life and Palliative Care Science Needs Assessment: Funding Source... Collection: The NINR End-of-Life Science Palliative Care (EOL PC) Needs Assessment: Funding Source...

Empowering Change Agents in Hierarchical Organizations: Participatory Action Research in Prisons

PubMed Central

Penrod, Janice; Loeb, Susan J.; Ladonne, Robert A.; Martin, Lea M.

2017-01-01

Participatory action research (PAR) approaches harness collaborative partnerships to stimulate change in defined communities. The purpose of this article is to illustrate key methodological strategies used in the application of PAR methods in the particularly challenging environment of a hierarchical organization. A study designed to promote sustainable, insider-generated system-level changes in the provision of end-of-life (EOL) care in the restrictive setting of six state prisons is used as an exemplar of the application of three cardinal principles of PAR. First, development of a collaborative network with active partnership between outsider academic researchers and insider co-researchers began with careful attention to understanding the culture and processes of prisons and gaining the support of organizational leadership, using qualitative data gathering and trust-building. During the implementation phase, promoting co-ownership of change in EOL care through the co-construction of knowledge and systems to enhance sustainable change required carefully-orchestrated strategies to maximize the collaborative spirit of the project. Co-researchers were empowered to examine their worlds and capture opportunities for change using new leadership skills role-modeled by the research team. Third, their local knowledge of the barriers inherent in the contextual reality of prisons was translated into achievable system change by production of a toolkit of formalized and well-rehearsed change strategies that collaborative teams were empowered to enact within their hierarchical prison environment. PMID:27028096

Characterizing the Public's Preferential Attitudes Toward End-of-Life Care Options: A Role for the Threshold Technique?

PubMed Central

Trafford Crump, R; Llewellyn-Thomas, H

2013-01-01

Objectives. To assess the Threshold Technique's (TT) feasibility in community-wide surveys of U.S. Medicare beneficiaries' preferences for end-of-life (EOL) care options. Study Setting. Study participants were community-dwelling Medicare beneficiaries in four different regions in the United States. Study Design. During personal interviews, participants considered four EOL scenarios, each presenting a choice between a less intense and more intense care option. Data Collection. Participants selected their initially favored option. Depending on that choice, in the subsequent TT the length of life offered by the more intense option was systematically increased or decreased until the participant “switched” to his or her initially rejected option. Principal Findings. Participants were able to select an initially favored option (in 3 of the 4 scenarios; this was the less intense option). The majority of participants were able to engage with the subsequent TT. In all scenarios, regardless of the increase/decrease in the length of life offered by the more intense option, the majority of participants were unwilling to “switch” to their initially rejected option. Conclusions. In surveys of populations' preferential attitudes toward EOL care options, the TT was a feasible elicitation method, engaging most participants and measuring the strength of their attitudes. Further methodological work is merited, involving (1) populations with various participant characteristics, and (2) different attributes in the TT task itself. PMID:23444844

Clergy Views on a Good Versus a Poor Death: Ministry to the Terminally Ill

PubMed Central

Cooke, Amanda; Resmini, Jonathan; Garinther, Alexander; Chow, Vinca; Quiñones, Rebecca; Noveroske, Sarah; Baccari, Andrew; Smith, Patrick T.; Peteet, John; Balboni, Tracy A.; Balboni, Michael J.

2015-01-01

Abstract Background: Clergy are often important sources of guidance for patients and family members making medical decisions at the end-of-life (EOL). Previous research revealed spiritual support by religious communities led to more aggressive care at the EOL, particularly among minority patients. Understanding this phenomenon is important to help address disparities in EOL care. Objective: The study objective was to explore and describe clergy perspectives regarding “good” versus “poor” death within the participant's spiritual tradition. Methods: This was a qualitative, descriptive study. Community clergy from various spiritual backgrounds, geographical locations within the United States, and races/ethnicities were recruited. Participants included 35 clergy who participated in one-on-one interviews (N = 14) and two focus groups (N = 21). Semistructured interviews explored clergy viewpoints on factors related to a “good death.” Principles of grounded theory were used to identify a final set of themes and subthemes. Results: A good death was characterized by wholeness and certainty and emphasized being in relationship with God. Conversely, a “poor death” was characterized by separation, doubt, and isolation. Clergy identified four primary determinants of good versus poor death: dignity, preparedness, physical suffering, and community. Participants expressed appreciation for contextual factors that affect the death experience; some described a “middle death,” or one that integrates both positive and negative elements. Location of death was not viewed as a significant contributing factor. Conclusions: Understanding clergy perspectives regarding quality of death can provide important insights to help improve EOL care, particularly for patients highly engaged with faith communities. These findings can inform initiatives to foster productive relationships between clergy, clinicians, and congregants and reduce health disparities. PMID:26317801

End of life care for people with dementia: The views of health professionals, social care service managers and frontline staff on key requirements for good practice

PubMed Central

Lee, Richard Philip; Bamford, Claire; Poole, Marie; McLellan, Emma; Exley, Catherine; Robinson, Louise

2017-01-01

Background Evidence consistently shows that people with advanced dementia experience suboptimal end of life care compared to those with cancer; with increased hospitalisation, inadequate pain control and fewer palliative care interventions. Understanding the views of those service managers and frontline staff who organise and provide care is crucial in order to develop better end of life care for people with dementia. Methods and findings Qualitative interviews and focus groups were conducted from 2013 to 2015 with 33 service managers and 54 staff involved in frontline care, including doctors, nurses, nursing and care home managers, service development leads, senior managers/directors, care assistants and senior care assistants/team leads. All were audio recorded and transcribed verbatim. Participants represented a diverse range of service types and occupation. Transcripts were subject to coding and thematic analysis in data meetings. Analysis of the data led to the development of seven key themes: Recognising end of life (EOL) and tools to support end of life care (EOLC), Communicating with families about EOL, Collaborative working, Continuity of care, Ensuring comfort at EOL, Supporting families, Developing and supporting staff. Each is discussed in detail and comprise individual and collective views on approaches to good end of life care for people with dementia. Conclusions The significant challenges of providing good end of life care for people with dementia requires that different forms of expertise should be recognised and used; including the skills and knowledge of care assistants. Successfully engaging with people with dementia and family members and helping them to recognise the dying trajectory requires a supportive integration of emotional and technical expertise. The study strengthens the existing evidence base in this area and will be used with a related set of studies (on the views of other stakeholders and observations and interviews conducted in four services) to develop an evidence-based intervention. PMID:28622379

End of life care for people with dementia: The views of health professionals, social care service managers and frontline staff on key requirements for good practice.

PubMed

Lee, Richard Philip; Bamford, Claire; Poole, Marie; McLellan, Emma; Exley, Catherine; Robinson, Louise

2017-01-01

Evidence consistently shows that people with advanced dementia experience suboptimal end of life care compared to those with cancer; with increased hospitalisation, inadequate pain control and fewer palliative care interventions. Understanding the views of those service managers and frontline staff who organise and provide care is crucial in order to develop better end of life care for people with dementia. Qualitative interviews and focus groups were conducted from 2013 to 2015 with 33 service managers and 54 staff involved in frontline care, including doctors, nurses, nursing and care home managers, service development leads, senior managers/directors, care assistants and senior care assistants/team leads. All were audio recorded and transcribed verbatim. Participants represented a diverse range of service types and occupation. Transcripts were subject to coding and thematic analysis in data meetings. Analysis of the data led to the development of seven key themes: Recognising end of life (EOL) and tools to support end of life care (EOLC), Communicating with families about EOL, Collaborative working, Continuity of care, Ensuring comfort at EOL, Supporting families, Developing and supporting staff. Each is discussed in detail and comprise individual and collective views on approaches to good end of life care for people with dementia. The significant challenges of providing good end of life care for people with dementia requires that different forms of expertise should be recognised and used; including the skills and knowledge of care assistants. Successfully engaging with people with dementia and family members and helping them to recognise the dying trajectory requires a supportive integration of emotional and technical expertise. The study strengthens the existing evidence base in this area and will be used with a related set of studies (on the views of other stakeholders and observations and interviews conducted in four services) to develop an evidence-based intervention.

Learning by (video) example: a randomized study of communication skills training for end-of-life and error disclosure family care conferences.

PubMed

Schmitz, Connie C; Braman, Jonathan P; Turner, Norman; Heller, Stephanie; Radosevich, David M; Yan, Yelena; Miller, Jane; Chipman, Jeffrey G

2016-11-01

Teaching residents to lead end of life (EOL) and error disclosure (ED) conferences is important. We developed and tested an intervention using videotapes of EOL and error disclosure encounters from previous Objective Structured Clinical Exams. Residents (n = 72) from general and orthopedic surgery programs at 2 sites were enrolled. Using a prospective, pre-post, block group design with stratified randomization, we hypothesized the treatment group would outperform the control on EOL and ED cases. We also hypothesized that online course usage would correlate positively with post-test scores. All residents improved (pre-post). At the group level, treatment effects were insignificant, and post-test performance was unrelated to course usage. At the subgroup level for EOL, low performers assigned to treatment scored higher than controls at post-test; and within the treatment group, post graduate year 3 residents outperformed post graduate year ​1 residents. To be effective, online curricula illustrating communication behaviors need face-to-face interaction, individual role play with feedback and discussion. Copyright © 2016 Elsevier Inc. All rights reserved.

Multi-Cultural Long Term Care Nurses’ Perceptions of Factors Influencing Patient Dignity at the End of Life

PubMed Central

Periyakoil, Vyjeyanthi S.; Stevens, Marguerite; Kraemer, Helena

2012-01-01

The goal of this mixed-methods study was to characterize the perceptions of multi-cultural long-term care nurses about patient dignity at the end-of-life (EOL). The study was conducted in a large, urban long-term care (LTC) facility. The participants were forty-five long-term care nurses and 26 terminally ill nursing home patients. Nurses completed an open-ended interview about their perceptions of the concept of dying with dignity and the data were analyzed using grounded theory methods. Main themes identified as promoting patient dignity at the EOL included treating them with respect, helping them prepare for their EOL, promoting shared decision making and providing high quality tenor of care. The nurses’ cultural and religious backgrounds influenced their perceptions of what constitutes dignity-conserving care. Foreign-born nurses stressed the need for end-of-life rituals but this was strikingly absent in the statements of US-born nurses. Foreign-born Catholic nurses stated that the dying experience should not be altered using analgesics to relieve suffering or by attempts to hasten death by forgoing curative therapy or by other means. Both nurses and terminally ill patients completed the Dignity Card-sort Tool (DCT). A comparison of the LTC nurses cohort to the terminally ill patient responses on the DCT revealed that the nurses felt that patient dignity was eroded when her/his wishes were not carried out and when s/he is treated without respect. In contrast, dying LTC patients felt that poor medical care and loss of ability to choose care options to be the most important factors leading to erosion of dignity. PMID:23496266

Is Survival Better at Hospitals With Higher “End-of-Life” Treatment Intensity?

PubMed Central

Barnato, Amber E.; Chang, Chung-Chou H.; Farrell, Max H.; Lave, Judith R.; Roberts, Mark S.; Angus, Derek C.

2013-01-01

Background Concern regarding wide variations in spending and intensive care unit use for patients at the end of life hinges on the assumption that such treatment offers little or no survival benefit. Objective To explore the relationship between hospital “end-of-life” (EOL) treatment intensity and postadmission survival. Research Design Retrospective cohort analysis of Pennsylvania Health Care Cost Containment Council discharge data April 2001 to March 2005 linked to vital statistics data through September 2005 using hospital-level correlation, admission-level marginal structural logistic regression, and pooled logistic regression to approximate a Cox survival model. Subjects A total of 1,021,909 patients ≥65 years old, incurring 2,216,815 admissions in 169 Pennsylvania acute care hospitals. Measures EOL treatment intensity (a summed index of standardized intensive care unit and life-sustaining treatment use among patients with a high predicted probability of dying [PPD] at admission) and 30- and 180-day postadmission mortality. Results There was a nonlinear negative relationship between hospital EOL treatment intensity and 30-day mortality among all admissions, although patients with higher PPD derived the greatest benefit. Compared with admission at an average intensity hospital, admission to a hospital 1 standard deviation below versus 1 standard deviation above average intensity resulted in an adjusted odds ratio of mortality for admissions at low PPD of 1.06 (1.04–1.08) versus 0.97 (0.96–0.99); average PPD: 1.06 (1.04–1.09) versus 0.97 (0.96–0.99); and high PPD: 1.09 (1.07–1.11) versus 0.97 (0.95– 0.99), respectively. By 180 days, the benefits to intensity attenuated (low PPD: 1.03 [1.01–1.04] vs. 1.00 [0.98–1.01]; average PPD: 1.03 [1.02–1.05] vs. 1.00 [0.98–1.01]; and high PPD: 1.06 [1.04–1.09] vs. 1.00 [0.98–1.02]), respectively. Conclusions Admission to higher EOL treatment intensity hospitals is associated with small gains in postadmission survival. The marginal returns to intensity diminish for admission to hospitals above average EOL treatment intensity and wane with time. PMID:20057328

Stimulation and inhibition of enzymatic hydrolysis by organosolv lignins as determined by zeta potential and hydrophobicity.

PubMed

Huang, Yang; Sun, Shaolong; Huang, Chen; Yong, Qiang; Elder, Thomas; Tu, Maobing

2017-01-01

Lignin typically inhibits enzymatic hydrolysis of cellulosic biomass, but certain organosolv lignins or lignosulfonates enhance enzymatic hydrolysis. The hydrophobic and electrostatic interactions between lignin and cellulases play critical roles in the enzymatic hydrolysis process. However, how to incorporate these two interactions into the consideration of lignin effects has not been investigated. We examined the physicochemical properties and the structures of ethanol organosolv lignins (EOL) from hardwood and softwood and ascertained the association between lignin properties and their inhibitory and stimulatory effects on enzymatic hydrolysis. The zeta potential and hydrophobicity of EOL lignin samples, isolated from organosolv pretreatment of cottonwood (CW), black willow (BW), aspen (AS), eucalyptus (EH), and loblolly pine (LP), were determined and correlated with their effects on enzymatic hydrolysis of Avicel. EOLs from CW, BW, and AS improved the 72 h hydrolysis yield by 8-12%, while EOLs from EH and LP decreased the 72 h hydrolysis yield by 6 and 16%, respectively. The results showed a strong correlation between the 72 h hydrolysis yield with hydrophobicity and zeta potential. The correlation indicated that the hydrophobicity of EOL had a negative effect and the negative zeta potential of EOL had a positive effect. HSQC NMR spectra showed that β- O -4 linkages in lignin react with ethanol to form an α -ethoxylated β- O -4' substructure (A') during organosolv pretreatment. Considerable amounts of C 2,6 -H 2,6 correlation in p -hydroxybenzoate (PB) units were observed for EOL-CW, EOL-BW, and EOL-AS, but not for EOL-EH and EOL-LP. This study revealed that the effect of lignin on enzymatic hydrolysis is a function of both hydrophobic interactions and electrostatic repulsions. The lignin inhibition is controlled by lignin hydrophobicity and the lignin stimulation is governed by the negative zeta potential. The net effect of lignin depends on the combined influence of hydrophobicity and zeta potential. This study has potential implications in biomass pretreatment for the reduction of lignin inhibition by increasing lignin negative zeta potential and decreasing hydrophobicity.

Contrasting patient, family, provider, and societal goals at the end of life complicate decision making and induce variability of care after trauma.

PubMed

Martin, Niels Douglas; Stefanelli, Anthony; Methvin, Laura; Fischer, Charles; Counsilman, MayJean; Mazandi, Vanessa; Laganosky, Dean; Zubair, Muhammad; Beekley, Alec C; Weinstein, Michael S

2014-08-01

End-of-life (EoL) decision making during critical illness and injury is important in facilitating compassionate care that is congruent with patient, family, and societal expectations. Herein, we evaluate factors that may effect and induce variability in practitioner EoL decision making, particularly years in practice, use of advance directives (ADs), and cost. An anonymous, online survey was offered to all active members of the Eastern Association for the Surgery of Trauma (n = 1,359) in June 2012. Demographic information and a series of questions dealing with common potentially influential factors were included. Responses were 5-point Likert scale based. A total of 375 responses (27.6%) were received. Ninety-two percent of the respondents were physicians, 70% were male, and 77% were from Level 1 trauma centers. Of respondents, 65.8% rely on family to make EoL decisions most or all of the time, while 80.7% feel family members are rarely or only sometimes in appropriate emotional states to make such choices. A significant number of practitioners felt comfortable making decisions without family input at all, more so with experienced practitioners as compared with those in practice for less than 15 years (38.2% and 24.1% respectively, p < 0.01).Of the practitioners, 59.6% rely on ADs most or all of the time, only 61.1% agree or strongly agree that ADs are useful, and only 56.3% feel families follow their loved one's ADs most or all of the time. A patient's family support or ability to pay for aftercare was rarely or never considered important by 80.1% of the practitioners, despite 85.1% reporting that quality of life postillness/injury was important most or all of the time. Practitioner comfort and motivation to influence EoL decision making varies with experience level. ADs are not uniformly perceived to be helpful, and costs are uncommonly considered. To improve EoL quality, these factors need to be considered. Care management study, level IV.

'Talk to me': a mixed methods study on preferred physician behaviours during end-of-life communication from the patient perspective.

PubMed

Abdul-Razzak, Amane; Sherifali, Diana; You, John; Simon, Jessica; Brazil, Kevin

2016-08-01

Despite the recognized importance of end-of-life (EOL) communication between patients and physicians, the extent and quality of such communication is lacking. We sought to understand patient perspectives on physician behaviours during EOL communication. In this mixed methods study, we conducted quantitative and qualitative strands and then merged data sets during a mixed methods analysis phase. In the quantitative strand, we used the quality of communication tool (QOC) to measure physician behaviours that predict global rating of satisfaction in EOL communication skills, while in the qualitative strand we conducted semi-structured interviews. During the mixed methods analysis, we compared and contrasted qualitative and quantitative data. Seriously ill inpatients at three tertiary care hospitals in Canada. We found convergence between qualitative and quantitative strands: patients desire candid information from their physician and a sense of familiarity. The quantitative results (n = 132) suggest a paucity of certain EOL communication behaviours in this seriously ill population with a limited prognosis. The qualitative findings (n = 16) suggest that at times, physicians did not engage in EOL communication despite patient readiness, while sometimes this may represent an appropriate deferral after assessment of a patient's lack of readiness. Avoidance of certain EOL topics may not always be a failure if it is a result of an assessment of lack of patient readiness. This has implications for future tool development: a measure could be built in to assess whether physician behaviours align with patient readiness. © 2015 The Authors. Health Expectations Published by John Wiley & Sons Ltd.

Hospice Exposure Is Associated With Lower Health Care Expenditures in Taiwanese Cancer Decedents' Last Year of Life: A Population-Based Retrospective Cohort Study.

PubMed

Hung, Yen-Ni; Wen, Fur-Hsing; Liu, Tsang-Wu; Chen, Jen-Shi; Tang, Siew Tzuh

2018-03-01

Evidence for the association of hospice exposure with lower health care expenditures at end of life (EOL) remains inconclusive and neglects EOL care being concentrated in patients' last few months. The association between hospice exposure and health care expenditures in cancer patients' last one, three, six, and 12 months was evaluated. In this population-based, retrospective cohort study, Taiwanese cancer decedents in 2001-2010 (N = 195,228) were matched 1:1, with proportions of matched hospice users reaching 87.8%, by a hospice-utilization propensity score. For each matched pair, exposure to hospice (time from hospice enrollment to death) was matched to equivalent periods for hospice nonusers before death. Hospice-care associations with health care expenditures were evaluated by hospice use/exposure interactions with multilevel linear regression modeling using generalized estimating equations. The unadjusted main effect showed lower total mean health care expenditures for hospice users than for hospice nonusers only in the last one and three months (rate ratio [95% CI]: 0.86 [0.81, 0.90] and 0.93 [0.89, 0.96], respectively). However, after accounting for exposure time, hospice care was significantly associated with lower health care expenditures at exposures of ≤30, ≤60, and ≤180 days for health care expenditures measured in the last one and three months, six months, and 12 months, respectively. Savings for patients with lengthy hospice stays were neutralized or even disappeared. Hospice care was associated with lower health care expenditures when it could actively intervene in EOL care. Hospice philosophy should be applied not only shortly before death but also throughout the dying trajectory to achieve maximum cost savings. Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

End-of-Life in Disney and Pixar Films: An opportunity for Engaging in Difficult Conversation.

PubMed

Tenzek, Kelly E; Nickels, Bonnie M

2017-01-01

This study expanded upon previous scholarship by examining end-of-life (EOL) depictions and messages of death within Disney and Pixar animated films. We argue Disney and Pixar depictions of EOL and death can provide critical opportunities for discussing death and dying processes with children and adults alike. A content analysis of 57 movies resulted in a total of 71 character deaths. These instances of death became the discourse used for analysis. The EOL discourse was coded based on five categories (character status, depiction of death, death status, emotional reaction, and causality). After quantitative analysis, the films were qualitatively analyzed. Four themes emerged from analysis, unrealistic moments, managing EOL, intentions to kill, and transformation and spiritual connection. Discussion of results, limitations, and directions for future research are included.

Knowledge, Attitudes, and Preferences of Advance Decisions, End-of-Life Care, and Place of Care and Death in Hong Kong. A Population-Based Telephone Survey of 1067 Adults.

PubMed

Chung, Roger Yat-Nork; Wong, Eliza Lai-Yi; Kiang, Nicole; Chau, Patsy Yuen-Kwan; Lau, Janice Y C; Wong, Samuel Yeung-Shan; Yeoh, Eng-Kiong; Woo, Jean W

2017-04-01

According to the 2015 Quality of Death Index published by the Intelligence Unit of the Economist, Hong Kong is ranked 22nd in terms of quality of palliative care in the world, behind many other major developed countries in Asia, including Taiwan, Singapore, Japan, and South Korea. The objectives of the present study were to describe the knowledge, attitude, and preferences of the general Hong Kong adult population across different age groups regarding end-of-life (EOL) care decisions, place of care and death, as well as advance directive (AD). This was a population-based cross-sectional survey conducted by telephone. A total of 1067 adults over 30 years old were contacted through residential telephone lines using a random sampling method and were interviewed. Information on sociodemographic factors, general health status, chronic diseases, knowledge, attitude and preferences of advance decisions, EOL care, and place of death were collected. A total of 85.7% had not heard of AD, but 60.9% would prefer to make their own AD if legislated after explanation; and for those who did not prefer to have an AD, the predominant concern was the possible change of mind afterward. Adjusted logistic regression suggested that female participants were less willing to make an AD, whereas those with prior knowledge of do-not-attempt-cardiopulmonary-resuscitation significantly increased the chance of making an AD. In terms of life-sustaining treatments, a predominant 87.6% preferred to receive appropriate palliative care that gives comfort rather than to prolong life if being diagnosed to be terminally ill; 43% disagreed that doctors should generally try to keep patients alive for as long as possible; and 86.2% agreed that the patient's own wishes should determine what treatment he/she should receive. Adjusted logistic regression showed that palliative care was more preferred by age groups 50 years or above but was less preferred by those who did not care for their family members with chronic diseases. Regarding place of death, 31.2% of the participants would choose to die at home, and among those, 19.5% would still prefer to die at home even if they did not have sufficient support. Adjusted logistic regression showed a decreased trend for all older age groups from 40-49 years to 80+ years, as well as having poor self-rated health, to prefer to die at home. Being a female participant and having education level of tertiary or above, however, had higher preference for death at home. This is the first population-representative survey of the general Hong Kong adult population on the knowledge, attitude, and preferences of AD, EOL care, and place of care/death. The main implication of this study was that preferences to have autonomy over own EOL care, to receive palliative care, and to die at home were greater than the actual practice currently, highlighting the service gaps for better EOL care in the future. Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Nurses' Experiences of End-of-life Photography in NICU Bereavement Support.

PubMed

Martel, Sara; Ives-Baine, Lori

2018-06-07

To qualitatively explore neonatal intensive care nurses' experiences with end-of-life photography as part of their bereavement support work with families. An Interpretive Phenomenological Analysis with data collected through a focus group (n = 6) and one semi-structured interview (n = 1) with neonatal nurses from a Level 3/4 NICU in a Canadian pediatric hospital. Participants' comfort with EOL photography developed over time through exposure to bereavement scenarios and positive experiences with families. Participants' experienced a feeling of pressure to balance the photography with clinical responsibilities and find the right time to introduce photography while being sensitive to family experiences. Participants experienced EOL photography as something tangible to give families and were satisfied knowing the images might play an important role in the family's healing after the NICU. All participants had come to value EOL photography as a positive and meaningful part of their work with bereaved families. Identified challenges related to balancing the practice with the unpredictable flow and demands of critical care and to developing an appreciation for and comfort with the photography as part of their healing and the families' healing. Findings contribute insight into care-provider experience that can inform best practices, training, and staff support for palliative and bereavement work in neonatal and pediatric settings. The findings suggest a need to support nurses emotionally and clinically in carrying out this photography as part of their care for families. Copyright © 2018 Elsevier Inc. All rights reserved.

Damping of surface waves due to oil emulsions in application to ocean remote sensing

NASA Astrophysics Data System (ADS)

Sergievskaya, I.; Ermakov, S.; Lazareva, T.; Lavrova, O.

2017-10-01

Applications of different radar and optical methods for detection of oil pollutions based on the effect of damping of short wind waves by surface films have been extensively studied last decades. The main problem here is poor knowledge of physical characteristics of oil films, in particular, emulsified oil layers (EOL). The latter are ranged up to 70% of all pollutants. Physical characteristics of EOL which are responsible for wave damping and respectively for possibilities of their remote sensing depend on conditions of emulsification processes, e.g., mixing due to wave breaking, on percentage of water in the oil, etc. and are not well studied by now. In this paper results of laboratory studies of damping of gravity-capillary waves due to EOL on water are presented and compared to oil layers (OL). A laboratory method used previously for monomolecular films and OL, and based on measuring the damping coefficient and wavelength of parametrically generated standing waves has been applied for determination of EOL characteristics. Investigations of characteristics of crude oil, oil emulsions and crude OL and EOL have been carried out in a wide range of surface wave frequencies (from 10 to 25 Hz) and OL and EOL film thickness (from hundredths of millimeter to a few millimeters. The selected frequency range corresponds to Bragg waves for microwave, X- to Ka-band radars typically used for ocean remote sensing. An effect of enhanced wave damping due to EOL compared to non emulsified crude OL is revealed.

Attitudes of Slovene paediatricians to end-of-life care.

PubMed

Grosek, Stefan; Orazem, Miha; Kanic, Maja; Vidmar, Gaj; Groselj, Urh

2016-03-01

The aims of this study were to assess the attitudes of Slovene paediatricians to aspects of end-of-life (EOL) care and compare these attitudes between paediatric intensivists, paediatric specialists and paediatric residents. We performed a cross-sectional survey, using a specifically designed 43-item anonymous questionnaire. We included 323 out of 586 Slovene paediatricians and residents, while 46.7% (151 of 323) of them responded to our questionnaire. More than half of intensivists (54.2%) had sought counsel from the Committee for Medical Ethics in the past as compared with 12.0% and 12.1% of specialists and residents, respectively (P < 0.001). The decision to limit life-sustaining treatment (LST) was found to be ethically acceptable in all groups of respondents. The highest level of agreement was found in residents (90.2%), followed by 83.3% among intensivists and 73.8% among specialists (P = not statistically significant (NS)). Disagreement with termination of hydration was highest among residents (85%) and intensivists (79.2%) while it was lower among specialists (66.7%) (P = NS). Patient's best interest, good clinical practice and patient's autonomous decision were graded as the top three aspects of the EOL care, while cost effectiveness and availability of patient's bed in intensive care were the least important. The decision to limit LST measures was found to be ethically acceptable for Slovene paediatricians. No major differences were found among paediatric intensivists, specialist paediatricians and paediatric residents in the attitudes towards the EOL care. © 2015 The Authors. Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

Forging a Frailty-Ready Healthcare System to Meet Population Ageing

PubMed Central

Lim, Wee Shiong; Wong, Sweet Fun; Leong, Ian; Choo, Philip; Pang, Weng Sun

2017-01-01

The beginning of the 21st century has seen health systems worldwide struggling to deliver quality healthcare amidst challenges posed by ageing populations. The increasing prevalence of frailty with older age and accompanying complexities in physical, cognitive, social and psychological dimensions renders the present modus operandi of fragmented, facility-centric, doctor-based, and illness-centered care delivery as clearly unsustainable. In line with the public health framework for action in the World Health Organization’s World Health and Ageing Report, meeting these challenges will require a systemic reform of healthcare delivery that is integrated, patient-centric, team-based, and health-centered. These reforms can be achieved through building partnerships and relationships that engage, empower, and activate patients and their support systems. To meet the challenges of population ageing, Singapore has reorganised its public healthcare into regional healthcare systems (RHSs) aimed at improving population health and the experience of care, and reducing costs. This paper will describe initiatives within the RHS frameworks of the National Health Group (NHG) and the Alexandra Health System (AHS) to forge a frailty-ready healthcare system across the spectrum, which includes the well healthy (“living well”), the well unhealthy (“living with illness”), the unwell unhealthy (“living with frailty”), and the end-of-life (EoL) (“dying well”). For instance, the AHS has adopted a community-centered population health management strategy in older housing estates such as Yishun to build a geographically-based care ecosystem to support the self-management of chronic disease through projects such as “wellness kampungs” and “share-a-pot”. A joint initiative by the Lien Foundation and Khoo Teck Puat Hospital aims to launch dementia-friendly communities across the island by building a network comprising community partners, businesses, and members of the public. At the National Healthcare Group, innovative projects to address the needs of the frail elderly have been developed in the areas of: (a) admission avoidance through joint initiatives with long-term care facilities, nurse-led geriatric assessment at the emergency department and geriatric assessment clinics; (b) inpatient care, such as the Framework for Inpatient care of the Frail Elderly, orthogeriatric services, and geriatric surgical services; and (c) discharge to care, involving community transitional care teams and the development of community infrastructure for post-discharge support; and an appropriate transition to EoL care. In the area of EoL care, the National Strategy for Palliative Care has been developed to build an integrated system to: provide care for frail elderly with advance illnesses, develop advance care programmes that respect patients’ choices, and equip healthcare professionals to cope with the challenges of EoL care. PMID:29186782

Forging a Frailty-Ready Healthcare System to Meet Population Ageing.

PubMed

Lim, Wee Shiong; Wong, Sweet Fun; Leong, Ian; Choo, Philip; Pang, Weng Sun

2017-11-24

The beginning of the 21st century has seen health systems worldwide struggling to deliver quality healthcare amidst challenges posed by ageing populations. The increasing prevalence of frailty with older age and accompanying complexities in physical, cognitive, social and psychological dimensions renders the present modus operandi of fragmented, facility-centric, doctor-based, and illness-centered care delivery as clearly unsustainable. In line with the public health framework for action in the World Health Organization's World Health and Ageing Report, meeting these challenges will require a systemic reform of healthcare delivery that is integrated, patient-centric, team-based, and health-centered. These reforms can be achieved through building partnerships and relationships that engage, empower, and activate patients and their support systems. To meet the challenges of population ageing, Singapore has reorganised its public healthcare into regional healthcare systems (RHSs) aimed at improving population health and the experience of care, and reducing costs. This paper will describe initiatives within the RHS frameworks of the National Health Group (NHG) and the Alexandra Health System (AHS) to forge a frailty-ready healthcare system across the spectrum, which includes the well healthy ("living well"), the well unhealthy ("living with illness"), the unwell unhealthy ("living with frailty"), and the end-of-life (EoL) ("dying well"). For instance, the AHS has adopted a community-centered population health management strategy in older housing estates such as Yishun to build a geographically-based care ecosystem to support the self-management of chronic disease through projects such as "wellness kampungs" and "share-a-pot". A joint initiative by the Lien Foundation and Khoo Teck Puat Hospital aims to launch dementia-friendly communities across the island by building a network comprising community partners, businesses, and members of the public. At the National Healthcare Group, innovative projects to address the needs of the frail elderly have been developed in the areas of: (a) admission avoidance through joint initiatives with long-term care facilities, nurse-led geriatric assessment at the emergency department and geriatric assessment clinics; (b) inpatient care, such as the Framework for Inpatient care of the Frail Elderly, orthogeriatric services, and geriatric surgical services; and (c) discharge to care, involving community transitional care teams and the development of community infrastructure for post-discharge support; and an appropriate transition to EoL care. In the area of EoL care, the National Strategy for Palliative Care has been developed to build an integrated system to: provide care for frail elderly with advance illnesses, develop advance care programmes that respect patients' choices, and equip healthcare professionals to cope with the challenges of EoL care.

Time from last chemotherapy to death and its correlation with the end of life care in a referral hospital

PubMed Central

Karim, Syed Mustafa; Zekri, Jamal; Abdelghany, Ehab; Dada, Reyad; Munsoor, Husna; Ahmad, Imran

2015-01-01

Background: A substantial number of cancer patients receive chemotherapy until the end of life (EoL). Various factors have been shown to be associated with receipt of chemotherapy until near death. In this study, we determine our average time from last chemotherapy to death (TLCD) and explore different factors that may be associated with decreased TLCD. Materials and Methods: A retrospective review of medical records of adult cancer patients who received chemotherapy during their illness and died in our hospital between January 2010 and January 2012 was conducted. Chi-square test and t-test were used to examine the correlation between selected factors and use of chemotherapy within 60 days of death. Multivariate analysis was used to test independent significance of factors testing positive in univariate analysis. Kaplan-Meier method was used to perform survival analysis. Results: Of the 115 cancer patients who died in the hospital, 41 (35.6%) had TLCD of 60 days or less. Patients with better performance status and those dying under medical oncology service were more likely to be in this group of patients. Univariate analysis showed that these patients were less likely to have palliative care involvement, were more likely to die of treatment related causes, and more likely to have died in the Intensive Care Unit. Multivariate analysis confirmed lack of palliative care involvement and better performance status as independent factors for TLCD less than 60 days. Survival analyses showed that patients with palliative care involvement and those dying under palliative care service were likely to have significantly longer TLCD. Conclusions: Cancer patients who have no involvement of palliative care team in their management tend to receive chemotherapy near the EoL, have more aggressive EoL care, and have higher risk of dying die from treatment related complications. Palliative care should be involved early in the care of cancer patients. PMID:25810576

Measuring comfort in caregivers and patients during late end-of-life care.

PubMed

Novak, B; Kolcaba, K; Steiner, R; Dowd, T

2001-01-01

The purpose of this study was to test several formats of end-of-life comfort instruments for patients and closely involved caregivers. Kolcaba's Comfort Theory was the theoretical framework utilized. Different response formats for two end-of-life (EOL) comfort questionnaires (for patients and caregivers, respectively), and horizontal and vertical visual analog scales for total comfort (TC) lines were compared in two phases. Evaluable data were collected from both members of 38 patient-caregiver dyads in each phase. Suitable dyads were recruited from two hospice agencies in northeastern Ohio. Cronbach's alpha for the EOL comfort questionnaire (six response Likert-type format) tested during phase I for patients was .98 and for caregivers was .97. Test-retest reliability for the vertical TC line tested during phase I for patients was .64 and for caregivers was .79. The implications of this study for nursing practice and research are derived from the American Nursing Association (ANA) position statement about EOL care, which states that comfort is the goal of nursing for this population. These instruments will be useful for assessing comfort in actively dying patients and comfort of their caregivers as well as for developing evidence-based practice for this population.

Family Communication about End-of-Life Decisions and the Enactment of the Decision-Maker Role.

PubMed

Trees, April R; Ohs, Jennifer E; Murray, Meghan C

2017-06-07

End-of-life (EOL) decisions in families are complex and emotional sites of family interaction necessitating family members coordinate roles in the EOL decision-making process. How family members in the United States enact the decision-maker role in EOL decision situations was examined through in-depth interviews with 22 individuals who participated in EOL decision-making for a family member. A number of themes emerged from the data with regard to the enactment of the decision-maker role. Families varied in how decision makers enacted the role in relation to collective family input, with consulting, informing and collaborating as different patterns of behavior. Formal family roles along with gender- and age-based roles shaped who took on the decision-maker role. Additionally, both family members and medical professionals facilitated or undermined the decision-maker's role enactment. Understanding the structure and enactment of the decision-maker role in family interaction provides insight into how individuals and/or family members perform the decision-making role within a cultural context that values autonomy and self-determination in combination with collective family action in EOL decision-making.

Empowering Change Agents in Hierarchical Organizations: Participatory Action Research in Prisons.

PubMed

Penrod, Janice; Loeb, Susan J; Ladonne, Robert A; Martin, Lea M

2016-06-01

Participatory action research (PAR) approaches harness collaborative partnerships to stimulate change in defined communities. The purpose of this article is to illustrate key methodological strategies used in the application of PAR methods in the particularly challenging environment of a hierarchical organization. A study designed to promote sustainable, insider-generated system-level changes in the provision of end-of-life (EOL) care in the restrictive setting of six state prisons is used as an exemplar of the application of three cardinal principles of PAR. First, development of a collaborative network with active partnership between outsider academic researchers and insider co-researchers began with careful attention to understanding the culture and processes of prisons and gaining the support of organizational leadership, using qualitative data gathering and trust-building. During the implementation phase, promoting co-ownership of change in EOL care through the co-construction of knowledge and systems to enhance sustainable change required carefully-orchestrated strategies to maximize the collaborative spirit of the project. Co-researchers were empowered to examine their worlds and capture opportunities for change using new leadership skills role-modeled by the research team. Third, their local knowledge of the barriers inherent in the contextual reality of prisons was translated into achievable system change by production of a toolkit of formalized and well-rehearsed change strategies that collaborative teams were empowered to enact within their hierarchical prison environment. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

How The Fault in Our Stars illuminates four themes of the Adolescent End of Life Narrative.

PubMed

Kirkman, Anna Obergfell; Hartsock, Jane A; Torke, Alexia M

2018-05-26

Adolescents who face life-limiting illness have unique developmental features and strong personal preferences around end of life (EOL) care. Understanding and documenting those preferences can be enhanced by practising narrative medicine. This paper aims to identify a new form of narrative, the Adolescent End of Life Narrative, and recognise four central themes. The Adolescent EOL Narrative can be observed in young adult fiction, The Fault in Our Stars , which elucidates the notion that terminally ill adolescents have authentic preferences about their life and death. Attaining narrative competence and appreciating the distinct perspective of the dying adolescent allows medical providers and parents to support the adolescent in achieving a good death. By thinking with the Adolescent EOL Narrative, adults can use Voicing my CHOiCES, an EOL planning guide designed for adolescents, to effectively capture the adolescent's preferences, and the adolescent can make use of this type of narrative to make sense of their lived experience. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

End-of-Life Medical Treatment Choices

PubMed Central

Chao, Li-Wei; Pagán, José A.; Soldo, Beth J.

2008-01-01

Background Out-of-pocket medical expenditures incurred prior to the death of a spouse could deplete savings and impoverish the surviving spouse. Little is known about the public’s opinion as to whether spouses should forego such end-of-life (EOL) medical care to prevent asset depletion. Objectives To analyze how elderly and near elderly adults assess hypothetical EOL medical treatment choices under different survival probabilities and out-of-pocket treatment costs. Methods Survey data on a total of 1143 adults, with 589 from the Asset and Health Dynamics Among the Oldest Old (AHEAD) and 554 from the Health and Retirement Study (HRS), were used to study EOL cancer treatment recommendations for a hypothetical anonymous married woman in her 80s. Results Respondents were more likely to recommend treatment when it was financed by Medicare than by the patient’s own savings and when it had 60% rather than 20% survival probability. Black and male respondents were more likely to recommend treatment regardless of survival probability or payment source. Treatment uptake was related to the order of presentation of treatment options, consistent with starting point bias and framing effects. Conclusions Elderly and near elderly adults would recommend that the hypothetical married woman should forego costly EOL treatment when the costs of the treatment would deplete savings. When treatment costs are covered by Medicare, respondents would make the recommendation to opt for care even if the probability of survival is low, which is consistent with moral hazard. The sequence of presentation of treatment options seems to affect patient treatment choice. PMID:18441252

End-of-life flows of multiple cycle consumer products.

PubMed

Tsiliyannis, C A

2011-11-01

Explicit expressions for the end-of-life flows (EOL) of single and multiple cycle products (MCPs) are presented, including deterministic and stochastic EOL exit. The expressions are given in terms of the physical parameters (maximum lifetime, T, annual cycling frequency, f, number of cycles, N, and early discard or usage loss). EOL flows are also obtained for hi-tech products, which are rapidly renewed and thus may not attain steady state (e.g., electronic products, passenger cars). A ten-step recursive procedure for obtaining the dynamic EOL flow evolution is proposed. Applications of the EOL expressions and the ten-step procedure are given for electric household appliances, industrial machinery, tyres, vehicles and buildings, both for deterministic and stochastic EOL exit, (normal, Weibull and uniform exit distributions). The effect of the physical parameters and the stochastic characteristics on the EOL flow is investigated in the examples: it is shown that the EOL flow profile is determined primarily by the early discard dynamics; it also depends strongly on longevity and cycling frequency: higher lifetime or early discard/loss imply lower dynamic and steady state EOL flows. The stochastic exit shapes the overall EOL dynamic profile: Under symmetric EOL exit distribution, as the variance of the distribution increases (uniform to normal to deterministic) the initial EOL flow rise becomes steeper but the steady state or maximum EOL flow level is lower. The steepest EOL flow profile, featuring the highest steady state or maximum level, as well, corresponds to skew, earlier shifted EOL exit (e.g., Weibull). Since the EOL flow of returned products consists the sink of the reuse/remanufacturing cycle (sink to recycle) the results may be used in closed loop product lifecycle management operations for scheduling and sizing reverse manufacturing and for planning recycle logistics. Decoupling and quantification of both the full age EOL and of the early discard flows is useful, the latter being the target of enacted legislation aiming at increasing reuse. Copyright © 2011 Elsevier Ltd. All rights reserved.

Lethal and sublethal effects of essential oil of Lippia sidoides (Verbenaceae) and monoterpenes on Chagas’ disease vector Rhodnius prolixus

PubMed Central

Figueiredo, Marcela B; Gomes, Geovany A; Santangelo, Jayme M; Pontes, Emerson G; Azambuja, Patricia; Garcia, Elói S; de Carvalho, Mário G

2016-01-01

The aim of this study was to identify the composition of the essential oil from leaves of Lippia sidoides (EOLS), a typical shrub commonly found in the dry northeast of Brazil, popularly known as “alecrim-pimenta”. Additionally, we investigated the nymphicidal, ovicidal, phagoinhibitory and excretion effects of EOLS, its major constituent thymol and its isomer carvacrol, on fourth instar nymphs and eggs of Rhodnius prolixus, the Chagas’ disease vector. The nymphicidal and ovicidal activity of thymol, carvacrol, and EOLS was assessed by tests using impregnated Petri dishes. The lethal concentration values (LC50) for EOLS, carvacrol, and thymol were 54.48, 32.98, and 9.38 mg/cm2, respectively. The ovicidal test showed that both carvacrol and thymol (50 mg/cm2) inhibited hatching (50% and 23.3%, respectively), while treatments with 10 mg/cm2 or 50 mg/cm2 EOLS did not affect the hatching rate at all (80% and 90%, respectively). We observed an anti-feeding effect in insects fed with blood containing natural products at the higher concentrations (100 µg/mL). Finally, excretion rate was affected by EOLS and carvacrol, but not by thymol. These findings offer novel insights into basic physiological processes that make the tested natural compounds interesting candidates for new types of insecticides. PMID:27878214

Paediatric advance care planning survey: a cross-sectional examination of congruence and discordance between adolescents with HIV/AIDS and their families.

PubMed

Lyon, Maureen E; Dallas, Ronald H; Garvie, Patricia A; Wilkins, Megan L; Garcia, Ana; Cheng, Yao Iris; Wang, Jichuan

2017-09-21

To identify patient-reported paediatric advance care planning (pACP) needs of adolescents living with HIV and to examine the congruence with their family's perception of their needs. A cross-sectional survey among six paediatric hospital-based outpatient HIV specialty clinics. Participants included 48 adolescent/family dyads (n=96 participants) within a larger study facilitating pACP. The main outcome measure was the Lyon Advance Care Planning Survey - Adolescent and Surrogate Versions-Revised. Adolescents' mean age was 18 years (range ≥14-<21); 54% male; 92% African-American; 27% with prior AIDS diagnosis. If dying, 92% believed in completing an advance directive ; 85% preferred to die at home ; 88% knowing how to say good bye ; 71% being off machines that extend life and 77% dying a natural death . Best timing for end-of-life (EOL) decisions was while healthy (38%), when first diagnosed (17%), when first sick from a life-threatening illness (4%), when first hospitalised (8%), if dying (4%) and all of the above (19%). Prevalence-adjusted bias-adjusted Kappa (PABAK) measured congruence in pACP needs within adolescent/family dyads. There was substantial congruence in that being free from pain (PABAK=0.83), and understanding your treatment choices (PABAK=0.92) were very important or important. There was discordance about being off machines that extend life (PABAK=0.08) and when is the best time to bring up EOL decisions (PABAK=0.32). Areas of discordance were associated with life-sustaining choices and when to have the EOL conversation. Targeted, adolescent/family-centred, evidence-based pACP interventions are needed to improve family understanding of youth's EOL wishes. NCT01289444; Results. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

International Space Station End-of-Life Probabilistic Risk Assessment

NASA Technical Reports Server (NTRS)

Duncan, Gary W.

2014-01-01

The International Space Station (ISS) end-of-life (EOL) cycle is currently scheduled for 2020, although there are ongoing efforts to extend ISS life cycle through 2028. The EOL for the ISS will require deorbiting the ISS. This will be the largest manmade object ever to be de-orbited therefore safely deorbiting the station will be a very complex problem. This process is being planned by NASA and its international partners. Numerous factors will need to be considered to accomplish this such as target corridors, orbits, altitude, drag, maneuvering capabilities etc. The ISS EOL Probabilistic Risk Assessment (PRA) will play a part in this process by estimating the reliability of the hardware supplying the maneuvering capabilities. The PRA will model the probability of failure of the systems supplying and controlling the thrust needed to aid in the de-orbit maneuvering.

Emergency end of life operations for CNES remote sensing satellites—Management and operational process

NASA Astrophysics Data System (ADS)

Bertrand, Régis; Alby, Fernand; Costes, Thierry; Dejoie, Joël; Delmas, Dominique-Roland; Delobette, Damien; Gibek, Isabelle; Gleyzes, Alain; Masson, Françoise; Meyer, Jean-Renaud; Moreau, Agathe; Perret, Lionel; Riclet, François; Ruiz, Hélène; Schiavon, Françoise; Spizzi, Pierre; Viallefont, Pierre; Villaret, Colette

2012-10-01

The French Space Agency (CNES) is currently operating thirteen satellites among which five remote sensing satellites. This fleet is composed of two civilian (SPOT) and three military (HELIOS) satellites and it has been recently completed by the first PLEIADES satellite which is devoted to both civil and military purposes. The CNES operation board decided to appoint a Working Group (WG) in order to anticipate and tackle issues related to the emergency End Of Life (EOL) operations due to unexpected on-board events affecting the satellite. This is of particular interest in the context of the French Law on Space Operations (LSO), entered in force on Dec. 2010, which states that any satellite operator must demonstrate its capability to control the space vehicle whatever the mission phase from the launch up to the EOL. Indeed, after several years in orbit the satellites may be affected by on-board anomalies which could damage the implementation of EOL operations, i.e. orbital manoeuvres or platform disposal. Even if automatic recovery actions ensure autonomous reconfigurations on redundant equipment, i.e. setting for instance the satellite into a safe mode, it is crucial to anticipate the consequences of failures of every equipment and functions necessary for the EOL operations. For this purpose, the WG has focused on each potential anomaly by analysing: its emergency level, as well as the EOL operations potentially inhibited by the failure and the needs of on-board software workarounds… The main contribution of the WG consisted in identifying a particular satellite configuration called "minimal Withdrawal From Service (WFS) configuration". This configuration corresponds to an operational status which involves a redundancy necessary for the EOL operations. Therefore as soon as a satellite reaches this state, a dedicated steering committee is activated and decides of the future of the satellite with respect to three options: a/. the satellite is considered safe and can continue its mission using the redundancy, b/. the EOL operations must be planned within a mid-term period, or c/. the EOL operations must be implemented as soon as possible by the operational teams. The paper describes this management and operational process illustrated with study cases of failures on SPOT and PLEIADES satellites corresponding to various emergency situations.

Why Is Spiritual Care Infrequent at the End of Life? Spiritual Care Perceptions Among Patients, Nurses, and Physicians and the Role of Training

PubMed Central

Balboni, Michael J.; Sullivan, Adam; Amobi, Adaugo; Phelps, Andrea C.; Gorman, Daniel P.; Zollfrank, Angelika; Peteet, John R.; Prigerson, Holly G.; VanderWeele, Tyler J.; Balboni, Tracy A.

2013-01-01

Purpose To determine factors contributing to the infrequent provision of spiritual care (SC) by nurses and physicians caring for patients at the end of life (EOL). Patients and Methods This is a survey-based, multisite study conducted from March 2006 through January 2009. All eligible patients with advanced cancer receiving palliative radiation therapy and oncology physician and nurses at four Boston academic centers were approached for study participation; 75 patients (response rate = 73%) and 339 nurses and physicians (response rate = 63%) participated. The survey assessed practical and operational dimensions of SC, including eight SC examples. Outcomes assessed five factors hypothesized to contribute to SC infrequency. Results Most patients with advanced cancer had never received any form of spiritual care from their oncology nurses or physicians (87% and 94%, respectively; P for difference = .043). Majorities of patients indicated that SC is an important component of cancer care from nurses and physicians (86% and 87%, respectively; P = .1). Most nurses and physicians thought that SC should at least occasionally be provided (87% and 80%, respectively; P = .16). Majorities of patients, nurses, and physicians endorsed the appropriateness of eight examples of SC (averages, 78%, 93%, and 87%, respectively; P = .01). In adjusted analyses, the strongest predictor of SC provision by nurses and physicians was reception of SC training (odds ratio [OR] = 11.20, 95% CI, 1.24 to 101; and OR = 7.22, 95% CI, 1.91 to 27.30, respectively). Most nurses and physicians had not received SC training (88% and 86%, respectively; P = .83). Conclusion Patients, nurses, and physicians view SC as an important, appropriate, and beneficial component of EOL care. SC infrequency may be primarily due to lack of training, suggesting that SC training is critical to meeting national EOL care guidelines. PMID:23248245

Pediatric Cancer Patients' Important End-of-Life Issues, Including Quality of Life: A Survey of Pediatric Oncologists and Nurses in Japan.

PubMed

Nagoya, Yuko; Miyashita, Mitsunori; Shiwaku, Hitoshi

2017-05-01

Research into the key themes and concepts of quality of life (QOL) relevant to the end-of-life (EOL) care of pediatric cancer patients in the Japanese context is imperative. This study aimed at identifying the key items and constructive concepts of QOL at EOL of pediatric cancer patients. In 2015, pediatricians and nurses were recruited from 163 pediatric oncology treatment facilities in Japan. The questionnaire was developed on the basis of a previous qualitative study. Items that were rated as "very important" or "important" by at least 80% of the respondents were considered as "common and important" QOL items. Exploratory factor analysis was performed to conceptualize QOL of the pediatric cancer patients during EOL care. A total of 157 pediatricians and 270 nurses participated in this study. Fifty-five items were refined to 35 "common and important" QOL items. On factor analysis, 12 domains (containing 29 items) were identified: playing and learning; fulfilling wishes; spending time with family; receiving relief from physical and psychological suffering; making many wonderful memories; having a good relationship with the medical staff; having a peaceful death in the presence of family; spending time with a minimum of medical treatment; living one's life as usual; spending time in a calm hospital environment; being oneself; and having a close family. Although the respondents in this study were medical care providers rather than the patients or their family members, findings should help medical staff provide better palliative care to Japanese pediatric cancer patients.

Provision of Spiritual Care to Patients With Advanced Cancer: Associations With Medical Care and Quality of Life Near Death

PubMed Central

Balboni, Tracy Anne; Paulk, Mary Elizabeth; Balboni, Michael J.; Phelps, Andrea C.; Loggers, Elizabeth Trice; Wright, Alexi A.; Block, Susan D.; Lewis, Eldrin F.; Peteet, John R.; Prigerson, Holly Gwen

2010-01-01

Purpose To determine whether spiritual care from the medical team impacts medical care received and quality of life (QoL) at the end of life (EoL) and to examine these relationships according to patient religious coping. Patients and Methods Prospective, multisite study of patients with advanced cancer from September 2002 through August 2008. We interviewed 343 patients at baseline and observed them (median, 116 days) until death. Spiritual care was defined by patient-rated support of spiritual needs by the medical team and receipt of pastoral care services. The Brief Religious Coping Scale (RCOPE) assessed positive religious coping. EoL outcomes included patient QoL and receipt of hospice and any aggressive care (eg, resuscitation). Analyses were adjusted for potential confounders and repeated according to median-split religious coping. Results Patients whose spiritual needs were largely or completely supported by the medical team received more hospice care in comparison with those not supported (adjusted odds ratio [AOR] = 3.53; 95% CI, 1.53 to 8.12, P = .003). High religious coping patients whose spiritual needs were largely or completely supported were more likely to receive hospice (AOR = 4.93; 95% CI, 1.64 to 14.80; P = .004) and less likely to receive aggressive care (AOR = 0.18; 95% CI, 0.04 to 0.79; P = .02) in comparison with those not supported. Spiritual support from the medical team and pastoral care visits were associated with higher QOL scores near death (20.0 [95% CI, 18.9 to 21.1] v 17.3 [95% CI, 15.9 to 18.8], P = .007; and 20.4 [95% CI, 19.2 to 21.1] v 17.7 [95% CI, 16.5 to 18.9], P = .003, respectively). Conclusion Support of terminally ill patients' spiritual needs by the medical team is associated with greater hospice utilization and, among high religious copers, less aggressive care at EoL. Spiritual care is associated with better patient QoL near death. PMID:20008625

Evolution of Atmosphere and Ocean Boundary Layers from Aircraft Observations and Coupled COAMPS/NCOM

DTIC Science & Technology

2012-09-01

the NCAR EOL C-130 Investigator Handbook [Available at http://www.eol.ucar.edu/instrumentation/aircraft/C-130/documentation/c- 130-investigator...sensors are summarized in Table 1. Additional details are described in the NCAR EOL C-130 Investigator Handbook, Chapter 6 (NCAR EOL , 2012). The...during the GOTEX experiment. Additional information is available in the NCAR EOL C-130 Investigator Handbook [Available at http://www.eol.ucar.edu

Oncology nurses’ communication challenges with patients and families: A qualitative study

PubMed Central

Banerjee, Smita C.; Manna, Ruth; Coyle, Nessa; Shen, Megan Johnson; Pehrson, Cassandra; Zaider, Talia; Hammonds, Stacey; Krueger, Carol A.; Parker, Patricia A.; Bylund, Carma L.

2016-01-01

The benefits of effective communication in an oncology setting are multifold and include the overall well-being of patients and health professionals, adherence to treatment regimens, psychological functioning, and improvements in quality of life. Nevertheless, there are substantial barriers and communication challenges reported by oncology nurses. This study was conducted to present a summary of communication challenges faced by oncology nurses. From November 2012 to March 2014, 121 inpatient nurses working in the oncology setting participated in an online pre-training qualitative survey that asked nurses to describe common communication challenges in communicating empathy and discussing death, dying, and end-of-life (EOL) goals of care. The results revealed six themes that describe the challenges in communicating empathically: dialectic tensions, burden of carrying bad news, lack of skills for providing empathy, perceived institutional barriers, challenging situations, and perceived dissimilarities between the nurse and the patient. The results for challenges in discussing death, dying and EOL goals of care revealed five themes: dialectic tensions, discussing specific topics related to EOL, lack of skills for providing empathy, patient/family characteristics, and perceived institutional barriers. This study emphasizes the need for institutions to provide communication skills training to their oncology nurses for navigating through challenging patient interactions. PMID:26278636

Oncology nurses' communication challenges with patients and families: A qualitative study.

PubMed

Banerjee, Smita C; Manna, Ruth; Coyle, Nessa; Shen, Megan Johnson; Pehrson, Cassandra; Zaider, Talia; Hammonds, Stacey; Krueger, Carol A; Parker, Patricia A; Bylund, Carma L

2016-01-01

The benefits of effective communication in an oncology setting are multifold and include the overall well-being of patients and health professionals, adherence to treatment regimens, psychological functioning, and improvements in quality of life. Nevertheless, there are substantial barriers and communication challenges reported by oncology nurses. This study was conducted to present a summary of communication challenges faced by oncology nurses. From November 2012 to March 2014, 121 inpatient nurses working in the oncology setting participated in an online pre-training qualitative survey that asked nurses to describe common communication challenges in communicating empathy and discussing death, dying, and end-of-life (EOL) goals of care. The results revealed six themes that describe the challenges in communicating empathically: dialectic tensions, burden of carrying bad news, lack of skills for providing empathy, perceived institutional barriers, challenging situations, and perceived dissimilarities between the nurse and the patient. The results for challenges in discussing death, dying and EOL goals of care revealed five themes: dialectic tensions, discussing specific topics related to EOL, lack of skills for providing empathy, patient/family characteristics, and perceived institutional barriers. This study emphasizes the need for institutions to provide communication skills training to their oncology nurses for navigating through challenging patient interactions. Copyright © 2015 Elsevier Ltd. All rights reserved.

An interprofessional workshop for students to improve communication and collaboration skills in end-of-life care.

PubMed

Erickson, Jeanne M; Blackhall, Leslie; Brashers, Valentina; Varhegyi, Nikole

2015-12-01

Interprofessional care is critical for patients at the end of life (EOL), but programs to teach communication skills to medical and nursing students are rare. The aims of this study were to determine whether an interprofessional workshop improves (1) student attitudes toward teamwork and (2) self-efficacy for communicating in difficult situations. Nursing and medical students attended a workshop with collaborative role play of an EOL conversation. Before the workshop, students showed different attitudes toward teamwork and collaboration and varying levels of confidence about communication skills. After the workshop, both groups reported more positive attitudes toward teamwork but a mixed picture of confidence in communication. Experiential interprofessional education workshops enhance perceptions about the benefits of teamwork, but further teaching and evaluation methods are needed to maximize the effectiveness. © The Author(s) 2014.

International Space Station End-of-Life Probabilistic Risk Assessment

NASA Technical Reports Server (NTRS)

Duncan, Gary

2014-01-01

Although there are ongoing efforts to extend the ISS life cycle through 2028, the International Space Station (ISS) end-of-life (EOL) cycle is currently scheduled for 2020. The EOL for the ISS will require de-orbiting the ISS. This will be the largest manmade object ever to be de-orbited, therefore safely de-orbiting the station will be a very complex problem. This process is being planned by NASA and its international partners. Numerous factors will need to be considered to accomplish this such as target corridors, orbits, altitude, drag, maneuvering capabilities, debris mapping etc. The ISS EOL Probabilistic Risk Assessment (PRA) will play a part in this process by estimating the reliability of the hardware supplying the maneuvering capabilities. The PRA will model the probability of failure of the systems supplying and controlling the thrust needed to aid in the de-orbit maneuvering.

Activity coefficients of NiO and CoO in CaO-Al2O3-SiO2 slag and their application to the recycling of Ni-Co-Fe-based end-of-life superalloys via remelting

NASA Astrophysics Data System (ADS)

Lu, Xin; Miki, Takahiro; Nagasaka, Tetsuya

2017-01-01

To design optimal pyrometallurgical processes for nickel and cobalt recycling, and more particularly for the end-of-life process of Ni-Co-Fe-based end-of-life (EoL) superalloys, knowledge of their activity coefficients in slags is essential. In this study, the activity coefficients of NiO and CoO in CaO-Al2O3-SiO2 slag, a candidate slag used for the EoL superalloy remelting process, were measured using gas/slag/metal equilibrium experiments. These activity coefficients were then used to consider the recycling efficiency of nickel and cobalt by remelting EoL superalloys using CaO-Al2O3-SiO2 slag. The activity coefficients of NiO and CoO in CaO-Al2O3-SiO2 slag both show a positive deviation from Raoult's law, with values that vary from 1 to 5 depending on the change in basicity. The activity coefficients of NiO and CoO peak in the slag with a composition near B = (%CaO)/(%SiO2) = 1, where B is the basicity. We observed that controlling the slag composition at approximately B = 1 effectively reduces the cobalt and nickel oxidation losses and promotes the oxidation removal of iron during the remelting process of EoL superalloys.

Essentials of Literacy: From A Pilot Site at Davis Street School To District-Wide Intervention

ERIC Educational Resources Information Center

Brown, Fay E.; Murray, Edward T.

2005-01-01

Since the mid 1990s, reading instruction has changed and so has the School Development Program's (SDP) Essentials of Literacy (EOL) process. Beginning as a teaching suggestion at one New Haven, Connecticut school, Lincoln Bassett, EOL became a pilot project at Davis Street School in New Haven for the 1996-1997 school year and continues to be an…

Analysis of the process applied to end-of-life vehicles in Authorised Treatment Facilities

NASA Astrophysics Data System (ADS)

Muñoz, C.; Garraín, D.; Franco, V.; Royo, M.; Justel, D.; Vidal, R.

2009-11-01

Authorised treatment facilities (ATFs) play a key role in the process undergone by vehicles when they reach their end of life (EoL) within the context of Directive 2000/53/EC. Whenever an EoL vehicle is received at an ATF, a certificate of destruction is issued. The process continues with the depollution of hazardous waste materials from the vehicle and dismantling of parts that will be reused or recycled. Finally, the remaining parts of the vehicle are transported to a shredding plant. Directive 2000/53/EC sets a number of environmental goals regarding the reuse and recycling of vehicle parts and the recovery of waste materials at the EoL of vehicles. These goals will condition the evolution of ATFs as they gradually become more restrictive. As of today, the goals set by Directive 2000/53/EC for the year 2006 are being met (1). However, it would be necessary to assess the situation of those parts that comprise the fraction of the vehicle that is not recycled, reused or recovered in order to predict the degree of compliance with the goals set for the year 2015 (recycling, reusing or recovering 95% by weight of EoL vehicles). The use of lighter materials—light alloys and reinforced plastics—as a vehicle weight-reducing strategy should be coordinated with the process carried out at ATFs in order to ensure compliance with the aforementioned goals. The results of our study seem to indicate that the most usual EoL scenario today—that in which practically all of the ferrous and non-ferrous metals are recycled and the lightweight fraction of vehicles and remaining inert materials are sent to a landfill—should be revised in order to reach the environmental goals set for the year 2015. To that avail, new strategies will have to be developed to allow for an adequate treatment—recycling, reuse or recovery—of those vehicle components that are presently sent to a landfill.

Pediatric advance care planning (pACP) for teens with cancer and their families: Design of a dyadic, longitudinal RCCT.

PubMed

Curtin, Katherine B; Watson, Anne E; Wang, Jichuan; Okonkwo, Obianuju C; Lyon, Maureen E

2017-11-01

Cancer is the leading cause of disease-related death for adolescents and young adults (AYAs) in the United States. Parents of AYAs with life-threatening illnesses have expressed the desire to talk to their children about end of life (EOL) care, yet, like caregivers of adult patients, struggle to initiate this conversation. Building Evidence for Effective Palliative/End of Life Care for Teens with Cancer is a longitudinal, randomized, controlled, single-blinded clinical trial aimed at evaluating the efficacy of FAmily CEntered disease-specific advance care planning (ACP) for teens with cancer (FACE-TC). A total of 130 dyads (260 subjects) composed of AYAs 14-20years old with cancer and their family decision maker (≥18years old) will be recruited from pediatric oncology programs at Akron Children's Hospital and St. Jude Children's Research Hospital. Dyads will be randomized to either the FACE-TC intervention or Treatment as Usual (TAU) control. FACE-TC intervention dyads will complete three 60-minute ACP sessions held at weekly intervals. Follow-up data will be collected at 3, 6, 12, and 18months post-intervention by a blinded research assistant (RA). The effects of FACE-TC on patient-family congruence in treatment preferences, quality of life (QOL), and advance directive completion will be analyzed. FACE-TC is an evidenced-based and patient-centered intervention that considers QOL and EOL care according to the AYA's representation of illness. The family is involved in the ACP process to facilitate shared decision making, increase understanding of the AYA's preferences, and make a commitment to honor the AYA's wishes. Copyright © 2017 Elsevier Inc. All rights reserved.

Education Intervention "Caregivers Like Me" for Latino Family Caregivers Improved Attitudes Toward Professional Assistance at End-of-life Care.

PubMed

Cruz-Oliver, Dulce M; Malmstrom, Theodore K; Fernández, Natalia; Parikh, Manas; García, Jessica; Sanchez-Reilly, Sandra

2016-07-01

This study explores the ability of a culturally sensitive and case-based education intervention, Caregivers Like Me, to improve knowledge and attitudes regarding end-of-life (EOL) resources among Latino caregivers. A multicentered, cross-sectional study of Latino communities from different geographical regions and cultural backgrounds. An educational intervention was administered to family caregivers of Latino elders using a case-based video "telenovela" and pretest-posttest questionnaires. Participants (N = 145) were mostly females (79%) with mean age of 56 ± 15 years. They reported active learning from intervention (91%) and high satisfaction (92%) with educational experience. Both caregiver stress self-awareness and willingness to accept professional help improved significantly from pretest to posttest. A culturally sensitive educational intervention increased Latino caregivers' self-awareness about caregiver stress and the need to consider professional assistance for EOL care. © The Author(s) 2015.

Centenarians' End-of-Life Thoughts and Plans: Is Their Social Network on the Same Page?

PubMed

Boerner, Kathrin; Kim, Kyungmin; Kim, Yijung; Rott, Christoph; Jopp, Daniela S

2018-05-22

To explore how centenarians think about and plan for the end of life (EOL) and to what extent their primary contacts (proxy informants) are aware of these thoughts. Population-based study with semistructured in-person interviews. Defined geographical region approximately 60 km around Heidelberg, Germany. Subsample drawn from the larger study of centenarians (N = 78) with data on centenarians' EOL thoughts from the centenarian and the proxy informant. Centenarians reported on their thoughts about the EOL, perception of the EOL as threatening, longing for death, engagement in any EOL planning, and type of EOL plan (will, living will, healthcare surrogate) in place. Proxy respondents answered the same set of questions based on what they thought the centenarians' perspective was. In nearly half of cases, proxies misjudged whether the centenarian thought about EOL. Although only few centenarians perceived the EOL as threatening, and approximately one-quarter reported longing for death, proxies overestimated centenarians' reports on the former and underestimated the latter. Proxies reported more centenarian EOL planning than centenarians themselves. Even though enrolled proxies were mostly persons very close to the centenarian, many of them did not seem to be well informed about the centenarians' thoughts and plans regarding the EOL, suggesting a lack of communication between centenarians and social network members in this respect. Healthcare professionals should be aware that, even for very old adults approaching the end of their lives, discussions about EOL and EOL planning may need to be actively encouraged and supported. © 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.

Planning and Providing End-of-life Care in Rural Areas

ERIC Educational Resources Information Center

Wilson, Donna M.; Justice, Christopher; Sheps, Sam; Thomas, Roger; Reid, Pam; Leibovici, Karen

2006-01-01

Context: Approximately 20% of North Americans and 25% of Europeans reside in rural areas. Planning and providing end-of-life (EOL) care in rural areas presents some unique challenges. Purpose: In order to understand these challenges, and other important issues or circumstances, a literature search was conducted to assess the state of science on…

Parental perceptions of forgoing artificial nutrition and hydration during end-of-life care.

PubMed

Rapoport, Adam; Shaheed, Jenny; Newman, Christine; Rugg, Maria; Steele, Rose

2013-05-01

Forgoing artificial nutrition and hydration (FANH) in children at the end of life (EOL) is a medically, legally, and ethically acceptable practice under specific circumstances. However, most of the evidence on FANH involves dying adults. There is a paucity of pediatric evidence to guide health care providers' and parents' decision-making around this practice. Objectives were (1) to explore the experiences of bereaved parents when a decision had been made to FANH during EOL care for their child and (2) to describe the perceived quality of death in these children, as reported by their parents. This was a qualitative study using in-depth interviews with parents whose children died after a decision to FANH. Parental perceptions about the experience and their child's quality of death were explored. Interviews were audiotaped and transcribed, then data were analyzed by using interpretive description methodology. All parents were satisfied with their decision to FANH and believed that their child's death was generally peaceful and comfortable. The child's perceived poor quality of life was central to the decision to FANH, with feeding intolerance often contributing to this perception. Despite overall satisfaction, all parents had doubts and questions about the decision and benefited from ongoing assurances from the clinical team. FANH in children at the EOL is an acceptable form of palliation for some parents and may contribute to a death that is perceived to be peaceful and comfortable. In situations in which FANH may be a reasonable possibility, physicians should be prepared to introduce the option.

The Encyclopedia of Life v2: Providing Global Access to Knowledge About Life on Earth

PubMed Central

2014-01-01

Abstract The Encyclopedia of Life (EOL, http://eol.org) aims to provide unprecedented global access to a broad range of information about life on Earth. It currently contains 3.5 million distinct pages for taxa and provides content for 1.3 million of those pages. The content is primarily contributed by EOL content partners (providers) that have a more limited geographic, taxonomic or topical scope. EOL aggregates these data and automatically integrates them based on associated scientific names and other classification information. EOL also provides interfaces for curation and direct content addition. All materials in EOL are either in the public domain or licensed under a Creative Commons license. In addition to the web interface, EOL is also accessible through an Application Programming Interface. In this paper, we review recent developments added for Version 2 of the web site and subsequent releases through Version 2.2, which have made EOL more engaging, personal, accessible and internationalizable. We outline the core features and technical architecture of the system. We summarize milestones achieved so far by EOL to present results of the current system implementation and establish benchmarks upon which to judge future improvements. We have shown that it is possible to successfully integrate large amounts of descriptive biodiversity data from diverse sources into a robust, standards-based, dynamic, and scalable infrastructure. Increasing global participation and the emergence of EOL-powered applications demonstrate that EOL is becoming a significant resource for anyone interested in biological diversity. PMID:24891832

Pilot Evaluation of a Palliative and End-of-Life Communication Intervention for Parents of Children With a Brain Tumor.

PubMed

Hendricks-Ferguson, Verna L; Pradhan, Kamnesh; Shih, Chie-Schin; Gauvain, Karen M; Kane, Javier R; Liu, Jingxia; Haase, Joan E

Providing timely palliative and end-of-life care (PC/EOL) information to parents of children with a serious illness is a national health care priority. The goals of this study were to determine feasibility, acceptability, and parent responses related to a PC/EOL communication intervention, titled "Communication Plan: Early through End of Life (COMPLETE)" to parents of children with a brain tumor. The study was a 2-site prospective, single-group pilot study targeting parents' stress and coping outcomes. The sample included 13 parents of 11 children (ie, 11 families). During the first 6 months postdiagnosis, we evaluated parent outcomes at 4 time points (baseline and 3 post-sessions). Our findings included significant decline in decision regret ( P = .0089); strong, significantly increased hope ( P ≤ .0001); and significantly decreased uncertainty ( P = .04). Over time, more than half of the parents (61.5%) preferred to receive information about their child's current condition and PC/EOL options. Our findings provide evidence to suggest that the COMPLETE intervention is feasible and acceptable and produces promising effects on 3 parent outcomes (ie, decision regret, hope, and uncertainty) in parents of children with a brain tumor. Further research is indicated to evaluate COMPLETE with a larger sample of parents of children with cancer and with a control group.

Survey of controversial issues of end-of-life treatment decisions in Korea: similarities and discrepancies between healthcare professionals and the general public

PubMed Central

2013-01-01

Introduction End-of-life (EOL) treatment issues have recently gained societal attention after the Korean Supreme Court’s ruling that the presumed wishes of an elderly woman in a persistent vegetative state (PVS) should be honored. We tried to evaluate what Koreans thought about controversial issues regarding EOL treatments. Methods We surveyed Koreans with the following questions: 1) are ventilator-dependent PVS patients candidates for end-of life treatment decisions? 2) Is withholding and withdrawing EOL treatment the same thing? 3) In an unconscious, terminally ill patient, whose wishes are unknown, how should EOL decisions be made? 4) How should we settle disagreement amongst medical staff and the patient’s family on EOL decisions? Results One thousand Koreans not working in healthcare and five hundred healthcare professionals responded to the survey. Fifty-seven percent of Koreans not working in healthcare and sixty seven percent of Korean healthcare professionals agreed that ventilator-dependent PVS patients are candidates for EOL treatment decisions. One quarter of all respondents regarded withholding and withdrawing EOL treatment as equal. Over 50% thought that EOL treatment decisions should be made through discussions between the physician and the patient’s family. For conflict resolution, 75% of Koreans not working in healthcare preferred direct settlement between the medical staff and the patient’s family while 55% of healthcare professionals preferred the hospital ethics committee. Conclusions Unsettled issues in Korea regarding EOL treatment decision include whether to include ventilator-dependent PVS patients as candidates of EOL treatment decision and how to sort out disagreements regarding EOL treatment decisions. Koreans viewed withholding and withdrawing EOL treatment issues differently. PMID:24093519

Engaging homeless persons in end of life preparations.

PubMed

Song, John; Wall, Melanie M; Ratner, Edward R; Bartels, Dianne M; Ulvestad, Nancy; Gelberg, Lillian

2008-12-01

There are no prospective studies that have investigated the effects of an intervention to improve end of life (EOL) care in an underserved population. To determine whether homeless persons will complete an advance directive (AD). Randomized trial comparing two modes of providing an opportunity for homeless persons to complete an AD. Half of the subjects were randomized to a self-guided group (SG) who were given an AD and written instructions; the other half were given the same material but, in addition, were offered the opportunity to receive guidance to complete the AD (CG). Fifty-nine homeless persons recruited from a drop-in center. Rate of AD completion and baseline and 3-month follow-up EOL-related knowledge, attitudes, and behaviors. The overall AD completion rate was 44%, with a statistically significant higher completion rate of 59% in the CG group compared to 30% in the self-guided only group. Frequency of worry about death decreased among those who filled out an AD from 50% to 12.5%, and also among those who did not (25% to 12.5%) (p < .05). Among those who filled out an AD, there were increases in plans to write down EOL wishes (56% to 100%; p < .05) and plans to talk about these wishes with someone (63% to 94%; p < .05). This study demonstrates that people living in dire economic and social situations will complete an AD when offered the opportunity. While offering guidance resulted in higher rates of completion; even a simple self-guided AD process can achieve completion of ADs in this population.

EOL-1, the Homolog of the Mammalian Dom3Z, Regulates Olfactory Learning in C. elegans

PubMed Central

Shen, Yu; Zhang, Jiangwen; Calarco, John A.

2014-01-01

Learning is an essential function of the nervous system. However, our understanding of molecular underpinnings of learning remains incomplete. Here, we characterize a conserved protein EOL-1 that regulates olfactory learning in Caenorhabditis elegans. A recessive allele of eol-1 (enhanced olfactory learning) learns better to adjust its olfactory preference for bacteria foods and eol-1 acts in the URX sensory neurons to regulate learning. The mammalian homolog of EOL-1, Dom3Z, which regulates quality control of pre-mRNAs, can substitute the function of EOL-1 in learning regulation, demonstrating functional conservation between these homologs. Mutating the residues of Dom3Z that are critical for its enzymatic activity, and the equivalent residues in EOL-1, abolishes the function of these proteins in learning. Together, our results provide insights into the function of EOL-1/Dom3Z and suggest that its activity in pre-mRNA quality control is involved in neural plasticity. PMID:25274815

Modeling the Value Recovery of Rare Earth Permanent Magnets at End-of-Life

DOE PAGES

Cong, Liang; Jin, Hongyue; Fitsos, Pete; ...

2015-05-21

Permanent magnets containing rare earth elements (REEs) such as Dysprosium and Neodymium offer an advantage over non-REE containing magnets (e.g. ferrite or AlNiCo) in terms of power relative to size. However, REE availability has varied significantly in recent years leading to volatility in the cost of rare earth permanent magnets (REPMs). The supply of REEs can be increased by recycling consumer products and industrial machinery that contain REPMs at product end-of-life (EOL). This paper discusses the REE recovery process for EOL products. The optimal dismantling of products is examined with an emphasis placed on obtaining used REPMs. The challenge ofmore » collecting, managing, transporting, and processing used products is addressed through the development of a cost model for REPM recovery. This model is used to investigate several EOL strategies for recovering REPMs. Sensitivity analysis is conducted to identify the key factors that influence value recovery economics. A hard disk drive serves as a case study for model demonstration.« less

Lessons we are learning: using participatory action research to integrate palliative care, health promotion and public health through the DöBra research program in Sweden.

PubMed

Tishelman, Carol

2018-01-01

Public health and health promotion approaches to end-of-life (EoL) research and care are still rare in Sweden. People remain generally ill-prepared for encounters with death and unable to advocate for quality EoL care; this may be reflected in Sweden's low scores for community engagement in the 2015 Quality of Death index. We have consolidated our endeavours into a cohesive national transdisciplinary research program, DöBra (a pun meaning both 'dying well' and 'awesome' in Swedish). In DöBra, we investigate how culture, the environment and conversation can promote constructive change and support better quality of life and death among the general population, in specific subgroups and in interventions directed to staff caring for dying individuals, their friends and families. DöBra uses ideas from new public health and the Ottawa Charter as umbrella theoretical frameworks and participatory action research as an overarching methodological approach. In DöBra we aim to achieve change in communities in a broad sense. In this interactive workshop, we therefore focus on the particular challenges we encounter in conducting stringent research when trying to catalyse, rather than control, change processes. We will share our ideas, experiences, reflections, tools and approaches as well as results, related to using a variety of strategies to bring together a broad range of stakeholders to co-create experience-based evidence through innovative approaches. We begin by linking theory, research and practice through discussion of the overarching ideas and individual projects, with the second part of the session based on audience engagement with various tools used in DöBra.

Comparative Analysis of Dibutyric cAMP and Butyric Acid on the Differentiation of Human Eosinophilic Leukemia EoL-1 Cells.

PubMed

Jung, YunJae

2015-12-01

Purification of enough numbers of circulating eosinophils is difficult because eosinophils account for less than 5% peripheral blood leukocytes. Human eosinophilic leukemia EoL-1 cells have been considered an in vitro source of eosinophils as they can differentiate into mature eosinophil-like cells when incubated with dibutyryl cAMP (dbcAMP) or butyric acid. In this study, the viability and phenotypic maturation of EoL-1 cells stimulated by either dbcAMP or butyric acid were comparatively analyzed. After treatment with 100 µM dbcAMP or 0.5 µM butyric acid, EoL-1 cells showed morphological signs of differentiation, although the number of nonviable EoL-1 cells was significantly increased following butyric acid treatment. Stimulation of EoL-1 cells with 0.5 µM butyric acid more effectively induced the expression of mature eosinophil markers than stimulation with dbcAMP. These results suggest that treatment of EoL-1 cells with 0.5 µM butyric acid for limited duration could be an effective strategy for inducing their differentiation. Considering that expression of CCR3 was not sufficient in EoL-1 cells stimulated with 0.5 µM butyric acid, treatment of the chemically stimulated EoL-1 cells with cytokines, which primarily support eosinophil maturation, would help to obtain differentiated EoL-1 cells with greater functional maturity.

The supportive roles of religion and spirituality in end-of-life and palliative care of patients with cancer in a culturally diverse context: a literature review.

PubMed

López-Sierra, Héctor E; Rodríguez-Sánchez, Jesús

2015-03-01

This is a literature review of the supportive roles of religion and spirituality (R/S) in end-of-life (EoL) and palliative care of patients with cancer in a culturally diverse context. This review examines 26 noteworthy articles published between August 2013 and August 2014 from five well supported databases. Current evidence shows that R/S evokes in patients the sources to find the necessary inner strengths, which includes perspective thinking, rituals for transcending immediate physical condition and modalities of coping with their oncological illnesses. R/S are not a monolithically experience for they always manifest themselves in diverse cultural settings. As such, R/S provide the individual and their families with a practical context and social memory, which includes traditions and social family practices for maintaining meaning and well-being. Nonetheless, although various dimensions of R/S show a link between cancer risk factors and well being in cancer patients, more specific dimensions of R/S need to be studied taking into account the individuals' particular religious and cultural contexts, so that R/S variables within that context can provide a greater integrative structure for understanding and to move the field forward. Behavioral, cognitive and psychosocial scientists have taken a more in-depth look at the claims made in the past, suggesting that a relationship between R/S, cultural diversity and health exists. Case in point are the studies on EoL care, which have progressively considered the role of cultural, religion and spiritual diversity in the care of patients with oncological terminal illnesses. Beyond these facts, this review also shows that EoL supportive and palliative care providers could further enhance their practical interventions by being sensitive and supportive of cultural diversity. http://links.lww.com/COSPC/A10

Affective science and avoidant end-of-life communication: Can the science of emotion help physicians talk with their patients about the end of life?

PubMed

Soodalter, Jesse A; Siegle, Greg J; Klein-Fedyshin, Michele; Arnold, Robert; Schenker, Yael

2018-05-01

Despite believing end-of-life (EOL) discussions with patients are important, doctors often do not have them. Multiple factors contribute to this shortfall, which interventions including reimbursement changes and communication skills training have not significantly improved to date. One commonly cited but under-researched reason for physician avoidance of EOL discussion is emotional difficulty. High occupational demand for frequent difficult discussions may overload physicians' normal emotional functioning, leading to avoidance or failure. We propose that cognitive, behavioral, and neuroscience evidence from affective science may offer helpful insights into this problem. Data from other populations show that strong emotion impairs cognitive performance and multiple demands can overload cognitive resources. We discuss several affective processes that may apply to physicians attempting EOL discussions. We then discuss selected interventions that have been shown to modify some of these processes and associated behavioral outcomes. Evidence for change in behavioral outcomes of interest includes performance and mood enhancement in healthy populations. We suggest that such mechanistically-targeted interventions may be hypothesized to help decrease physician avoidance of EOL discussion. Physicians may be motivated to adopt such interventions in order to enhance normal emotional functioning to meet supra-normal occupational demand. We propose this as a promising area of future study. Copyright © 2017 Elsevier B.V. All rights reserved.

EOL-1, the homolog of the mammalian Dom3Z, regulates olfactory learning in C. elegans.

PubMed

Shen, Yu; Zhang, Jiangwen; Calarco, John A; Zhang, Yun

2014-10-01

Learning is an essential function of the nervous system. However, our understanding of molecular underpinnings of learning remains incomplete. Here, we characterize a conserved protein EOL-1 that regulates olfactory learning in Caenorhabditis elegans. A recessive allele of eol-1 (enhanced olfactory learning) learns better to adjust its olfactory preference for bacteria foods and eol-1 acts in the URX sensory neurons to regulate learning. The mammalian homolog of EOL-1, Dom3Z, which regulates quality control of pre-mRNAs, can substitute the function of EOL-1 in learning regulation, demonstrating functional conservation between these homologs. Mutating the residues of Dom3Z that are critical for its enzymatic activity, and the equivalent residues in EOL-1, abolishes the function of these proteins in learning. Together, our results provide insights into the function of EOL-1/Dom3Z and suggest that its activity in pre-mRNA quality control is involved in neural plasticity. Copyright © 2014 the authors 0270-6474/14/3413364-07$15.00/0.

An Exploratory Survey of End-of-Life Attitudes, Beliefs and Experiences of Adolescents With HIV/AIDS and Their Families

PubMed Central

Garvie, Patricia A.; He, Jianping; Wang, Jichuan; D'Angelo, Lawrence J.; Lyon, Maureen E.

2012-01-01

Context For youths with life-limiting conditions, little is known regarding families’ understanding of their adolescent’s wishes for end-of-life care. Objectives To examine congruence in HIV positive adolescents’ and their families’ thoughts about death and dying. Methods The Lyon Advance Care Planning Survey-Adolescent and Surrogate versions were administered within a randomized controlled trial. Participants (n =48) were medically stable adolescents aged 14 to 21 years with HIV/AIDS and their families. Congruence was measured by intraclass correlation coefficients (ICC) for continuous variables and by kappa for ordinal or dichotomous responses. Results Adolescent participants were: mean age 16.6 years (range 14–21); 37.5% males; 92% African American; 38% CD4 count <200 and viral load mean=32,079 copies/mL (range <400–91,863 copies/mL). Adolescent/family dyads agreed it is important to complete an advance directive to let loved ones know their wishes (21/24 dyads), yet no dyads agreed an advance directive had been completed. Dyads endorsed incongruent thoughts about the adolescent being afraid of dying in pain (64%; congruent afraid=8 dyads, kappa=−0.0769) and being off life support machines (congruent important=9 dyads, ICC=−0.133, 95% confidence interval=−0.540 to 0.302, P=0.721). Families’ knowledge of teens’ preferences for the timing of end-of-life (EOL) conversations (early vs. late in course of illness) was poor (kappa=−0.1186). Adolescents (90%) wanted to talk about EOL issues before they entered the dying phase. Conclusion Although important areas of congruence emerged, equally important areas, such as the timing of these conversations and adolescents’ EOL needs and wishes, are not known by their families. Families need help initiating conversations to assure their adolescents’ EOL wishes are known to them. PMID:22771129

Comparative Analysis of Dibutyric cAMP and Butyric Acid on the Differentiation of Human Eosinophilic Leukemia EoL-1 Cells

PubMed Central

2015-01-01

Purification of enough numbers of circulating eosinophils is difficult because eosinophils account for less than 5% peripheral blood leukocytes. Human eosinophilic leukemia EoL-1 cells have been considered an in vitro source of eosinophils as they can differentiate into mature eosinophil-like cells when incubated with dibutyryl cAMP (dbcAMP) or butyric acid. In this study, the viability and phenotypic maturation of EoL-1 cells stimulated by either dbcAMP or butyric acid were comparatively analyzed. After treatment with 100 µM dbcAMP or 0.5 µM butyric acid, EoL-1 cells showed morphological signs of differentiation, although the number of nonviable EoL-1 cells was significantly increased following butyric acid treatment. Stimulation of EoL-1 cells with 0.5 µM butyric acid more effectively induced the expression of mature eosinophil markers than stimulation with dbcAMP. These results suggest that treatment of EoL-1 cells with 0.5 µM butyric acid for limited duration could be an effective strategy for inducing their differentiation. Considering that expression of CCR3 was not sufficient in EoL-1 cells stimulated with 0.5 µM butyric acid, treatment of the chemically stimulated EoL-1 cells with cytokines, which primarily support eosinophil maturation, would help to obtain differentiated EoL-1 cells with greater functional maturity. PMID:26770185

Examining the Role of Primary Care Physicians and Challenges Faced When Their Patients Transition to Home Hospice Care.

PubMed

Shalev, Ariel; Phongtankuel, Veerawat; Lampa, Katherine; Reid, M C; Eiss, Brian M; Bhatia, Sonica; Adelman, Ronald D

2018-04-01

The transition into home hospice care is often a critical time in a patient's medical care. Studies have shown patients and caregivers desire continuity with their physicians at the end of life (EoL). However, it is unclear what roles primary care physicians (PCPs) play and what challenges they face caring for patients transitioning into home hospice care. To understand PCPs' experiences, challenges, and preferences when their patients transition to home hospice care. Nineteen semi-structured phone interviews with PCPs were conducted. Study data were analyzed using standard qualitative methods. Participants included PCPs from 3 academic group practices in New York City. Measured: Physician recordings were transcribed and analyzed using content analysis. Most PCPs noted that there was a discrepancy between their actual role and ideal role when their patients transitioned to home hospice care. Primary care physicians expressed a desire to maintain continuity, provide psychosocial support, and collaborate actively with the hospice team. Better establishment of roles, more frequent communication with the hospice team, and use of technology to communicate with patients were mentioned as possible ways to help PCPs achieve their ideal role caring for their patients receiving home hospice care. Primary care physicians expressed varying degrees of involvement during a patient's transition to home hospice care, but many desired to be more involved in their patient's care. As with patients, physicians desire to maintain continuity with their patients at the EoL and solutions to improve communication between PCPs, hospice providers, and patients need to be explored.

Assessing medicare beneficiaries’ strength‐of‐preference scores for health care options: how engaging does the elicitation technique need to be?

PubMed Central

Crump, Trafford; Llewellyn‐Thomas, Hilary A.

2011-01-01

Abstract Objective  The objective was to determine if participants’ strength‐of‐preference scores for elective health care interventions at the end‐of‐life (EOL) elicited using a non‐engaging technique are affected by their prior use of an engaging elicitation technique. Design  Medicare beneficiaries were randomly selected from a larger survey sample. During a standardized interview, participants considered four scenarios involving a choice between a relatively less‐ or more‐intense EOL intervention. For each scenario, participants indicated their favoured intervention, then used a 7‐point Leaning Scale (LS1) to indicate how strongly they preferred their favoured intervention relative to the alternative. Next, participants engaged in a Threshold Technique (TT), which, depending on the participant’s initially favoured intervention, systematically altered a particular attribute of the scenario until the participant switched preferences. Finally, they repeated the LS (LS2) to indicate how strongly they preferred their initially‐favoured intervention. Results  Two hundred and two participants were interviewed (189–198 were included in this study). The concordance of individual participants’ LS1 and LS2 scores was assessed using Kendall tau‐b correlation coefficients; scores of 0.74, 0.84, 0.85 and 0.89 for scenarios 1–4, respectively, were observed. Conclusion  Kendall tau‐b statistics indicate a high concordance between LS scores, implying that the interposing engaging TT exercise had no significant effects on the LS2 strength‐of‐preference scores. Future investigators attempting to characterize the distributions of strength‐of‐preference scores for EOL care from a large, diverse community could use non‐engaging elicitation methods. The potential limitations of this study require that further investigation be conducted into this methodological issue. PMID:21323819

WA3 Room for death - international museum - visitors' preferences regarding the end of their life.

PubMed

Lindqvist, Olav; Tishelman, Carol

2015-04-01

Just as pain medications aim to relieve physical suffering, supportive surrounding for death and dying may facilitate well-being and comfort. However, little has been written of the experience of or preferences for settings for death and dying. We investigate preferences for and reflections about settings for end-of-life (EoL) in an international sample of museum visitors. Data derive from a project teaming artists and craftspeople together to create prototypes of space for difficult conversations in EoL settings. These prototypes were presented in a museum exhibition, "Room for Death", in Stockholm in 2012. As project consultants, we contributed a question to the public viewing the exhibition: "How would you like it to be around you when you are dying?" and analysed responses with a phenomenographic approach. Five-hundred twelve responses were obtained from visitors from 46 countries. Responses were categorised in the following inductively- derived categories of types of deaths: The "Familiar", "Larger-than life", "Lone", "Mediated" "Calm and peaceful", "Sensuous", "'Green'", and "Distanced" death. Responses could relate to one category or be composites uniting different categories in individual combinations. These data provide insight into different facets of contemporary reflections about death and dying. Despite the selective sample, the findings give reason to consider how underlying assumptions and care provision in established forms for EoL care may differ from people's preferences. This project can be seen as an example of innovative endeavours to promote public awareness of issues related to death and dying, within the framework of health-promoting palliative care. © 2015, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Nurses' attitudes and experiences surrounding palliative sedation: components for developing policy for nursing professionals.

PubMed

Patel, Bansari; Gorawara-Bhat, Rita; Levine, Stacie; Shega, Joseph W

2012-04-01

Nurses play an integral role in providing care for patients with end of life (EOL) symptoms refractory to conventional treatments and that may necessitate palliative sedation (PS). A paucity of research on nurses' attitudes, knowledge, and experience with PS exists, despite nurses being instrumental in evaluating its appropriateness and carrying out the care plan. The objective of the study was to elicit nurses' perspectives and conceptualizations of knowledge and skills needed to administer PS in order to inform development of a hospital policy that addresses identified concerns. Four focus groups were conducted with nurses likely to have had exposure to PS (oncology, intensive care, and hospice) at an academic medical center. Focus groups were audiotaped, transcribed verbatim, and coded for salient themes. Grounded theory principles were used for the analysis. Among the four focus groups (n=31), 87% were female, 58% between the ages of 36 and 55, and more than 40% reported 10-plus years of providing patient care. Five domains emerged as important in developing a PS policy: 1) ability to define PS; 2) criterion for using PS; 3) skill set for administering PS; 4) policy and procedural guidelines; and 5) education on PS and EOL care. Nurses identified knowledge, skills, and guidelines as key considerations for implementing PS. Comprehensive policies along with adequate training are needed to expand the availability of PS in acute care hospitals and hospice programs.

Terminally Ill Taiwanese Cancer Patients' and Family Caregivers' Agreement on Patterns of Life-Sustaining Treatment Preferences Is Poor to Fair and Declines Over a Decade: Results From Two Independent Cross-Sectional Studies.

PubMed

Liu, Tsang-Wu; Wen, Fur-Hsing; Wang, Cheng-Hsu; Hong, Ruey-Long; Chow, Jyh-Ming; Chen, Jen-Shi; Chiu, Chang-Fang; Tang, Siew Tzuh

2017-07-01

Temporal changes have not been examined in patient-caregiver agreement on life-sustaining treatment (LST) preferences at end of life (EOL). We explored the extent of and changes in patient-caregiver agreement on LST-preference patterns for two independent cohorts of Taiwanese cancer patient-family caregiver dyads recruited a decade apart. We surveyed preferences for cardiopulmonary resuscitation, intensive care unit care, cardiac massage, intubation with mechanical ventilation, intravenous nutritional support, tube feeding, and dialysis among 1049 and 1901 dyads in 2003-2004 and 2011-2012, respectively. LST-preference patterns were examined by multi-group latent class analysis. Extent of patient-caregiver agreement on LST-preference patterns was determined by percentage agreement and kappa coefficients. For both patients and family caregivers, we identified seven distinct LST-preference classes. Patient-caregiver agreement on LST-preference patterns was poor to fair across both study cohorts, indicated by 24.4%-43.5% agreement and kappa values of 0.06 (95% CI: 0.04, 0.09) to 0.27 (0.23, 0.30), and declined significantly over time. Agreement on LST-preference patterns was most likely when both patients and caregivers uniformly rejected LSTs. When patients disagreed with caregivers on LST-preference patterns, discrepancies were most likely when patients totally rejected LSTs but caregivers uniformly preferred LSTs or preferred nutritional support but rejected other treatments. Patients and family caregivers had poor-to-fair agreement on LST-preference patterns, and agreement declined significantly over a decade. Encouraging an open dialogue between patients and their family caregivers about desired EOL care would facilitate patient-caregiver agreement on LST-preference patterns, thus honoring terminally ill cancer patients' wishes when they cannot make EOL-care decisions. Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Differentiation of eosinophilic leukemia EoL-1 cells into eosinophils induced by histone deacetylase inhibitors.

PubMed

Ishihara, Kenji; Takahashi, Aki; Kaneko, Motoko; Sugeno, Hiroki; Hirasawa, Noriyasu; Hong, JangJa; Zee, OkPyo; Ohuchi, Kazuo

2007-03-06

EoL-1 cells differentiate into eosinophils in the presence of n-butyrate, but the mechanism has remained to be elucidated. Because n-butyrate can inhibit histone deacetylases, we hypothesized that the inhibition of histone deacetylases induces the differentiation of EoL-1 cells into eosinophils. In this study, using n-butyrate and two other histone deacetylase inhibitors, apicidin and trichostatin A, we have analyzed the relationship between the inhibition of histone deacetylases and the differentiation into eosinophils in EoL-1 cells. It was demonstrated that apicidin and n-butyrate induced a continuous acetylation of histones H4 and H3, inhibited the proliferation of EoL-1 cells without attenuating the level of FIP1L1-PDGFRA mRNA, and induced the expression of markers for mature eosinophils such as integrin beta7, CCR1, and CCR3 on EoL-1 cells, while trichostatin A evoked a transient acetylation of histones and induced no differentiation into eosinophils. These findings suggest that the continuous inhibition of histone deacetylases in EoL-1 cells induces the differentiation into mature eosinophils.

The End-of-Life Experience in Long-Term Care: Five Themes Identified from Focus Groups with Residents, Family Members, and Staff

ERIC Educational Resources Information Center

Munn, Jean C.; Dobbs, Debra; Meier, Andrea; Williams, Christianna S.; Biola, Holly; Zimmerman, Sheryl

2008-01-01

Purpose: We designed this study to examine the end-of-life (EOL) experience in long-term care (LTC) based on input from key stakeholders. Design and Methods: The study consisted of 10 homogeneous focus groups drawn from a purposive sample of LTC residents (2 groups; total n = 11), family caregivers (2 groups; total n = 19), paraprofessional staff…

Helios1A EoL: A Success. For the first Time a Long Final Thrust Scenario, Respecting the French Law on Space Operations

NASA Astrophysics Data System (ADS)

Guerry, Agnes; Moussi, Aurelie; Sartine, Christian; Beaumet, Gregory

2013-09-01

HELIOS1A End Of Live (EOL) operations occurred in the early 2012. Through this EOL operation, CNES wanted to make an example of French Space Act compliance. Because the satellite wasn't natively designed for such an EOL phase, the operation was touchy and risky. It was organized as a real full project in order to assess every scenario details with dedicated Mission Analysis, to secure the operations through detailed risk analysis at system level and to consider the major failures that could occur during the EOL. A short scenario allowing to reach several objectives with benefits was eventually selected. The main objective of this project was to preserve space environment. The operations were led on a "best effort" basis. The French Space Operations Act (FSOA) requirements were met: HELIOS-1A EOL operations had been led successfully.

The role of the principle of double effect in ethics education at US medical schools and its potential impact on pain management at the end of life.

PubMed

Macauley, Robert

2012-03-01

Because opioids can suppress respiratory drive, the principle of double effect (PDE) has been used to justify their use for terminally ill patients. Recent studies, however, suggest that the risk of respiratory depression in typical end-of-life (EOL) situations may be overstated and that heightened concern for this rare occurrence can lead to inadequate treatment of pain. The purpose of this study is to examine the role of the PDE in medical school ethics education, with specific reference to its potential impact on pain management at EOL. After obtaining institutional review board approval, an electronic survey was sent to ethics educators at every allopathic medical school in the USA. One-third of ethics educators felt that opioids were 'likely' to cause significant respiratory depression that could hasten death. Educators' opinions of opioid effects did not influence their view of the relevance of the PDE, with approximately 70% deeming it relevant to EOL care. Only 15% of ethics educators believed that associating the PDE with opioid use might discourage clinicians from optimally treating pain, out of concern for respiratory depression. This study demonstrates that a significant minority of ethics educators believe, contrary to current evidence, that opioids are 'likely' to cause significant respiratory depression that could hasten death in terminally ill patients. Yet, many of those who do not feel this is likely still rely on the PDE to justify this possibility, potentially (and unknowingly) contributing to clinical misperceptions and underutilisation of opioids at EOL.

Academic and Resident Radiation Oncologists' Attitudes and Intentions Regarding Radiation Therapy near the End of Life.

PubMed

Lloyd, Shane; Dosoretz, Arie P; Yu, James B; Evans, Suzanne B; Decker, Roy H

2016-02-01

There has been increasing scrutiny about cancer treatment for patients very near the end of life (EoL), yet a substantial number receive palliative radiation therapy (RT) in this setting. Our aim was to document the attitudes and intentions of thought leaders and trainees in giving RT near the EoL. We distributed an anonymous survey to 473 radiation oncologists and residents. The survey examined the clinical and psychosocial factors considered as well as intentions and expectations in the delivery of RT near the EoL. Factors surrounding unfinished treatment courses, and the formative factors that shape opinions about RT at the EoL were also explored. We received 139 responses (29%). Eighty-nine percent of respondents worked at academic institutions. The factors that respondents most often consider very or extremely important to offer RT near the EoL were the preference of the patient to be treated (94%), the ability to tolerate treatment (88%), and palliative intent (70%). After instances when their patients were unable to complete treatment near the EoL, 42% of respondents said they would prescribe a shorter treatment the next time they see a similar patient. Personal experience (71%) was most often listed as very or extremely important in shaping their opinions about RT near the EoL. Survey respondents, 89% of whom were academic radiation oncologists, have a positive view of palliative RT near the EoL. They favor shorter fractionation for patients near the EoL. Personal experience is most important in shaping practices and attitudes.

Interaction of Typhoon and Ocean Project (ITOP) Data Management and Operations Support

DTIC Science & Technology

2012-09-30

EOL ) by Scot Loehrer and Steve Williams with input from Jim Moore (also EOL ) and Eric D’Asaro (University of Washington). The web page is the central...location for all ITOP-related information. It contains links to the data archives at EOL and the Monterey Bay Aquarium Research Institute (MBARI...the field catalogs from ITOP “dry run” 2009 and 2010 field deployments, meetings, publications, and documents. For all of the ITOP meetings, EOL

Interaction of Typhoon and Ocean Project ITOP Data Management and Operations Support

DTIC Science & Technology

2013-09-30

EOL ) by Scot Loehrer and Steve Williams with input from Jim Moore (also EOL ) and Eric D’Asaro (University of Washington). The web page is the...central location for all ITOP-related information. It contains links to the data archives at EOL and the Monterey Bay Aquarium Research Institute (MBARI...the field catalogs from ITOP “dry run” 2009 and 2010 field deployments, meetings, publications, and documents. For all of the ITOP meetings, EOL

Aircraft Measurements for Understanding Air-Sea Coupling and Improving Coupled Model Predictions Over the Indian Ocean

DTIC Science & Technology

2012-09-30

December 2011 • Daily weather forecasts and briefing for aircraft operations in Diego Garcia, reports posted on EOL field catalog in realtime (http...summary of aircraft missions posted on EOL website (http://catalog.eol.ucar.edu/cgi-bin/dynamo/report/index) 3. Post-field campaign (including on...going data analysis into FY13): • Dropsonde data analysis, worked with EOL on data quality control (QC), participated in the DYNAMO Sounding Workshop

An Efficient Deterministic Approach to Model-based Prediction Uncertainty Estimation

DTIC Science & Technology

2012-09-01

94035, USA abhinav.saxena@nasa.gov ABSTRACT Prognostics deals with the prediction of the end of life ( EOL ) of a system. EOL is a random variable, due...future evolution of the system, accumulating additional uncertainty into the predicted EOL . Prediction algorithms that do not account for these sources of...uncertainty are misrepresenting the EOL and can lead to poor decisions based on their results. In this paper, we explore the impact of uncertainty in

Physicians in Postgraduate Training Characteristics and Support of Palliative Sedation for Existential Distress.

PubMed

Cripe, Larry D; Perkins, Susan M; Cottingham, Ann; Tong, Yan; Kozak, Mary Ann; Mehta, Rakesh

2017-09-01

Palliative sedation for refractory existential distress (PS-ED) is ethically troubling but potentially critical to quality end-of-life (EOL) care. Physicians' in postgraduate training support toward PS-ED is unknown nor is it known how empathy, hope, optimism, or intrinsic religious motivation (IRM) affect their support. These knowledge gaps hinder efforts to support physicians who struggle with patients' EOL care preferences. One hundred thirty-four postgraduate physicians rated their support of PS for refractory physical pain (PS-PP) or PS-ED, ranked the importance of patient preferences in ethically challenging situations, and completed measures of empathy, hope, optimism, and IRM. Predictors of PS-ED and PS-PP support were examined using binary and multinomial logistic regression. Only 22.7% of residents were very supportive of PS-ED, and 82.0% were very supportive of PS-PP. Support for PS-PP or PS-ED did not correlate with levels of empathy, hope, optimism, or IRM; however, for residents with lower IRM, greater optimism was associated with greater PS-ED support. In contrast, among residents with higher IRM, optimism was not associated with PS-ED support. Comparing current results to published surveys, a similar proportion of residents and practicing physicians support PS-ED and PS-PP. In contrast to practicing physicians, however, IRM does not directly influence residents' supportiveness. The interaction between optimism and IRM suggests residents' beliefs and characteristics are salient to their EOL decisions. End-of-life curricula should provide physicians opportunities to reflect on the personal and ethical factors that influence their support for PS-ED.

An Efficient Deterministic Approach to Model-based Prediction Uncertainty Estimation

NASA Technical Reports Server (NTRS)

Daigle, Matthew J.; Saxena, Abhinav; Goebel, Kai

2012-01-01

Prognostics deals with the prediction of the end of life (EOL) of a system. EOL is a random variable, due to the presence of process noise and uncertainty in the future inputs to the system. Prognostics algorithm must account for this inherent uncertainty. In addition, these algorithms never know exactly the state of the system at the desired time of prediction, or the exact model describing the future evolution of the system, accumulating additional uncertainty into the predicted EOL. Prediction algorithms that do not account for these sources of uncertainty are misrepresenting the EOL and can lead to poor decisions based on their results. In this paper, we explore the impact of uncertainty in the prediction problem. We develop a general model-based prediction algorithm that incorporates these sources of uncertainty, and propose a novel approach to efficiently handle uncertainty in the future input trajectories of a system by using the unscented transformation. Using this approach, we are not only able to reduce the computational load but also estimate the bounds of uncertainty in a deterministic manner, which can be useful to consider during decision-making. Using a lithium-ion battery as a case study, we perform several simulation-based experiments to explore these issues, and validate the overall approach using experimental data from a battery testbed.

Failure analysis of fuel cell electrodes using three-dimensional multi-length scale X-ray computed tomography

NASA Astrophysics Data System (ADS)

Pokhrel, A.; El Hannach, M.; Orfino, F. P.; Dutta, M.; Kjeang, E.

2016-10-01

X-ray computed tomography (XCT), a non-destructive technique, is proposed for three-dimensional, multi-length scale characterization of complex failure modes in fuel cell electrodes. Comparative tomography data sets are acquired for a conditioned beginning of life (BOL) and a degraded end of life (EOL) membrane electrode assembly subjected to cathode degradation by voltage cycling. Micro length scale analysis shows a five-fold increase in crack size and 57% thickness reduction in the EOL cathode catalyst layer, indicating widespread action of carbon corrosion. Complementary nano length scale analysis shows a significant reduction in porosity, increased pore size, and dramatically reduced effective diffusivity within the remaining porous structure of the catalyst layer at EOL. Collapsing of the structure is evident from the combination of thinning and reduced porosity, as uniquely determined by the multi-length scale approach. Additionally, a novel image processing based technique developed for nano scale segregation of pore, ionomer, and Pt/C dominated voxels shows an increase in ionomer volume fraction, Pt/C agglomerates, and severe carbon corrosion at the catalyst layer/membrane interface at EOL. In summary, XCT based multi-length scale analysis enables detailed information needed for comprehensive understanding of the complex failure modes observed in fuel cell electrodes.

End-of-Life Care Patterns Associated with Pediatric Palliative Care Among Children Who Underwent Hematopoietic Stem Cell Transplant

PubMed Central

Ullrich, Christina K.; Lehmann, Leslie; London, Wendy B.; Guo, Dongjing; Sridharan, Madhumitha; Koch, Richard; Wolfe, Joanne

2017-01-01

Background Stem cell transplantation (SCT) is an intensive therapy offering the possibility of cure for life-threatening conditions although with risk of serious complications and death. Outcomes associated with pediatric palliative care (PPC) for children who undergo SCT are unknown. Objective To evaluate whether PPC consultation is associated with differences in end-of-life (EOL) care patterns for children who underwent SCT and did not survive Methods Medical records of children who underwent SCT at Boston Children’s Hospital/Dana-Farber Cancer Institute for any indication from September 2004-December 2012 and did not survive were reviewed. Child demographic and clinical characteristics and PPC consultation and EOL care patterns were abstracted. Children who received PPC (PPC group) were compared with those who did not (non-PPC group). Results Children who received PPC consultation (n=37) did not differ from the non-PPC group (n=110) with respect to demographic or clinical characteristics, except they were more likely to have undergone unrelated allogeneic SCT (PPC=68%, non-PPC=39%, p=0.02) or to have died from treatment-related toxicity (PPC=76%, non-PPC=54%, p=0.03). PPC consultation occurred at a median of 0.7 (interquartile range [IQR] 0.4–4.2) months before death. PPC consultations most commonly addressed goals of care/decision-making (92%), psychosocial support (84%), pain management (65%), and non-pain symptom management (70%). Prognosis discussions (i.e., the likelihood of survival) occurred more commonly in the PPC group (PPC=97%, non-PPC=83%, p=0.04), as did resuscitation status discussions (PPC=88%, non-PPC=58%, p=0.002). These discussions also occurred earlier in the PPC group, for prognosis a median of 8 (IQR 4–26) days prior to death compared to 2 (IQR 1–13) days in the non-PPC group and for resuscitation status a median of 7 (IQR 3–18) days compared to 2 (IQR 1–5) in the non-PPC group (p<0.001 for both of the timing of prognosis and resuscitation status discussions). The PPC group was also was more likely to have resuscitation status documented, (PPC=97%, non-PPC=68%, p=0.002). With respect to patterns of care, compared to non-PPC, the PPC group was as likely to die in a medicalized setting (i.e. the hospital) (PPC=84%, non-PPC=77%, p=0.06) or have hospice (PPC=22%, non-PPC=18%, p=0.6). However, among children who died in the hospital, those who received PPC were more likely to die outside the ICU (PPC=80%, non-PPC=58%, p=0.03). In addition, the PPC group was less likely to receive intervention-focused care such as intubation in the 24 hours prior to death (PPC=42%, non-PPC=66%, p=0.02) or cardiopulmonary resuscitation (CPR) (PPC=3%, non-PPC=20%, p=0.03) at EOL. Children who received PPC for at least a month were more likely to receive hospice (PPC=41%, non-PPC=5%, p=0.01). Conclusion Children who underwent SCT and do not survive were likely to die in a medicalized setting, irrespective of PPC. However, PPC was associated with less intervention-focused care and greater opportunity for EOL communication and advance preparation. In the intense, cure-oriented SCT setting, PPC may facilitate advance care planning in this high-risk population. PMID:26903381

Nurses' Attitudes and Experiences Surrounding Palliative Sedation: Components for Developing Policy for Nursing Professionals

PubMed Central

Gorawara-Bhat, Rita; Levine, Stacie; Shega, Joseph W.

2012-01-01

Abstract Background Nurses play an integral role in providing care for patients with end of life (EOL) symptoms refractory to conventional treatments and that may necessitate palliative sedation (PS). A paucity of research on nurses' attitudes, knowledge, and experience with PS exists, despite nurses being instrumental in evaluating its appropriateness and carrying out the care plan. Objective The objective of the study was to elicit nurses' perspectives and conceptualizations of knowledge and skills needed to administer PS in order to inform development of a hospital policy that addresses identified concerns. Methods Four focus groups were conducted with nurses likely to have had exposure to PS (oncology, intensive care, and hospice) at an academic medical center. Focus groups were audiotaped, transcribed verbatim, and coded for salient themes. Grounded theory principles were used for the analysis. Results Among the four focus groups (n=31), 87% were female, 58% between the ages of 36 and 55, and more than 40% reported 10-plus years of providing patient care. Five domains emerged as important in developing a PS policy: 1) ability to define PS; 2) criterion for using PS; 3) skill set for administering PS; 4) policy and procedural guidelines; and 5) education on PS and EOL care. Conclusions Nurses identified knowledge, skills, and guidelines as key considerations for implementing PS. Comprehensive policies along with adequate training are needed to expand the availability of PS in acute care hospitals and hospice programs. PMID:22500480

Determinants of patient-family caregiver congruence on preferred place of death in taiwan.

PubMed

Tang, Siew Tzuh; Chen, Cheryl Chia-Hui; Tang, Woung-Ru; Liu, Tsang-Wu

2010-08-01

Patient-family caregiver congruence on preferred place of death not only increases the likelihood of dying at home but also contributes significantly to terminally ill cancer patients' quality of life. To examine the determinants of patient-family caregiver congruence on the preferred place of death in Taiwan. Patient-family caregiver dyads (n=1,108) were surveyed on preferences and needs for end-of-life (EOL) care. Determinants of congruence on preferences were identified by multivariate logistic regression. Patient-caregiver dyads achieved 78.1% agreement on the preferred place of death. The kappa coefficient of congruence was 0.55 (95% confidence interval [CI]=0.50, 0.60). The extent of patient-family caregiver congruence on preferred place of death increased with the patient's higher functional dependence (adjusted odds ratio [AOR] and 95% CI=1.04 [1.02, 1.05]), higher patient-rated importance for dying at preferred place of death (AOR [95% CI]=1.60 [1.43, 1.79]), and having a spousal caregiver (AOR [95% CI]=1.62 [1.14, 2.31]). Other determinants of patient-family caregiver congruence included patient age (AOR [95% CI]=1.01 [1.00, 1.03]), patient-family concordance on preferred EOL care options (AOR=1.68-1.73), patient knowledge of prognosis (AOR [95% CI]=0.68 [0.48, 0.97]), and impact of caregiving on the family caregiver's life (AOR [95% CI]=0.98 [0.96, 0.99]). Increasing patient-family congruence on preferred place of death not only requires knowledge of the patient's prognosis and advance planning by both parties but also depends on family caregivers endorsing patient preferences for EOL care options and ensuring that supporting patients dying at home does not create an intolerable burden for family caregivers. Copyright (c) 2010 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Life cycle and nano-products: end-of-life assessment

NASA Astrophysics Data System (ADS)

Asmatulu, Eylem; Twomey, Janet; Overcash, Michael

2012-03-01

Understanding environmental impacts of nanomaterials necessitates analyzing the life cycle profile. The initial emphasis of nanomaterial life cycle studies has been on the environmental and health effects of nanoproducts during the production and usage stages. Analyzing the end-of-life (eol) stage of nanomaterials is also critical because significant impacts or benefits for the environment may arise at that particular stage. In this article, the Woodrow Wilson Center's Project on Emerging Nanotechnologies (PEN) Consumer Products Inventory (CPI) model was used, which contains a relatively large and complete nanoproduct list (1,014) as of 2010. The consumer products have wide range of applications, such as clothing, sports goods, personal care products, medicine, as well as contributing to faster cars and planes, more powerful computers and satellites, better micro and nanochips, and long-lasting batteries. In order to understand the eol cycle concept, we allocated 1,014 nanoproducts into the nine end-of-life categories (e.g., recyclability, ingestion, absorption by skin/public sewer, public sewer, burning/landfill, landfill, air release, air release/public sewer, and other) based on probable final destinations of the nanoproducts. This article highlights the results of this preliminary assessment of end-of-life stage of nanoproducts. The largest potential eol fate was found to be recyclability, however little literature appears to have evolved around nanoproduct recycling. At lower frequency is dermal and ingestion human uptake and then landfill. Release to water and air are much lower potential eol fates for current nanoproducts. In addition, an analysis of nano-product categories with the largest number of products listed indicated that clothes, followed by dermal-related products and then sports equipment were the most represented in the PEN CPI (http://www.nanotechproject.org/inventories/consumer/browse/categories/, 2010).

Ethical issues recognized by critical care nurses in the intensive care units of a tertiary hospital during two separate periods.

PubMed

Park, Dong Won; Moon, Jae Young; Ku, Eun Yong; Kim, Sun Jong; Koo, Young-Mo; Kim, Ock-Joo; Lee, Soon Haeng; Jo, Min-Woo; Lim, Chae-Man; Armstrong, John David; Koh, Younsuck

2015-04-01

This research aimed to investigate the changes in ethical issues in everyday clinical practice recognized by critical care nurses during two observation periods. We conducted a retrospective analysis of data obtained by prospective questionnaire surveys of nurses in the intensive care units (ICU) of a tertiary university-affiliated hospital in Seoul, Korea. Data were collected prospectively during two different periods, February 2002-January 2003 (Period 1) and August 2011-July 2012 (Period 2). Significantly fewer cases with ethical issues were reported in Period 2 than in Period 1 (89 cases [2.1%] of 4,291 ICU admissions vs. 51 [0.5%] of 9,302 ICU admissions, respectively; P < 0.001). The highest incidence of cases with identified ethical issues in both Periods occurred in MICU. The major source of ethical issues in Periods 1 and 2 was behavior-related. Among behaviorrelated issues, inappropriate healthcare professional behavior was predominant in both periods and mainly involved resident physicians. Ethical issue numbers regarding end-oflife (EOL) care significantly decreased in the proportion with respect to ethical issues during Period 2 (P = 0.044). In conclusion, the decreased incidence of cases with identified ethical issues in Period 2 might be associated with ethical enhancement related with EOL and improvements in the ICU care environment of the studied hospital. However, behaviorrelated issues involving resident physicians represent a considerable proportion of ethical issues encountered by critical care nurses. A systemic approach to solve behavior-related issues of resident physicians seems to be required to enhance an ethical environment in the studied ICU.

Understanding how prostate cancer patients value the current treatment options for metastatic castration resistant prostate cancer.

PubMed

Benidir, Tarik; Hersey, Karen; Finelli, Antonio; Hamilton, Rob; Joshua, Anthony M; Kulkarni, Girish; Zlotta, Alexandre; Fleshner, Neil

2018-05-01

Several new compounds are now available for castration resistant prostate cancer (CRPC). Individual costs range between $40,000 and $93,000 with mean survival extensions from 2.4 to 4.8 months. Currently, it remains unclear how patients with prostate cancer (PCa) value the effect of these therapies in the setting of CRPC. To assess patient understanding of core cancer concepts, opinions on the cost and overall benefit of CRPC drugs, whether out-of-pocket costs would change opinions and whether patients would ultimately opt out of CRPC drug treatment for an end-of-life (EOL) premium. We conducted a qualitative survey among patients with various PCa states ranging from active surveillance to CRPC and from various familial, financial and educational demographics. Through a series of hypothetical scenarios, we extrapolated opinions on CRPC drug value, efficacy and monetary worth. We assessed patient willingness to accept an EOL ($50,000) premium in lieu of CRPC drug treatment. Statistically, chi-squared analysis and Fisher's exact test were used when appropriate. In total, 103 patients completed the questionnaire, one-half of whom did not understand "advanced PCa" state and more than one-third of the concept of palliative care despite multiple meetings with Urologists. Patients willingness-to-pay and proposed drug value was higher than that accepted by government when government funded, with costs exceeding $250,000 per person, but lower than that accepted by government when self-funded. A majority (60%) would accept/consider the EOL premium in the setting of CRPC. Patients with higher education were more skeptical about CRPC drug value and more likely to accept the EOL premium (P = 0.003.) CONCLUSION: Patients have an incomplete understanding of their own disease prognosis and its therapeutic options. This ultimately influences patient decision-making. Education, income and out-of-pocket costs diminished opinion of CRPC drugs considerably. As such, an EOL premium should be considered in subsets of patients. Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.

House dust mite induces expression of intercellular adhesion molecule-1 in EoL-1 human eosinophilic leukemic cells.

PubMed

Kwon, Byoung Chul; Sohn, Myung Hyun; Kim, Kyung Won; Kim, Eun Soo; Kim, Kyu-Earn; Shin, Myeong Heon

2007-10-01

The house dust mite (HDM) is considered to be the most common indoor allergen associated with bronchial asthma. In this study, we investigated whether crude extract of the HDM Dermatophagoides farinae could activate human eosinophilic leukemic cells (EoL-1) to induce upregulation of cell-surface adhesion molecules. When EoL-1 cells were incubated with D. farinae extract, expression of intercellular adhesion molecule-1 (ICAM-1) significantly increased on the cell surfaces compared to cells incubated with medium alone. In contrast, surface expression of CD11b and CD49d in EoL-1 cells was not affected by D. farinae extract. In addition, pretreatment of cells with NF-kappaB inhibitor (MG-132) or JNK inhibitor (SP600125) significantly inhibited ICAM-1 expression promoted by HDM extract. However, neither p38 MAP kinase inhibitor nor MEK inhibitor prevented HDM-induced ICAM-1 expression in EoL-1 cells. These results suggest that crude extract of D. farinae induces ICAM-1 expression in EoL-1 cells through signaling pathways involving both NF-kappaB and JNK.

House Dust Mite Induces Expression of Intercellular Adhesion Molecule-1 in EoL-1 Human Eosinophilic Leukemic Cells

PubMed Central

Kwon, Byoung Chul; Sohn, Myung Hyun; Kim, Kyung Won; Kim, Eun Soo; Kim, Kyu-Earn

2007-01-01

The house dust mite (HDM) is considered to be the most common indoor allergen associated with bronchial asthma. In this study, we investigated whether crude extract of the HDM Dermatophagoides farinae could activate human eosinophilic leukemic cells (EoL-1) to induce upregulation of cell-surface adhesion molecules. When EoL-1 cells were incubated with D. farinae extract, expression of intercellular adhesion molecule-1 (ICAM-1) significantly increased on the cell surfaces compared to cells incubated with medium alone. In contrast, surface expression of CD11b and CD49d in EoL-1 cells was not affected by D. farinae extract. In addition, pretreatment of cells with NF-κB inhibitor (MG-132) or JNK inhibitor (SP600125) significantly inhibited ICAM-1 expression promoted by HDM extract. However, neither p38 MAP kinase inhibitor nor MEK inhibitor prevented HDM-induced ICAM-1 expression in EoL-1 cells. These results suggest that crude extract of D. farinae induces ICAM-1 expression in EoL-1 cells through signaling pathways involving both NF-κB and JNK. PMID:17982228

Prognostic categories and timing of negative prognostic communication from critical care physicians to family members at end-of-life in an intensive care unit.

PubMed

Gutierrez, Karen M

2013-09-01

Negative prognostic communication is often delayed in intensive care units, which limits time for families to prepare for end-of-life. This descriptive study, informed by ethnographic methods, was focused on exploring critical care physician communication of negative prognoses to families and identifying timing influences. Prognostic communication of critical care physicians to nurses and family members was observed and physicians and family members were interviewed. Physician perception of prognostic certainty, based on an accumulation of empirical data, and the perceived need for decision-making, drove the timing of prognostic communication, rather than family needs. Although prognoses were initially identified using intuitive knowledge for patients in one of the six identified prognostic categories, utilizing decision-making to drive prognostic communication resulted in delayed prognostic communication to families until end-of-life (EOL) decisions could be justified with empirical data. Providers will better meet the needs of families who desire earlier prognostic information by separating prognostic communication from decision-making and communicating the possibility of a poor prognosis based on intuitive knowledge, while acknowledging the uncertainty inherent in prognostication. This sets the stage for later prognostic discussions focused on EOL decisions, including limiting or withdrawing treatment, which can be timed when empirical data substantiate intuitive prognoses. This allows additional time for families to anticipate and prepare for end-of-life decision-making. © 2012 John Wiley & Sons Ltd.

Thermodynamic criteria for the removal of impurities from end-of-life magnesium alloys by evaporation and flux treatment

NASA Astrophysics Data System (ADS)

Hiraki, Takehito; Takeda, Osamu; Nakajima, Kenichi; Matsubae, Kazuyo; Nakamura, Shinichiro; Nagasaka, Tetsuya

2011-06-01

In this paper, the possibility of removing impurities during magnesium recycling with pyrometallurgical techniques has been evaluated by using a thermodynamic analysis. For 25 different elements that are likely to be contained in industrial magnesium alloys, the equilibrium distribution ratios between the metal, slag and gas phases in the magnesium remelting process were calculated assuming binary systems of magnesium and an impurity element. It was found that calcium, gadolinium, lithium, ytterbium and yttrium can be removed from the remelted end-of-life (EoL) magnesium products by oxidization. Calcium, cerium, gadolinium, lanthanum, lithium, plutonium, sodium, strontium and yttrium can be removed by chlorination with a salt flux. However, the other elements contained in magnesium alloy scrap are scarcely removed and this may contribute toward future contamination problems. The third technological option for the recycling of EoL magnesium products is magnesium recovery by a distillation process. Based on thermodynamic considerations, it is predicted that high-purity magnesium can be recovered through distillation because of its high vapor pressure, yet there is a limit on recoverability that depends on the equilibrium vapor pressure of the alloying elements and the large energy consumption. Therefore, the sustainable recycling of EoL magnesium products should be an important consideration in the design of advanced magnesium alloys or the development of new refining processes.

Thermodynamic criteria for the removal of impurities from end-of-life magnesium alloys by evaporation and flux treatment

PubMed Central

Hiraki, Takehito; Takeda, Osamu; Nakajima, Kenichi; Matsubae, Kazuyo; Nakamura, Shinichiro; Nagasaka, Tetsuya

2011-01-01

In this paper, the possibility of removing impurities during magnesium recycling with pyrometallurgical techniques has been evaluated by using a thermodynamic analysis. For 25 different elements that are likely to be contained in industrial magnesium alloys, the equilibrium distribution ratios between the metal, slag and gas phases in the magnesium remelting process were calculated assuming binary systems of magnesium and an impurity element. It was found that calcium, gadolinium, lithium, ytterbium and yttrium can be removed from the remelted end-of-life (EoL) magnesium products by oxidization. Calcium, cerium, gadolinium, lanthanum, lithium, plutonium, sodium, strontium and yttrium can be removed by chlorination with a salt flux. However, the other elements contained in magnesium alloy scrap are scarcely removed and this may contribute toward future contamination problems. The third technological option for the recycling of EoL magnesium products is magnesium recovery by a distillation process. Based on thermodynamic considerations, it is predicted that high-purity magnesium can be recovered through distillation because of its high vapor pressure, yet there is a limit on recoverability that depends on the equilibrium vapor pressure of the alloying elements and the large energy consumption. Therefore, the sustainable recycling of EoL magnesium products should be an important consideration in the design of advanced magnesium alloys or the development of new refining processes. PMID:27877407

Mechanism for the differentiation of EoL-1 cells into eosinophils by histone deacetylase inhibitors.

PubMed

Kaneko, Motoko; Ishihara, Kenji; Takahashi, Aki; Hong, Jangja; Hirasawa, Noriyasu; Zee, Okpyo; Ohuchi, Kazuo

2007-01-01

EoL-1 cells have a FIP1L1-PDGFRA fusion gene which causes the transformation of eosinophilic precursor cells into leukemia cells. Recently, we suggested that the induction of differentiation of EoL-1 cells into eosinophils by the HDAC inhibitors apicidin and n-butyrate is due to the continuous inhibition of HDACs. However, neither apicidin nor n-butyrate inhibited the expression of FIP1L1-PDGFRA mRNA, although both these inhibitors suppressed cell proliferation. Therefore, in this study, we analyzed whether the levels of FIP1L1-PDGFRalpha protein and phosphorylated-Stat5 involved in the signaling for the proliferation of EoL-1 cells are attenuated by HDAC inhibitors. EoL-1 cells were incubated in the presence of apicidin, TSA or n-butyrate. FIP1L1-PDGFRalpha and phosphorylated-Stat5 were detected by Western blotting. Treatment of EoL-1 cells with apicidin at 100 nM or n-butyrate at 500 microM decreased the levels of FIP1L1-PDGFRalpha protein and phosphorylated-Stat5, while that with trichostatin A at 30 nM did not. The decrease in the level of FIP1L1-PDGFRalpha protein caused by apicidin and n-butyrate might be one of the mechanisms by which EoL-1 cells are induced to differentiate into eosinophils by these HDAC inhibitors.

The Role of End-of-Life Issues in the Design and Reporting of Cancer Clinical Trials: A Structured Literature Review

PubMed Central

Lange, Stefan; Hausner, Elke; Gerhardus, Ansgar; Simon, Steffen T.; Voltz, Raymond; Becker, Gerhild; Schmacke, Norbert

2015-01-01

Background Randomized controlled trials (RCTs) are important sources of information on the benefits and harms patients may expect from treatment options. The aim of this structured literature review by the German Institute for Quality and Efficiency in Health Care was to explore whether and how the end-of-life (EoL) situation of patients with advanced cancer is considered in RCTs investigating anti-cancer treatments. Methods Our journal pool comprised 19 medical journals, namely five preselected key general medical journals as well as 14 specialist journals (mainly cancer) identified via a scoping search. We systematically searched these journals in MEDLINE to identify RCTs investigating anti-cancer treatments for the following four cancer types: glioblastoma, lung cancer (stage IIIb-IV), malignant melanoma (stage IV), and pancreatic cancer (search via OVID; November 2012). We selected a representative sample of 100 publications, that is, the 25 most recent publications for each cancer type. EoL was defined as a life expectancy of ≤ two years. We assessed the information provided on (1) the descriptions of the terminal stage of the disease, (2) the therapeutic goal (i.e. the intended therapeutic benefit of the intervention studied), (3) the study endpoints assessed, (4) the authors’ concluding appraisal of the intervention’s effects, and (5) the terminology referring to the patients’ EoL situation. Results Median survival was ≤ one year for each of the four cancer types. Descriptions of the terminal stage of the disease were ambiguous or lacking in 29/100 publications. One or more therapeutic goals were mentioned in 51/100 publications; these goals were patient-relevant in 38 publications (survival alone: 30/38; health-related quality of life (HRQoL) or HRQoL and survival: 6/38; symptom control or symptom control and survival: 2/38). Primary endpoints included survival (50%), surrogates (44%), and safety (3%). Patient-reported outcomes (PROs) were assessed in 36/100 RCTs. The implications of treatment-related harms for the patients were discussed in 22/100 appraisals. Terminology referring to the patients’ EoL situation (e.g. “terminal”) was scarce, whereas terms suggesting control of the disease (e.g. “cancer control“) were common. Conclusions The EoL situation of patients with advanced cancer should be more carefully considered in clinical trials. Although the investigation and robust reporting of PROs is a prerequisite for informed decision-making in healthcare, they are rarely defined as endpoints and HRQoL is rarely mentioned as a therapeutic goal. Suggestions for improving standards for study design and reporting are presented. PMID:26327232

Racial Differences In Hospitalizations Among Medicare-Medicaid Dual Eligible Dying Nursing Home Residents

PubMed Central

Cai, Shubing; Miller, Susan C.; Mukamel, Dana B.

2016-01-01

Objectives To examine whether racial differences in end of life (EOL) hospitalizations vary by the presence of advance directives, specifically the Do-Not-Hospitalize (DNH) order and individual cognitive status, among nursing home (NH) residents. Design National data, including the Medicare data and the Minimum Data Set (MDS) 2.0, between 01/01/2007 and 09/30/2010 were linked. EOL hospitalizations were hospitalizations in the last 30 days of life. Linear probability models with an interaction term (between race and DNH) and NH fixed-effects were estimated. The analyses were stratified by individual cognitive status. Setting NHs in the U.S. Participants We included decedents who were Medicare-Medicaid dually eligible, enrolled in Medicare fee-for-service plans and NH long-stayers (i.e., in NHs at least 90 days before their death). In total, 394,948 decedents were identified. Measurements The racial difference in EOL hospitalizations from a NH. Results EOL hospitalization rate was 31.7% for whites and 42.8% for blacks. Among those without DNH orders, adjusted probabilities of EOL hospitalizations were higher for blacks than for whites: 2.7 percentage points among those moderate cognitive impairment, P<0.01; and 4.7 percentage points among those with severe cognitive impairment, P<0.01. Among those with DNH orders, adjusted racial differences in EOL hospitalizations were not statistically significant among those with moderate or severe cognitive impairment (P=0.25 and 0.93), but blacks had a higher probability of EOL hospitalizations than whites if they had relatively intact cognitive status. Conclusion Racial differences in EOL hospitalizations varied with DNH orders and cognitive status among dying residents. Future research is necessary to understand the reasons behind these variations. PMID:27549337

Longitudinal Pediatric Palliative Care: Quality of Life & Spiritual Struggle (FACE): design and methods.

PubMed

Dallas, Ronald H; Wilkins, Megan L; Wang, Jichuan; Garcia, Ana; Lyon, Maureen E

2012-09-01

As life expectancy increases for adolescents ever diagnosed with AIDS due to treatment advances, the optimum timing of advance care planning is unclear. Left unprepared for end-of-life (EOL) decisions, families may encounter miscommunication and disagreements, resulting in families being charged with neglect, court battles and even legislative intervention. Advanced care planning (ACP) is a valuable tool rarely used with adolescents. The Longitudinal Pediatric Palliative Care: Quality of Life & Spiritual Struggle study is a two-arm, randomized controlled trial assessing the effectiveness of a disease specific FAmily CEntered (FACE) advanced care planning intervention model among adolescents diagnosed with AIDS, aimed at relieving psychological, spiritual, and physical suffering, while maximizing quality of life through facilitated conversations about ACP. Participants will include 130 eligible dyads (adolescent and family decision-maker) from four urban cities in the United States, randomized to either the FACE intervention or a Healthy Living Control. Three 60-minute sessions will be conducted at weekly intervals. The dyads will be assessed at baseline as well as 3-, 6-, 12-, and 18-month post-intervention. The primary outcome measures will be in congruence with EOL treatment preferences, decisional conflict, and quality of communication. The mediating and moderating effects of threat appraisal, HAART adherence, and spiritual struggle on the relationships among FACE and quality of life and hospitalization/dialysis use will also be assessed. This study will be the first longitudinal study of an AIDS-specific model of ACP with adolescents. If successful, this intervention could quickly translate into clinical practice. Copyright © 2012 Elsevier Inc. All rights reserved.

Collaborative Oceanography and Virtual Experiments

DTIC Science & Technology

2013-09-30

Observing Laboratory ( EOL ), but also contains an internal architecture which will allow it to evolve into a collaborative communication tool...an additional 50,988 "common" products were generated (241 plot types), along with 47,600 overlays (101 plot types). From 52 non- EOL sources...24,471 products were collected, and from 1486 EOL data collections, 643,263 "federated" products were indexed and made available through itop.org

A Distributed Approach to System-Level Prognostics

DTIC Science & Technology

2012-09-01

the end of (useful) life ( EOL ) and/or the remaining useful life (RUL) of components, subsystems, or systems. The prognostics problem itself can be...system state estimate, computes EOL and/or RUL. In this paper, we focus on a model-based prognostics approach (Orchard & Vachtse- vanos, 2009; Daigle...been focused on individual components, and determining their EOL and RUL, e.g., (Orchard & Vachtsevanos, 2009; Saha & Goebel, 2009; Daigle & Goebel

Propensity for home death among Taiwanese cancer decedents in 2001-2006, determined by services received at end of life.

PubMed

Tang, Siew Tzuh; Huang, Ean-Wen; Liu, Tsang-Wu; Rau, Kun-Ming; Hung, Yen-Ni; Wu, Shiao-Chi

2010-10-01

The discrepancy between patients' preferred and actual place of death highlights the dilemma inherent in achieving their preferences for home death. Research on determinants of home death has been limited largely by focusing on individual-level factors and somewhat on health care resources at the primary hospital and regional levels. To investigate factors associated with home death, specifically, services received by cancer patients at the end of life (EOL). This was a retrospective cohort study using administrative data from 201,201 Taiwanese cancer decedents in the period 2001-2006. Rates of home death decreased significantly over time (from 35.67% to 32.39%). Dying at home was associated with patient demographics (gender, age, and marital status) and disease characteristics (cancer type, metastatic status, postdiagnosis survival time, and comorbidity level). Taiwanese cancer patients were less likely to die at home if they received care from a medical oncologist and in hospitals or regions with abundant health care resources. Furthermore, Taiwanese cancer patients were less likely to die at home if they used life-sustaining treatments (intensive care unit care, cardiopulmonary resuscitation, intubation, and mechanical ventilation) in the last month of life. However, multiple emergency room visits in the last month of life and receiving hospice care increased Taiwanese cancer patients' propensity to die at home. Despite the causal ambiguity in interpreting our research findings, they indicate that using life-sustaining treatments at EOL not only exacts a substantial toll from patients, family members, and society, but also decreases the likelihood of dying at home. Copyright © 2010 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

The Right Place at the Right Time: Medical Oncology Outpatients' Perceptions of Location of End-of-Life Care.

PubMed

Waller, Amy; Sanson-Fisher, Rob; Zdenkowski, Nicholas; Douglas, Charles; Hall, Alix; Walsh, Justin

2018-01-01

Background: Helping people achieve their preferred location of care is an important indicator of quality end-of-life (EOL) care. Using a sample of Australian medical oncology outpatients, this study examined (1) their preferred location of EOL care; (2) their perceived benefits and worries of receiving care in that location; (3) the percentage who had discussed preferences with their doctor and/or support person; and (4) whether they wanted their doctor to ask them where they wanted to die. Methods: Adults with a confirmed diagnosis of cancer were approached between September 2015 and January 2016 in the waiting room of an Australian oncology outpatient clinic. Consenting participants completed a home-based pen-and-paper survey indicating preferred location of care, perceived benefits and worries of that location, whether they had discussed preferences with their doctors, and whether they were willing to be asked about their preferences. Results: A total of 203 patients returned the survey (47% of those eligible). Less than half preferred to be cared for at home (47%), 34% preferred a hospice/palliative care unit, and 19% preferred the hospital. Common benefits and worries associated with locations included perceived burden on others, familiarity of environment, availability of expert medical care, symptom management, and likelihood of having wishes respected. More patients had discussed preferences with their support persons (41%) than doctors (7%). Most wanted a doctor to ask them about preferred location of care (87%) and thought it was important to die in the location of their choice (93%). Conclusions: Patients were willing to have clinicians to ask them where they wanted to die, although few had discussed their preferences with doctors. Although home was the most preferred location for many patients, the overall variation suggests that clinicians should adopt a systematic approach to eliciting patient preferences. Copyright © 2018 by the National Comprehensive Cancer Network.

Bayesian Framework Approach for Prognostic Studies in Electrolytic Capacitor under Thermal Overstress Conditions

DTIC Science & Technology

2012-09-01

make end of life ( EOL ) and remaining useful life (RUL) estimations. Model-based prognostics approaches perform these tasks with the help of first...in parameters Degradation Modeling Parameter estimation Prediction Thermal / Electrical Stress Experimental Data State Space model RUL EOL ...distribution at given single time point kP , and use this for multi-step predictions to EOL . There are several methods which exits for selecting the sigma

Organizational capacities for 'residential care homes for the elderly' to provide culturally appropriate end-of-life care for Chinese elders and their families.

PubMed

Kong, Sui-Ting; Fang, Christine Meng-Sang; Lou, Vivian Weiqun

2017-01-01

Developing culturally appropriate end-of-life care for Chinese elderly and families is not an endemic challenge for Hong Kong, but that of the Western countries with a noticeable trend of rising Chinese population. The particular development of Hong Kong healthcare system, which is currently the major provider of end-of-life care, makes Hong Kong a fruitful case for understanding the confluence of the West and the East cultures in end-of-life care practices. This study therefore aims at building our best practice to enhance the capacity of residential care homes in providing culturally appropriate end-of-life care. We conducted two phases of research, a questionnaire survey and a qualitative study, which respectively aims at (1) understanding the EoL care service demand and provision in RCHEs, including death facts and perceived barriers and challenges in providing quality end-of-life care in care homes, and (2) identifying the necessary organizational capacities for the 'relational personhood' to be sustained in the process of ageing and dying in residential care homes. Findings shed light on how to empower residential care homes with necessary environmental, structural and cultural-resource-related capacity for providing quality end-of-life care for Chinese elders and their families. Copyright © 2016 Elsevier Inc. All rights reserved.

Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway.

PubMed

Anshushaug, Malin; Gynnild, Mari Aas; Kaasa, Stein; Kvikstad, Anne; Grønberg, Bjørn H

2015-03-01

Many cancer patients receive chemotherapy and radiotherapy their last 30 days [end of life (EOL)]. The benefit is questionable and side effects are common. The aim of this study was to investigate what characterized the patients who received chemo- and radiotherapy during EOL, knowledge that might be used to improve practice. Patients dead from cancer in 2005 and 2009 were analyzed. Data were collected from hospital medical records. When performance status (PS) was not stated, PS was estimated from other information in the records. A Glasgow Prognostic Score (GPS) of 0, 1 or 2 was assessed from blood values (CRP and albumin). A higher score is associated with a shorter prognosis. In total 616 patients died in 2005; 599 in 2009. Among the 723 analyzed, median age was 71; 42% had metastases at diagnosis (synchronous metastases); 53% had PS 2 and 16% PS 3-4 at the start of last cancer therapy. GPS at the start of last cancer therapy was assessable in 70%; of these, 26% had GPS 1 and 35% GPS 2. Overall, 10% received chemotherapy and 8% radiotherapy during EOL. The proportions varied significantly between the different types of cancer. Multivariate analyses revealed that those at age<70 years, GPS 2, no contact with our Palliative Care Unit and synchronous metastases received most chemotherapy the last 30 days. PS 3-4, GPS 2 and synchronous metastases were strongest associated with radiotherapy the last 30 days. Ten percent received chemotherapy and 8% radiotherapy the last 30 days of life. GPS 2 and synchronous metastases were most significantly associated with cancer therapy the last 30 days of life, indicating that in general, patients with the shortest survival time after diagnosis of cancer received more chemo- and radiotherapy during EOL than other patients.

QL-09TRAJECTORY OF QUALITY OF LIFE AT END OF LIFE IN MALIGNANT GLIOMA: SUPPORT FOR THE TERMINAL DROP THEORY

PubMed Central

Farace, Elana; Sheehan, Jonas

2014-01-01

Very little is known about quality of life (QOL) at end-of-life (EOL) in malignant brain tumor patients, which limits clinicians ability to best to help patients at this stage. The QOL trajectory at EOL has commonly been hypothesized to be "terminal decline," a linear relationship to time before death with a relatively gradual decline. Alternately, QOL at EOL could be hypothesized to be analogous to the "terminal drop" theory of cognitive aging, wherein the patient QOL has a curvilinear relationship to time before death; a relatively flat curve with a rapid decline a short time before death. 89 patients with malignant glioma were enrolled in this NCI funded study of QOL and neurocognition. Patients completed the EORTC-QLQ-C30 at three month intervals until death. Mean length of follow-up was 224 days (median 155 days). Mean age of patients was 52 years (range 18-80). The gender ratio was 49% men and 51% women. One patient was Latino (so 97% Non-Hispanic), 69 participants were Caucasian, one was African American, and one was Native American. The mean educational level was 13 years (range 8-20). Twenty-eight patients had glioblastoma (grade IV), nine had a grade III oligodendroglioma, and six had a grade III oligoastrocytoma. Data were plotted over time to determine if the shape of the curve resembles terminal decline or terminal drop. Interestingly, as can be seen from the graph, Global QOL slightly improved over time. Growth Curve Analysis confirms this finding. Results of this study may supporting the terminal drop theory but may also illustrate response shift, a conundrum for QOL researchers in which patients' perspective changes and thus they report improved QOL. Longer follow-up is necessary to delineate this pattern. A better understanding of QOL at EOL will improve medical and psychosocial palliative care.

Estimation of end of life mobile phones generation: The case study of the Czech Republic

DOE Office of Scientific and Technical Information (OSTI.GOV)

Polak, Milos, E-mail: mpolak@remasystem.cz; Drapalova, Lenka

Highlights: Black-Right-Pointing-Pointer In this paper, we define lifespan of mobile phones and estimate their average total lifespan. Black-Right-Pointing-Pointer The estimation of lifespan distribution is based on large sample of EoL mobile phones. Black-Right-Pointing-Pointer Total lifespan of Czech mobile phones is surprisingly long, exactly 7.99 years. Black-Right-Pointing-Pointer In the years 2010-20, about 26.3 million pieces of EoL mobile phones will be generated in the Czech Republic. - Abstract: The volume of waste electrical and electronic equipment (WEEE) has been rapidly growing in recent years. In the European Union (EU), legislation promoting the collection and recycling of WEEE has been in forcemore » since the year 2003. Yet, both current and recently suggested collection targets for WEEE are completely ineffective when it comes to collection and recycling of small WEEE (s-WEEE), with mobile phones as a typical example. Mobile phones are the most sold EEE and at the same time one of appliances with the lowest collection rate. To improve this situation, it is necessary to assess the amount of generated end of life (EoL) mobile phones as precisely as possible. This paper presents a method of assessment of EoL mobile phones generation based on delay model. Within the scope of this paper, the method has been applied on the Czech Republic data. However, this method can be applied also to other EoL appliances in or outside the Czech Republic. Our results show that the average total lifespan of Czech mobile phones is surprisingly long, exactly 7.99 years. We impute long lifespan particularly to a storage time of EoL mobile phones at households, estimated to be 4.35 years. In the years 1990-2000, only 45 thousands of EoL mobile phones were generated in the Czech Republic, while in the years 2000-2010 the number grew to 6.5 million pieces and it is estimated that in the years 2010-2020 about 26.3 million pieces will be generated. Current European legislation sets targets on collection and recycling of WEEE in general, but no specific collection target for EoL mobile phone exists. In the year 2010 only about 3-6% of Czech EoL mobile phones were collected for recovery and recycling. If we make similar estimation using an estimated average EU value, then within the next 10 years about 1.3 billion of EoL mobile phones would be available for recycling in the EU. This amount contains about 31 tonnes of gold and 325 tonnes of silver. Since Europe is dependent on import of many raw materials, efficient recycling of EoL products could help reduce this dependence. To set a working system of collection, it will be necessary to set new and realistic collection targets.« less

End-of-life (EoL) mobile phone management in Hong Kong households.

PubMed

Deng, Wen-Jing; Giesy, John P; So, C S; Zheng, Hai-Long

2017-09-15

A questionnaire survey and interviews were conducted in households and end-of-life (EoL) mobile phone business centres in Hong Kong. Widespread Internet use, combined with the rapid evolution of modern social networks, has resulted in the more rapid obsolescence of mobile phones, and thus a tremendous increase in the number of obsolete phones. In 2013, the volume of EoL mobile phones generated in Hong Kong totalled at least 330 tonnes, and the amount is rising. Approximately 80% of electronic waste is exported to Africa and developing countries such as mainland China or Pakistan for recycling. However, the material flow of the large number of obsolete phones generated by the territory's households remains unclear. Hence, the flow of EoL mobile phones in those households was analysed, with the average lifespan of a mobile phone in Hong Kong found to be just under two years (nearly 23 months). Most EoL mobile phones are transferred to mainland China for disposal. Current recycling methods are neither environmentally friendly nor sustainable, with serious implications for the environment and human health. The results of this analysis provide useful information for planning the collection system and facilities needed in Hong Kong and mainland China to better manage EoL mobile phones in the future. Copyright © 2017 Elsevier Ltd. All rights reserved.

Improving Computational Efficiency of Prediction in Model-Based Prognostics Using the Unscented Transform

NASA Technical Reports Server (NTRS)

Daigle, Matthew John; Goebel, Kai Frank

2010-01-01

Model-based prognostics captures system knowledge in the form of physics-based models of components, and how they fail, in order to obtain accurate predictions of end of life (EOL). EOL is predicted based on the estimated current state distribution of a component and expected profiles of future usage. In general, this requires simulations of the component using the underlying models. In this paper, we develop a simulation-based prediction methodology that achieves computational efficiency by performing only the minimal number of simulations needed in order to accurately approximate the mean and variance of the complete EOL distribution. This is performed through the use of the unscented transform, which predicts the means and covariances of a distribution passed through a nonlinear transformation. In this case, the EOL simulation acts as that nonlinear transformation. In this paper, we review the unscented transform, and describe how this concept is applied to efficient EOL prediction. As a case study, we develop a physics-based model of a solenoid valve, and perform simulation experiments to demonstrate improved computational efficiency without sacrificing prediction accuracy.

Development, Qualification and Production of Space Solar Cells with 30% EOL Efficiency

NASA Astrophysics Data System (ADS)

Guter, Wolfgang; Ebel, Lars; Fuhrmann, Daniel; Kostler, Wolfgang; Meusel, Matthias

2014-08-01

AZUR SPACE's latest qualified solar cell product 3G30-advanced provides a high end-of-life (EOL) efficiency of 27.8% for 5E14 (1 MeV e-/cm2) at low production costs. In order to further reduce the mass, the 3G30-advanced was thinned down to as thin as 20 μm and tested in space. Next generation solar cells must exceed the EOL efficiency of the 3G30-advanced and therefore will utilize the excess current of the Ge subcell. This can be achieved by a metamorphic cell concept. While average beginning-of-life efficiencies above 31% have already been demonstrated with upright metamorphic triple-junction cells, AZUR's next generation product will comprise a metamorphic 4- junction device targeting 30% EOL.

All-trans-retinoic acid enhances apoptosis induction by tyrosine kinase inhibitors in the eosinophilic leukemia-derived EoL-1 cell line.

PubMed

Robert, Carine; Apàti, Agota; Chomienne, Christine; Papp, Béla

2008-02-01

Imatinib and retinoids induce apoptosis in FIP1L1/PDGFRalpha-positive EoL-1 leukemia cells. Although imatinib induces complete remission in most FIP1L1/PDGFRalpha-positive patients, response to imatinib is sometimes suboptimal. In order to enhance the potency of the molecularly targeted therapy of eosinophilic leukemia, we investigated the effect of retinoids combined with tyrosine kinase inhibitors on EoL-1 cells. We demonstrate that retinoids combined with tyrosine kinase inhibitors lead to enhanced apoptosis induction in EoL-1 cells. Our results suggest that tyrosine kinase inhibitors combined with retinoids may constitute a valuable therapeutic approach for sensitive neoplasias that may display enhanced anti-leukemic potency when compared to single drug treatments.

End-of-Life Caregiver’s Perspectives on their Role: Generative Caregiving

PubMed Central

Phillips, Linda R.; Reed, Pamela G.

2010-01-01

Purpose: To describe caregivers’ constructions of their caregiving role in providing care to elders they knew were dying from life-limiting illnesses. Design and Methods: Study involved in-depth interviews with 27 family caregivers. Data were analyzed using constant comparative analysis. Results: Four categories were identified: centering life on the elder, maintaining a sense of normalcy, minimizing suffering, and gift giving. Generative caregiving was the term adopted to describe the end-of-life (EOL) caregiving role. Generative caregiving is situated in the present with a goal to enhance the elder’s present quality of life, but also draws from the past and projects into the future with a goal to create a legacy that honors the elder and the elder–caregiver relationship. Implications: Results contribute to our knowledge about EOL caregiving by providing an explanatory framework and setting the caregiving experience in the context of life-span development. PMID:19651667

Validation of Model-Based Prognostics for Pneumatic Valves in a Demonstration Testbed

DTIC Science & Technology

2014-10-02

predict end of life ( EOL ) and remaining useful life (RUL). The approach still follows the general estimation-prediction framework devel- oped in the...atmosphere, with linearly increasing leak area. kA2leak = Cleak (16) We define valve end of life ( EOL ) through open/close time limits of the valves, as in...represents end of life ( EOL ), and ∆kE represents remaining useful life (RUL). For valves, timing requirements are provided that de- fine the maximum

Diminishing Manufacturing Sources and Material Shortages: A Guidebook of Best Practices for Implementing a Robust DMSMS Management Program

DTIC Science & Technology

2012-08-01

EOL ) notices or other indicators of potential discontinuance. DMSMS monitoring and surveil- lance should begin as early as possible during the...throughout the duration of the program, when either the program receives a new EOL notice di- rectly, or the output of the program’s predictive tools or...OEM DMSMS mitigation efforts underway • OCM part number • Sources of active manufacturing • Actual or projected EOL • Function (active versus

An Integrated Framework for Model-Based Distributed Diagnosis and Prognosis

DTIC Science & Technology

2012-09-01

0 : t) denotes all measurements observed up to time t. The goal of prognosis is to determine the end of (use- ful) life ( EOL ) of a system, and/or its...remaining useful life (RUL). For a given fault, f , using the fault estimate, p(xf (t),θf (t)|y(0 : t)), a probability distribution of EOL , p(EOLf (tP...is stochas- tic, EOL /RUL are random variables and we represent them by probability distributions. The acceptable behavior of the system is expressed

A Definitive Interoperability Test Methodology for the Malicious Activity Simulation Tool (MAST)

DTIC Science & Technology

2013-03-01

Information Assurance Range DON Department of the Navy DON CIO Department of the Navy Chief Information Officer DoS Denial of Service EOL End-of...came “as part of PMW 160’s solution to the risk posed by Windows™ NT End-of-Life 43 ( EOL ).” Second, “[it] marked the beginning of a steady and...sometimes outdated, systems and programs. [34]. Table 1 shows the basic implementation and EOL timeline, the OS version for both server and

The Impact of Typhoons on the Ocean in the Pacific (ITOP) Field and Data Management Support

DTIC Science & Technology

2011-12-16

in October o f 2009 to develop effective sampling strategies for 20 I 0. EOL /Computing Data and Software Facil ity (CDS) supported the !TO P Dry Run...measurement strategies necessitated a dry run experiment in October of 2009 to develop effective sampling strategies for 2010. EOL /Computing Data and...contains products from 21 September through 32 October 2009. The catalog remains accessible at EOL at the above mentioned uri. The products listed by

Transitions Regarding Palliative and End-of-Life Care in Severe Chronic Obstructive Pulmonary Disease or Advanced Cancer: Themes Identified by Patients, Families, and Clinicians

PubMed Central

REINKE, LYNN F.; ENGELBERG, RUTH A.; SHANNON, SARAH E.; WENRICH, MARJORIE D.; VIG, ELIZABETH K.; BACK, ANTHONY L.; CURTIS, J. RANDALL

2015-01-01

Background Classic trajectories of illness at end of life (EOL) suggest different care needs for patients with cancer versus chronic obstructive pulmonary disease (COPD) and may lead to different experiences of transitions over the course of a life-limiting illness. Patients may experience transitions in different ways than clinicians. No prior studies have examined this issue from patients’, families’, and clinicians’ perspectives. Objectives We sought to explore transitions, defined as experiences that patients and family members viewed as milestones in the evolution of their illnesses and therapies, and compare these perceptions with the perspectives of the patient’s physician and nurse to provide insights about communication concerning EOL care. Methods We conducted a qualitative study using grounded theory to examine participants’ perspectives on the experiences of key transitions in the context of living with advanced COPD or cancer. In-depth interviews with patients, family members, nurses, and physicians were conducted by experienced interviewers. Results Six themes were identified regarding participants’ experiences with transitions. Themes that defined transitions among both patients with COPD and those with cancer included: new or different treatments and no more treatments available. Themes unique to patients with COPD were activity limitations due to functional decline and initiation of oxygen therapy. One theme unique to clinicians was acute exacerbation of illness or hospitalization. Conclusions This study identified differences in the meaning of transitions for patients versus clinicians and for patients with COPD versus those with cancer. These findings may offer clinicians the opportunity to provide a more patient-centered approach to communication about end-of-life care by acknowledging and addressing transitions in palliative care from the perspective of the patient and family. PMID:18454613

Looking Beyond Where Children Die: Determinants and Effects of Planning a Child’s Location of Death

PubMed Central

Dussel, Veronica; Kreicbergs, Ulrika; Hilden, Joanne M.; Watterson, Jan; Moore, Caron; Turner, Brian G.; Weeks, Jane C.; Wolfe, Joanne

2009-01-01

While dying at home may be the choice of many, where people die may be less important than argued. We examined factors associated with parental planning of a child’s location of death (LOD) and its effects on patterns of care and parent’s experience. In a cross-sectional study of 140 parents who lost a child to cancer at one of two tertiary level U.S. pediatric hospitals, 88 (63%) planned the child’s LOD and 97% accomplished their plan. After adjusting for disease and family characteristics, families whose primary oncologist clearly explained treatment options during the child’s end of life (EOL) and who had home care involved were more likely to plan LOD. Planning LOD was associated with more home deaths (72% versus 8% among those who did not plan, P<0.001) and fewer hospital admissions (54% versus 98%, P<0.001). Parents who planned were more likely to feel very prepared for the child’s EOL (33% versus 12%, P=0.007) and very comfortable with LOD (84% versus 40%, P<0.001), and less likely to have preferred a different LOD (2% versus 46%, P<0.001). Among the 73 non-home deaths, planning was associated with more deaths occurring in the ward than in the intensive care unit or other hospital (92% versus 33%, P<0.001), and fewer children being intubated (21% versus 48%, P=0.029). Comprehensive physician communication and home care involvement increase the likelihood of planning a child’s LOD. Opportunity to plan LOD is associated with outcomes consistent with high quality palliative care, even among non-home deaths, and thus may represent a more relevant outcome than actual LOD. PMID:18538973

Trust Building Recruitment Strategies for Researchers Conducting Studies in African American (AA) Churches: Lessons Learned.

PubMed

Bonner, Gloria; Williams, Sharon; Wilkie, Diana; Hart, Alysha; Burnett, Glenda; Peacock, Geraldine

2017-12-01

An initial and vital important step in recruiting participants for church-based hospice and palliative care research is the establishment of trust and credibility within the church community. Mistrust of medical research is an extremely important barrier hindering recruitment in African American (AA) communities. A church-based EOL dementia education project is currently being conducted at four large urban AA churches. Church leaders voiced mistrust concerns of previous researchers who conducted investigations in their faith-based institutions. We explored strategies to ameliorate the mistrust concerns. Specific aim: To identify trust-rebuilding elements for researchers following others who violated trust of AA church leaders. Face-to-face, in-depth interviews were conducted from a convenient sample of four established AA church leaders. Interviews were held in the informants' churches to promote candor and comfort in revealing sensitive information about trust /mistrust. Content analysis framework was used to analyze the data. Elements identified from the analysis were then used to create themes. Multidimensional overarching themes emerged from the analysis included: Experience with researchers (positive and extremely negative), violation of trust and trust building strategies. Findings suggest that researchers who wish to conduct successful studies in the AA religious institutions must implement trust rebuilding strategies that include mutual respect, collaboration and partnership building. If general moral practices continue to be violated, threat to future hospice and palliative care research within the institutions may prevail. Thus, potential benefits are thwarted for the church members, AA community, and advancement of EOL care scholarship.

Estimation of end of life mobile phones generation: the case study of the Czech Republic.

PubMed

Polák, Miloš; Drápalová, Lenka

2012-08-01

The volume of waste electrical and electronic equipment (WEEE) has been rapidly growing in recent years. In the European Union (EU), legislation promoting the collection and recycling of WEEE has been in force since the year 2003. Yet, both current and recently suggested collection targets for WEEE are completely ineffective when it comes to collection and recycling of small WEEE (s-WEEE), with mobile phones as a typical example. Mobile phones are the most sold EEE and at the same time one of appliances with the lowest collection rate. To improve this situation, it is necessary to assess the amount of generated end of life (EoL) mobile phones as precisely as possible. This paper presents a method of assessment of EoL mobile phones generation based on delay model. Within the scope of this paper, the method has been applied on the Czech Republic data. However, this method can be applied also to other EoL appliances in or outside the Czech Republic. Our results show that the average total lifespan of Czech mobile phones is surprisingly long, exactly 7.99 years. We impute long lifespan particularly to a storage time of EoL mobile phones at households, estimated to be 4.35 years. In the years 1990-2000, only 45 thousands of EoL mobile phones were generated in the Czech Republic, while in the years 2000-2010 the number grew to 6.5 million pieces and it is estimated that in the years 2010-2020 about 26.3 million pieces will be generated. Current European legislation sets targets on collection and recycling of WEEE in general, but no specific collection target for EoL mobile phone exists. In the year 2010 only about 3-6% of Czech EoL mobile phones were collected for recovery and recycling. If we make similar estimation using an estimated average EU value, then within the next 10 years about 1.3 billion of EoL mobile phones would be available for recycling in the EU. This amount contains about 31 tonnes of gold and 325 tonnes of silver. Since Europe is dependent on import of many raw materials, efficient recycling of EoL products could help reduce this dependence. To set a working system of collection, it will be necessary to set new and realistic collection targets. Copyright © 2012 Elsevier Ltd. All rights reserved.

Chemical composition and cytotoxic activity of Garcinia atroviridis Griff. ex T. Anders. essential oils in combination with tamoxifen.

PubMed

Tan, Wen-Nee; Lim, Jia-Qin; Afiqah, Fatin; Nik Mohamed Kamal, Nik Nur Syazni; Abdul Aziz, Fatin Athirah; Tong, Woei-Yenn; Leong, Chean-Ring; Lim, Jun-Wei

2018-04-01

Garcinia atroviridis Griff. ex T. Anders. is used as a medication agent in folkloric medicine. The present study was to examine the chemical composition of the stem bark and leaf of G. atroviridis as well as their cytotoxic effects against MCF-7 cells. The constituents obtained by hydrodistillation were identified using GC-MS. The stem bark oil (EO-SB) composed mainly the palmitoleic acid (51.9%) and palmitic acid (21.9%), while the leaf oil (EO-L) was dominated by (E)-β-farnesene (58.5%) and β-caryophyllene (16.9%). Treatment of MCF-7 cells using EO-L (100 μg/mL) caused more than 50% cell death while EO-SB did not induce cytotoxic effect. EO-L has stimulated the growth of BEAS-2B normal cells, but not in MCF-7 cancerous cells. The IC 50 of EO-L in MCF-7 and BEAS-2B cells were 71 and 95 μg/mL, respectively. A combination treatment of EO-L and tamoxifen induced more cell death than the treatment with drug alone at lower doses.

Building the Encyclopedia of Life

NASA Astrophysics Data System (ADS)

Mangiafico, P. A.; Patterson, D. J.

2010-04-01

The Encyclopedia of Life (EOL) is a collaborative project that indexes information about species, and makes it freely accessible to anyone. In order to accomplish this, EOL is building collaborative tools and infrastructure to unify the information.

Apoptosis- and differentiation-inducing activities of jacaric acid, a conjugated linolenic acid isomer, on human eosinophilic leukemia EoL-1 cells.

PubMed

Liu, Wai-Nam; Leung, Kwok-Nam

2014-11-01

Conjugated linolenic acids (CLNAs) are a group of naturally occurring positional and geometrical isomers of the C18 polyunsaturated essential fatty acid, linolenic acid (LNA), with three conjugated double bonds (C18:3). Although previous research has demonstrated the growth-inhibitory effects of CLNA on a wide variety of cancer cell lines in vitro, their action mechanisms and therapeutic potential on human myeloid leukemia cells remain poorly understood. In the present study, we found that jacaric acid (8Z,10E,12Z-octadecatrienoic acid), a CLNA isomer which is present in jacaranda seed oil, inhibited the in vitro growth of human eosinophilic leukemia EoL-1 cells in a time- and concentration-dependent manner. Mechanistic studies showed that jacaric acid triggered cell cycle arrest of EoL-1 cells at the G0/G1 phase and induced apoptosis of the EoL-1 cells, as measured by the Cell Death Detection ELISAPLUS kit, Annexin V assay and JC-1 dye staining. Notably, the jacaric acid-treated EoL-1 cells also underwent differentiation as revealed by morphological and phenotypic analysis. Collectively, our results demonstrated the capability of jacaric acid to inhibit the growth of EoL-1 cells in vitro through triggering cell cycle arrest and by inducing apoptosis and differentiation of the leukemia cells. Therefore, jacaric acid might be developed as a potential candidate for the treatment of certain forms of myeloid leukemia with minimal toxicity and few side effects.

The roles of MCP-1 and protein kinase C delta activation in human eosinophilic leukemia EoL-1 cells.

PubMed

Lee, Ji-Sook; Yang, Eun Ju; Kim, In Sik

2009-12-01

Idiopathic hypereosinophilc syndrome is a disorder associated with clonally eosinophilic proliferation. The importance of FIP1-like-1-platelet-derived growth factor receptor-alpha (FIP1L1-PDGFRA) in the pathogenesis and classification of HES has been recently reported. In this study, we investigated the contribution of monocyte chemoattractant protein-1 (MCP-1)/CCL2 to chemotactic activity and protein kinase C delta (PKC delta in the human eosinophilic leukemia cell line EoL-1. These cells express CCR2 protein among the CC chemokine receptors (CCR1-5). MCP-1 induces strong migration of EoL-1 cells and the chemotaxis signal in response to MCP-1 involves a G(i)/G(o) protein, phospholipase C (PLC), PKC delta, p38 MAPK and NF-kappaB. MCP-1 activates p38 MAPK via G(i)/G(o) protein, PLC and PKC delta cascade. MCP-1 also induces NF-kappaB translocation and the activation is inhibited by PKC delta activation. The increase in the basal expression and activity of PKC delta in EoL-1 cells, compared to normal eosinophils, inhibits apoptosis in EoL-1 cells. Anti-apoptotic mechanism of PKC delta is related to inhibition of caspase 3 and caspase 9, but not to FIP1L1-PDGFRA. PKC delta functions as an anti-apoptotic molecule, and is involved in EoL-1 cell movement stimulated by MCP-1. This study contributes to an understanding of MCP-1 in eosinophil biology and pathogenic mechanism of eosinophilic disorders.

Anti-proliferative and differentiation-inducing activities of the green tea catechin epigallocatechin-3-gallate (EGCG) on the human eosinophilic leukemia EoL-1 cell line.

PubMed

Lung, H L; Ip, W K; Wong, C K; Mak, N K; Chen, Z Y; Leung, K N

2002-12-06

A novel approach for the treatment of leukemia is the differentiation therapy in which immature leukemia cells are induced to attain a mature phenotype when exposed to differentiation inducers, either alone or in combinations with other chemotherapeutic or chemopreventive drugs. Over the past decade, numerous studies indicated that green tea catechins (GTC) could suppress the growth and induce apoptosis on a number of human cancer cell lines. However, the differentiation-inducing activity of GTC on human tumors remains poorly understood. In the present study, the effect of the major GTC epigallocatechin-3-gallate (EGCG) on the proliferation and differentiation of a human eosinophilc leukemic cell line, EoL-1, was examined. Our results showed that EGCG suppressed the proliferation of the EoL-1 cells in a dose-dependent manner, with an estimated IC(50) value of 31.5 microM. On the other hand, EGCG at a concentration of 40 microM could trigger the EoL-1 cells to undergo morphological differentiation into mature eosinophil-like cells. Using RT-PCR and flow cytometry, it was found that EGCG upregulated the gene and protein expression of two eosinophil-specific granule proteins, the major basic protein (MBP) and eosinophil peroxidase (EPO), in EoL-1 cells. Taken together, our findings suggest that EGCG can exhibit anti-leukemic activity on a human eosinophilic cell line EoL-1 by suppressing the proliferation and by inducing the differentiation of the leukemia cells.

What do we know about metal recycling rates?

USGS Publications Warehouse

Graedel, T.E.; Allwood, J.; Birat, J.-P.; Buchert, M.; Hageluken, C.; Reck, B.K.; Sibley, S.F.; Sonnemann, G.

2011-01-01

The recycling of metals is widely viewed as a fruitful sustainability strategy, but little information is available on the degree to which recycling is actually taking place. This article provides an overview on the current knowledge of recycling rates for 60 metals. We propose various recycling metrics, discuss relevant aspects of recycling processes, and present current estimates on global end-of-life recycling rates (EOL-RR; i.e., the percentage of a metal in discards that is actually recycled), recycled content (RC), and old scrap ratios (OSRs; i.e., the share of old scrap in the total scrap flow). Because of increases in metal use over time and long metal in-use lifetimes, many RC values are low and will remain so for the foreseeable future. Because of relatively low efficiencies in the collection and processing of most discarded products, inherent limitations in recycling processes, and the fact that primary material is often relatively abundant and low-cost (which thereby keeps down the price of scrap), many EOL-RRs are very low: Only for 18 metals (silver, aluminum, gold, cobalt, chromium, copper, iron, manganese, niobium, nickel, lead, palladium, platinum, rhenium, rhodium, tin, titanium, and zinc) is the EOL-RR above 50% at present. Only for niobium, lead, and ruthenium is the RC above 50%, although 16 metals are in the 25% to 50% range. Thirteen metals have an OSR greater than 50%. These estimates may be used in considerations of whether recycling efficiencies can be improved; which metric could best encourage improved effectiveness in recycling; and an improved understanding of the dependence of recycling on economics, technology, and other factors. ?? 2011 by Yale University.

Oncologists' communication about end of life: the relationship among secondary traumatic stress, compassion satisfaction, and approach and avoidance communication.

PubMed

Granek, Leeat; Nakash, Ora; Cohen, Michal; Ben-David, Merav; Ariad, Samuel

2017-11-01

Oncologists must communicate effectively with patients and their families about end of life (EOL). Despite the importance of communicating on this topic, many oncologists avoid these conversations. The objective of this study was to examine the associations between secondary traumatic stress and compassion satisfaction and approach and avoidant communication about EOL with cancer patients. A convenience sample of 79 oncologists (n = 27 men, n = 52 women) participated in the study. Oncologists completed a survey that included a sociodemographic and clinical information questionnaire, the Professional Quality of Life Scale, and Communication about End of Life Survey. To examine the effect of secondary traumatic stress and compassion satisfaction on approach and avoidant communication, while controlling for gender and age, 2 hierarchical linear regression analyses were computed. Oncologists reported high levels of secondary traumatic stress and high compassion satisfaction. Scores on the approach and avoidant communication scales were in the mid-range of the scale. Lower reports of secondary traumatic stress and higher compassion satisfaction were associated with higher approach communication strategies: however, only higher secondary traumatic stress was associated with higher avoidant communication strategies. Our findings indicate that there is an association between emotional factors and approach communication. The findings have clinical implications in designing effective communication skills training. Further research and training should take secondary traumatic stress and compassion satisfaction into consideration to be able to ensure that terminal patients and their families receive the best quality EOL care. Copyright © 2016 John Wiley & Sons, Ltd.

Metal Recovery from Industrial Solid Waste — Contribution to Resource Sustainability

NASA Astrophysics Data System (ADS)

Yang, Yongxiang

Increased demand of metals has driven the accelerated mining and metallurgical production in recent years, causing fast depletion of primary metals resources. On the contrary, the mining and metallurgical industry generates large amount of solid residues and waste such as tailings, slags, flue dust and leach residues, with relative low valuable metal contents. On the other hand, end-of-life (EoL) consumer products form another significant resources. The current technology and processes for primary metals production are not readily applicable for direct metals extraction from these waste materials, and special adaptation and tailor-made processes are required. In the present paper, various solid waste resources are reviewed, and current technologies and R&D trends are discussed. The recent research at author's group is illustrated for providing potential solutions to future resource problems, including metal recovery from MSW incinerator bottom ashes, zinc recovery from industrial ashes and residues, and rare earth metals recovery from EoL permanent magnets.

Cathode refunctionalization as a lithium ion battery recycling alternative

NASA Astrophysics Data System (ADS)

Ganter, Matthew J.; Landi, Brian J.; Babbitt, Callie W.; Anctil, Annick; Gaustad, Gabrielle

2014-06-01

An approach to battery end-of-life (EOL) management is developed involving cathode refunctionalization, which enables remanufacturing of the cathode from EOL materials to regain the electrochemical performance. To date, the optimal end-of-life management of cathode materials is based on economic value and environmental impact which can influence the methods and stage of recycling. Traditional recycling methods can recover high value metal elements (e.g. Li, Co, Ni), but still require synthesis of new cathode from a mix of virgin and recovered materials. Lithium iron phosphate (LiFePO4) has been selected for study as a representative cathode material due to recent mass adoption and limited economic recycling drivers due to the low inherent cost of iron. Refunctionalization of EOL LiFePO4 cathode was demonstrated through electrochemical and chemical lithiation methods where the re-lithiated LiFePO4 regained the original capacity of 150-155 mAh g-1. The environmental impact of the new recycling technique was determined by comparing the embodied energy of cathode material originating from virgin, recycled, and refunctionalized materials. The results demonstrate that the LiFePO4 refunctionalization process, through chemical lithiation, decreases the embodied energy by 50% compared to cathode production from virgin materials.

Antimicrobial Effect of Lippia sidoides and Thymol on Enterococcus faecalis Biofilm of the Bacterium Isolated from Root Canals

PubMed Central

Veras, H. N. H.; Rodrigues, F. F. G.; Botelho, M. A.; Menezes, I. R. A.; Coutinho, H. D. M.; da Costa, J. G. M.

2014-01-01

The species Lippia sidoides Cham. (Verbenaceae) is utilized in popular medicine as a local antiseptic on the skin and mucosal tissues. Enterococcus faecalis is the bacterium isolated from root canals of teeth with persistent periapical lesions and has the ability to form biofilm, where it is responsible for the failure of endodontic treatments. Essential oil of L. sidoides (EOLS) and its major component, thymol, were evaluated for reducing the CFU in biofilms of E. faecalis in vitro. The essential oil was obtained by hydrodistillation and examined with respect to the chemical composition, by gas chromatography-mass spectrometry (GC-MS). The GC-MS analysis has led to the identification of thymol (84.9%) and p-cymene (5.33%). EOLS and thymol reduced CFU in biofilms of E. faecalis in vitro (time of maturation, 72 h), with an exposure time of 30 and 60 min at concentrations of 2.5 and 10%. There was no statistical difference in effect between EOLS and thymol, demonstrating that this phenolic monoterpene was the possible compound responsible for the antimicrobial activity of EOLS. This study provides a basis for the possible utilization of EOLS as an adjuvant in the treatment of root canals that show colonization by E. faecalis. PMID:24683344

Dasatinib inhibits the growth and survival of neoplastic human eosinophils (EOL-1) through targeting of FIP1L1-PDGFRalpha.

PubMed

Baumgartner, Christian; Gleixner, Karoline V; Peter, Barbara; Ferenc, Veronika; Gruze, Alexander; Remsing Rix, Lily L; Bennett, Keiryn L; Samorapoompichit, Puchit; Lee, Francis Y; Pickl, Winfried F; Esterbauer, Harald; Sillaber, Christian; Superti-Furga, Giulio; Valent, Peter

2008-10-01

Chronic eosinophilic leukemia (CEL) is a myeloproliferative disorder characterized by molecular and/or cytogenetic evidence of clonality of eosinophils, marked eosinophilia, and organ damage. In many patients, the transforming mutation FIP1L1-PDGFRalpha and the related CHIC2 deletion are found. The respective oncoprotein, FIP1L1-PDGFRalpha, is considered to play a major role in malignant cell growth in CEL. The tyrosine kinase (TK) inhibitor imatinib (STI571) has been described to counteract the TK activity of FIP1L1-PDGFRalpha in most patients. However, not all patients with CEL show a response to imatinib. Therefore, several attempts have been made to identify other TK inhibitors that counteract growth of neoplastic eosinophils. We provide evidence that dasatinib, a multi-targeted kinase inhibitor, blocks the growth and survival of EOL-1, an eosinophil leukemia cell line carrying FIP1L1-PDGFRalpha. The effects of dasatinib on proliferation of EOL-1 cells were dose-dependent, with an IC50 of 0.5 to 1 nM, which was found to be in the same range when compared to IC50 values produced with imatinib. Dasatinib was also found to induce apoptosis in EOL-1 cells in a dose-dependent manner (IC50: 1-10 nM). The apoptosis-inducing effects of dasatinib on EOL-1 cells were demonstrable by light microscopy, flow cytometry, and in a TUNEL assay. In Western blot experiments, dasatinib completely blocked the phosphorylation of FIP1L1-PDGFRalpha in EOL-1 cells. Dasatinib inhibits the growth of leukemic eosinophils through targeting of the disease-related oncoprotein FIP1L1-PDGFRalpha. Based on this observation, dasatinib may be considered as a new interesting treatment option for patients with CEL.

Trust Building Recruitment Strategies for Researchers Conducting Studies in African American (AA) Churches: Lessons Learned

PubMed Central

Bonner, Gloria; Williams, Sharon; Wilkie, Diana; Hart, Alysha; Burnett, Glenda; Peacock, Geraldine

2017-01-01

Background An initial and vital important step in recruiting participants for church-based hospice and palliative care research is the establishment of trust and credibility within the church community. Mistrust of medical research is an extremely important barrier hindering recruitment in African American (AA) communities. A church-based EOL dementia education project is currently being conducted at four large urban AA churches. Church leaders voiced mistrust concerns of previous researchers who conducted investigations in their faith-based institutions. We explored strategies to ameliorate the mistrust concerns. Specific aim To identify trust-rebuilding elements for researchers following others who violated trust of AA church leaders. Methods Face-to-face, in-depth interviews were conducted from a convenient sample of four established AA church leaders. Interviews were held in the informants’ churches to promote candor and comfort in revealing sensitive information about trust/mistrust. Content analysis framework was used to analyze the data. Elements identified from the analysis were then used to create themes. Results Multidimensional overarching themes emerged from the analysis included: Experience with researchers (positive and extremely negative), violation of trust and trust building strategies. Conclusions Findings suggest that researchers who wish to conduct successful studies in the AA religious institutions must implement trust rebuilding strategies that include mutual respect, collaboration and partnership building. If general moral practices continue to be violated, threat to future hospice and palliative care research within the institutions may prevail. Thus, potential benefits are thwarted for the church members, AA community, and advancement of EOL care scholarship. PMID:27577723

Predictors of high healthcare costs in elderly patients with liver cancer in end-of-life: a longitudinal population-based study.

PubMed

Chiang, Jui-Kun; Kao, Yee-Hsin

2017-08-24

Studies have indicated a pervasive pattern of decreasing healthcare costs during elderly patients' last year of life. The aim of this study was to explore the predictors of high healthcare costs (HC) in elderly liver cancer patients in Taiwan during their last month of life (LML). Costs of hospitalization, outpatient visits, aggressiveness of care, and associated costs for elderly (age ≥ 65 y) patients with liver cancer in the LML were analyzed using a national insurance database. An HC was defined as being greater than the 90th percentile (US $5093) in the LML, amounting to 38.95% of total healthcare costs. We enrolled 2121 subjects who died during 1997-2011. Mean healthcare costs per person in their LML were US $8042 ± 3477 in the HC group and US $1407 ± 1464 in the non-HC group (p < 0.001). For patients receiving aggressive end-of-life (EOL) cancer care (e.g. intensive care, cardiopulmonary resuscitation, anticancer treatment, and a high number of admission days), comorbidities of chronic kidney disease, esophageal bleeding, and receiving opioids in the LML, were significantly independent positive predictors of HCs; but admission times, comorbidities of ascites, and hypertension were negative predictors. These findings could inform healthcare providers by avoiding aggressive treatments during EOL for elderly patients with liver cancer and to save on healthcare costs. Shorter admission days and more admission times in the last month of life could decrease healthcare costs.

ENVIRONMENTS and EOL: identification of Environment Ontology terms in text and the annotation of the Encyclopedia of Life.

PubMed

Pafilis, Evangelos; Frankild, Sune P; Schnetzer, Julia; Fanini, Lucia; Faulwetter, Sarah; Pavloudi, Christina; Vasileiadou, Katerina; Leary, Patrick; Hammock, Jennifer; Schulz, Katja; Parr, Cynthia Sims; Arvanitidis, Christos; Jensen, Lars Juhl

2015-06-01

The association of organisms to their environments is a key issue in exploring biodiversity patterns. This knowledge has traditionally been scattered, but textual descriptions of taxa and their habitats are now being consolidated in centralized resources. However, structured annotations are needed to facilitate large-scale analyses. Therefore, we developed ENVIRONMENTS, a fast dictionary-based tagger capable of identifying Environment Ontology (ENVO) terms in text. We evaluate the accuracy of the tagger on a new manually curated corpus of 600 Encyclopedia of Life (EOL) species pages. We use the tagger to associate taxa with environments by tagging EOL text content monthly, and integrate the results into the EOL to disseminate them to a broad audience of users. The software and the corpus are available under the open-source BSD and the CC-BY-NC-SA 3.0 licenses, respectively, at http://environments.hcmr.gr. © The Author 2015. Published by Oxford University Press.

The Eole experiment - Early results and current objectives.

NASA Technical Reports Server (NTRS)

Morel, P.; Bandeen, W.

1973-01-01

The Eole experiment with 480 constant level balloons released in the Southern Hemisphere is described. Each balloon, floating freely at approximately the 200-mb level, is a precise tracer of the horizontal motion of air masses, the accuracy of which is limited only by the laminated structure of the stratospheric flow, within an rms uncertainty of 1.5 m/sec. The balloons were found after 2 months to distribute at random over the whole hemisphere outside the tropics, irrespective of their original launching site. Early results of Eulerian and Lagrangian averages of the Eole wind data are given for describing the mean 200-mb zonal and meridional circulations.

Development of an in-home standardized end-of-life treatment program for pediatric patients dying of brain tumors.

PubMed

Arland, Lesley C; Hendricks-Ferguson, Verna L; Pearson, Joanne; Foreman, Nicholas K; Madden, Jennifer R

2013-04-01

To evaluate an end-of-life (EOL) program related to specific outcomes (i.e., number of hospitalizations and place of death) for children with brain tumors. From 1990 to 2005, a retrospective chart review was performed related to specified outcomes for 166 children with admission for pediatric brain tumors. Patients who received the EOL program were hospitalized less often (n = 114; chi-square = 5.001 with df = 1, p <.05) than patients who did not receive the program. An EOL program may improve symptom management and decrease required hospital admissions for children with brain tumors. © 2013, Wiley Periodicals, Inc.

The HIPPO Project Archive: Carbon Cycle and Greenhouse Gas Data

NASA Astrophysics Data System (ADS)

Christensen, S. W.; Aquino, J.; Hook, L.; Williams, S. F.

2012-12-01

The HIAPER (NSF/NCAR Gulfstream V Aircraft) Pole-to-Pole Observations (HIPPO) project measured a comprehensive suite of atmospheric trace gases and aerosols pertinent to understanding the global carbon cycle from the surface to the tropopause and approximately pole-to-pole over the Pacific Ocean. Flights took place over five missions during different seasons from 2009 to 2011. Data and documentation are available to the public from two archives: (1) NCAR's Earth Observing Laboratory (EOL) provides complete aircraft and flight operational data, and (2) the U.S. DOE's Carbon Dioxide Information Analysis Center (CDIAC) provides integrated measurement data products. The integrated products are more generally useful for secondary analyses. Data processing is nearing completion, although improvements to the data will continue to evolve and analyses will continue many years into the future. Periodic new releases of integrated measurement (merged) products will be generated by EOL when individual measurement data have been updated as directed by the Lead Principal Investigator. The EOL and CDIAC archives will share documentation and supplemental links and will ensure that the latest versions of data products are available to users of both archives. The EOL archive (http://www.eol.ucar.edu/projects/hippo/) provides the underlying investigator-provided data, including supporting data sets (e.g. operational satellite, model output, global observations, etc.), and ancillary flight operational information including field catalogs, data quality reports, software, documentation, publications, photos/imagery, and other detailed information about the HIPPO missions. The CDIAC archive provides integrated measurement data products, user documentation, and metadata through the HIPPO website (http://hippo.ornl.gov). These merged products were derived by consistently combining the aircraft state parameters for position, time, temperature, pressure, and wind speed with meteorological, atmospheric chemistry and aerosol measurements made by several teams of investigators. Files are in ASCII text format. Selected data products have been loaded into a relational database for customized data subsetting and export formatting. We anticipate adding model-generated products to the archive. Metadata records have been compiled into a searchable CDIAC index and have been submitted to climate change research metadata clearinghouses (e.g., GCMD). Each data product is given a complete bibliographic citation and a persistent identifier (DOI) to facilitate attribution and access. A data policy was adopted that balances the needs of the project investigators with the interests of the scientific user community.

Compassionate communities: design and preliminary results of the experience of Vic (Barcelona, Spain) caring city.

PubMed

Gómez-Batiste, Xavier; Mateu, Silvia; Serra-Jofre, Susagna; Molas, Magda; Mir-Roca, Sarah; Amblàs, Jordi; Costa, Xavier; Lasmarías, Cristina; Serrarols, Marta; Solà-Serrabou, Alvar; Calle, Candela; Kellehear, Allan

2018-04-01

A program of Compassionate City or Community (CC) has been designed and developed in the City of Vic (43,964 habitants, Barcelona, Spain), based on The Compassionate City Charter and other public health literature and experiments, with the joint leadership of the City Council and the Chair of Palliative Care at the University of Vic, and as an expansion of a comprehensive and integrated system of palliative care. The program started with an assessment of needs of the city as identified by 48 social organizations with a foundational workshop and a semi-structured survey. After this assessment, the mission, vision, values and aims were agreed. The main aims consisted in promoting changes in social and cultural attitudes toward the end of life (EoL) and providing integrated care for people with advanced chronic conditions and social needs such as loneliness, poverty, low access to services at home, or conflict. The selected slogan was "Living with meaning, dignity, and support the end of life". The program for the first year has included 19 activities (cultural, training, informative, and mixed) and followed by 1,260 attendants, and the training activities were followed by 147 people. Local and regional sponsors are funding the initiative. After a year, a quantitative and qualitative evaluation was performed, showing high participation and satisfaction of the attendants and organizations. In the second year, the care for particular vulnerable people defined as targets (EoL and social factors described before) will start with volunteers with more organizations to join the project. The key identified factors for the initial success are: the strong joint leadership between social department of the Council and the University; clear aims and targets; high participation rates; the limited size of the geographical context; which allowed high participation and recognition; and the commitment to evaluate results.

Adaptation, Acceptance and Adaptive Preferences in Health and Capability Well-Being Measurement Amongst Those Approaching End of Life.

PubMed

Coast, Joanna; Bailey, Cara; Orlando, Rosanna; Armour, Kathy; Perry, Rachel; Jones, Louise; Kinghorn, Philip

2018-05-09

Adaptive preferences occur when people subconsciously alter their views to account for the possibilities available to them. Adaptive preferences may be problematic where these views are used in resource allocation decisions because they may lead to underestimation of the true benefits of providing services. This research explored the nature and extent of both adaptation (changing to better suit the context) and adaptive preferences (altering preferences in response to restricted options) in individuals approaching the end of life (EoL). Qualitative data from 'thinkaloud' interviews with 33 hospice patients, 22 close persons and 17 health professionals were used alongside their responses to three health/well-being measures for use in resource allocation decisions: EQ-5D-5L (health status); ICECAP-A (adult capability); and ICECAP-SCM (Supportive Care Measure; EoL capability). Constant comparative analysis combined a focus on both verbalised perceptions across the three groups and responses to the measures. Data collection took place between October 2012 and February 2014. Informants spoke clearly about how patients had adapted their lives in response to symptoms associated with their terminal condition. It was often seen as a positive choice to accept their state and adapt in this way but, at the same time, most patients were fully aware of the health and capability losses that they had faced. Self-assessments of health and capability generally appeared to reflect the pre-adaptation state, although there were exceptions. Despite adapting to their conditions, the reference group for individuals approaching EoL largely remained a healthy, capable population, and most did not show evidence of adaptive preferences.

Longitudinal Analysis of Severe Anxiety Symptoms in the Last Year of Life Among Patients With Advanced Cancer: Relationships With Proximity to Death, Burden, and Social Support.

PubMed

Tang, Siew Tzuh; Chen, Jen-Shi; Chou, Wen-Chi; Chang, Wen-Cheng; Wu, Chiao-En; Hsieh, Chia-Hsun; Chiang, Ming-Chu; Kuo, Mei-Ling

2016-06-01

Temporal changes in the prevalence of anxiety disorders/symptoms for patients with cancer at the end of life (EOL) remain unclear. This study was undertaken to describe changes in the prevalence of severe anxiety symptoms and to identify its correlates in the last year of life for patients with cancer. A convenience sample of 325 patients with cancer was followed until death. Severe anxiety symptoms were identified as anxiety subscale scores of 11 or greater on the Hospital Anxiety and Depression Scale. Longitudinal changes in and correlates of severe anxiety symptoms were examined from demographics, disease-related characteristics, disease burden, perceived burden to others, and social support using multivariate logistic regression modeling with generalized estimating equations. The prevalence of severe anxiety symptoms increased as death approached (18.6%, 21.9%, 26.7%, and 33.4% at 181-365, 91-180, 31-90, and 1-30 days before death, respectively). However, after controlling for covariates, this temporal increase was not significant. The prevalence of severe anxiety symptoms was not associated with fixed demographics and disease-related characteristics, except for diagnosis and metastatic status, but was significantly higher in patients with cancer with high physical symptom distress, severe depressive symptoms, high perceived burden to others, and strong perceived social support. Severe anxiety symptoms were not associated with time proximity to death per se but were related to factors modifiable by high-quality EOL care. Clinicians may decrease the likelihood of severe anxiety symptoms at EOL by adequately managing physical and depressive symptoms and lightening perceived burden to others for patients strongly connected with their social network to improve their psychological well-being. Copyright © 2016 by the National Comprehensive Cancer Network.

Design of high-efficiency, radiation-hard, GaInP/GaAs solar cells

NASA Technical Reports Server (NTRS)

Kurtz, Sarah R.; Bertness, K. A.; Kibbler, A. E.; Kramer, C.; Olson, J. M.

1994-01-01

In recently years, Ga(0.5)In((0.5)P/GaAs cells have drawn increased attention both because of their high efficiencies and because they are well suited for space applications. They can be grown and processed as two-junction devices with roughly twice the voltage and half the current of GaAs cells. They have low temperature coefficients, and have good potential for radiation hardness. We have previously reported the effects of electron irradiation on test cells which were not optimally designed for space. From those results we estimated that an optimally designed cell could achieve 20 percent after irradiation with 10(exp 15) cm(exp -2) 1 MeV electrons. Modeling studies predicted that slightly higher efficiencies may be achievable. Record efficiencies for EOL performance of other types of cells are significantly lower. Even the best Si and InP cells have BOL efficiencies lower than the EOL efficiency we report here. Good GaAs cells have an EOL efficiency of 16 percent. The InP/Ga(0.5)In(0.5)As two-junction, two-terminal device has a BOL efficiency as high as 22.2 percent, but radiation results for these cells were limited. In this study we use the previous modeling and irradiation results to design a set of Ga(0.5)In(0.5)P/GaAs cells that will demonstrate the importance of the design parameters and result in high-efficiency devices. We report record AMO efficiencies: a BOL efficiency of 25.7 percent for a device optimized for BOL performance and two of different designs with EOL efficiencies of 19.6 percent (at 10(exp 15) cm(exp -2) 1MeV electrons). We vary the bottom-cell base doping and the top-cell thickness to show the effects of these two important design parameters. We get an unexpected result indicating that the dopant added to the bottom-cell base also increases the degradation of the top cell.

What Moderates the Accuracy of Ease of Learning Judgments?

ERIC Educational Resources Information Center

Jemstedt, Andreas; Kubik, Veit; Jönsson, Fredrik U.

2017-01-01

When people begin to study new material, they may first judge how difficult it will be to learn. Surprisingly, these "ease of learning" (EOL) judgments have received little attention by metacognitive researchers so far. The aim of this study was to systematically investigate how well EOL judgments can predict actual learning, and what…

ATS-5 12 year in orbit evaluation

NASA Technical Reports Server (NTRS)

Kissel, F. J.; Schaffer, J.

1981-01-01

The results of the ATS 5 End-of-Life (EOL) tests are presented. Whenever possible, the test data were compared with prelaunch and inflight data. Pertinent memos and other informal documents containing these data are included as appendixes. The EOL tests include communication subsystems tests, power sybsystem tests, and gravity gradient television camera system tests.

ENVIRONMENTS and EOL: identification of Environment Ontology terms in text and the annotation of the Encyclopedia of Life

PubMed Central

Pafilis, Evangelos; Frankild, Sune P.; Schnetzer, Julia; Fanini, Lucia; Faulwetter, Sarah; Pavloudi, Christina; Vasileiadou, Katerina; Leary, Patrick; Hammock, Jennifer; Schulz, Katja; Parr, Cynthia Sims; Arvanitidis, Christos; Jensen, Lars Juhl

2015-01-01

Summary: The association of organisms to their environments is a key issue in exploring biodiversity patterns. This knowledge has traditionally been scattered, but textual descriptions of taxa and their habitats are now being consolidated in centralized resources. However, structured annotations are needed to facilitate large-scale analyses. Therefore, we developed ENVIRONMENTS, a fast dictionary-based tagger capable of identifying Environment Ontology (ENVO) terms in text. We evaluate the accuracy of the tagger on a new manually curated corpus of 600 Encyclopedia of Life (EOL) species pages. We use the tagger to associate taxa with environments by tagging EOL text content monthly, and integrate the results into the EOL to disseminate them to a broad audience of users. Availability and implementation: The software and the corpus are available under the open-source BSD and the CC-BY-NC-SA 3.0 licenses, respectively, at http://environments.hcmr.gr Contact: pafilis@hcmr.gr or lars.juhl.jensen@cpr.ku.dk Supplementary information: Supplementary data are available at Bioinformatics online. PMID:25619994

Impact of End-of-Life manoeuvres on the collision risk in protected regions

NASA Astrophysics Data System (ADS)

Frey, Stefan; Lemmens, Stijn; Bastida Virgili, Benjamin; Flohrer, Tim; Gass, Volker

2017-09-01

The Inter-Agency Space Debris Coordination Committee (IADC) Space Debris Mitigation Guidelines, issued in 2002 and revised in 2007, address the post mission disposal of objects in orbit. After their mission, objects crossing the Low Earth Orbit (LEO) should have a remaining lifetime in orbit not exceeding 25 years. Objects near the Geostationary Orbit (GEO) region should be placed in an orbit that remains outside of the GEO protected region. In this paper, the impact of satellites and rocket bodies performing End-of-Life (EOL) orbital manoeuvres on the collision risk in the LEO and GEO protected regions is investigated. The cases of full or partial compliance with the IADC post mission disposal guideline are studied. ESA's Meteoroid and Space Debris Terrestrial Environment Reference (MASTER) model is used to compare the space debris flux rate of the object during the remaining lifetime estimated for the pre-EOL-manoeuvre and for the post-EOL-manoeuvre orbit. The study shows that, on average, the probability of collision can be significantly decreased by performing an EOL-manoeuver.

High-efficiency, radiation-resistant GaAs space cells

NASA Technical Reports Server (NTRS)

Bertness, K. A.; Ristow, M. Ladle; Grounner, M.; Kuryla, M. S.; Werthen, J. G.

1991-01-01

Although many GaAs solar cells are intended for space applicatons, few measurements of cell degradation after radiation are available, particularly for cells with efficiencies exceeding 20 percent (one-sun, AMO). Often the cell performance is optimized for the highest beginning-of-life (BOL) efficiency, despite the unknown effect of such design on end-of-life (EOL) efficiencies. The results of a study of the radiation effects on p-n GaAs cells are presented. The EOL efficiency of GaAs space cell can be increased by adjusting materials growth parameters, resulting in a demonstration of 16 percent EOL efficiency at one-sun, AMO. Reducing base doping levels to below 3 x 10(exp 17)/cu m and decreasing emitter thickness to 0.3 to 0.5 micron for p-n cells led to significant improvements in radiation hardness as measured by EOL/BOL efficiency ratios for irradiation of 10(exp -15)/sq cm electrons at 1 MeV. BOL efficiency was not affected by changes in emitter thickness but did improve with lower base doping.

The effect of tributyltin on human eosinophilic [correction of eosinophylic] leukemia EoL-1 cells.

PubMed

Sroka, Jolanta; Włosiak, Przemysław; Wilk, Anna; Antonik, Justyna; Czyz, Jarosław; Madeja, Zbigniew

2008-01-01

Organotin compounds are chemicals that are widely used in industry and agriculture as plastic stabilizers, catalysts and biocides. Many of them, including tributyltin (TBT), have been detected in human food and, as a consequence, detectable levels have been found in human blood. As organotin compounds were shown to possess immunotoxic activity, we focused our attention on the effect of TBT on the basic determinants of the function of eosinophils, i.e. cell adhesiveness and motility. We used human eosinophylic leukemia EoL-1 cells, a common in vitro cellular model of human eosinophils. Here, we demonstrate that TBT causes a dose-dependent decrease in the viability of EoL-1 cells. When administered at sub-lethal concentrations, TBT significantly decreases the adhesion of EoL-1 cells to human fibroblasts (HSFs) and inhibits their migration on fibroblast surfaces. Since the basic function of eosinophils is to invade inflamed tissues, our results indicate that TBT, and possibly other organotin compounds, may affect major cellular properties involved in the determination of in vivo eosinophil function.

Trisubstituted purine inhibitors of PDGFRα and their antileukemic activity in the human eosinophilic cell line EOL-1.

PubMed

Malínková, Veronika; Řezníčková, Eva; Jorda, Radek; Gucký, Tomáš; Kryštof, Vladimír

2017-12-15

Inhibition of protein kinases is a validated concept for pharmacological intervention in cancers. Many kinase inhibitors have been approved for clinical use, but their practical application is often limited. Here, we describe a collection of 23 novel 2,6,9-trisubstituted purine derivatives with nanomolar inhibitory activities against PDGFRα, a receptor tyrosine kinase often found constitutively activated in various tumours. The compounds demonstrated strong and selective cytotoxicity in the human eosinophilic leukemia cell line EOL-1, whereas several other cell lines were substantially less sensitive. The cytotoxicity in EOL-1, which is known to express the FIP1L1-PDGFRA fusion gene encoding an oncogenic kinase, correlated significantly with PDGFRα inhibition. EOL-1 cells treated with the compounds also exhibited dose-dependent inhibition of PDGFRα autophosphorylation and suppression of its downstream signaling pathways with concomitant G 1 phase arrest, confirming the proposed mechanism of action. Our results show that substituted purines can be used as platforms for preparing tyrosine kinase inhibitors with specific activity towards eosinophilic leukemia. Copyright © 2017 Elsevier Ltd. All rights reserved.

The effect of sudden server breakdown on the performance of a disassembly line

NASA Astrophysics Data System (ADS)

Udomsawat, Gun; Gupta, Surendra M.

2005-11-01

Product and material recovery relies on the disassembly process to separate target components or materials from the end-of-life (EOL) products. Disassembly line is especially effective when products in large quantity are disassembled. Unlike an assembly line, a disassembly line is more complex and is subjected to numerous uncertainties including stochastic and multi-level arrivals of component demands, stochastic arrival times for EOL products, and process interruption due to equipment failure. These factors seriously impair the control mechanism in the disassembly line. A common production control mechanism is the traditional push system (TPS). TPS responds to the aforementioned complications by carrying substantial amounts of inventories. An alternative control mechanism is a newly developed multi-kanban pull system (MKS) that relies on dynamic routing of kanbans, which tends to minimize the system's inventories while maintaining demand serviceability. In this paper we explore the impact of sudden breakdown of server on the performance of a disassembly line. We compare the overall performances of the TPS and MKS by considering two scenarios. We present the solution procedure and results for these cases.

Modeling of defect-tolerant thin multi-junction solar cells for space application

NASA Astrophysics Data System (ADS)

Mehrotra, A.; Alemu, A.; Freundlich, A.

2012-02-01

Using drift-diffusion model and considering experimental III-V material parameters, AM0 efficiencies of lattice-matched multijunction solar cells have been calculated and the effects of dislocations and radiation damage have been analyzed. Ultrathin multi-junction devices perform better in presence of dislocations or/and radiation harsh environment compared to conventional thick multijunction devices. Our results show that device design optimization of Ga0.51In0.49P/GaAs multijunction devices leads to an improvement in EOL efficiency from 4.8%, for the conventional thick device design, to 12.7%, for the EOL optimized thin devices. In addition, an optimized defect free lattice matched Ga0.51In0.49P/GaAs solar cell under 1016cm-2 1Mev equivalent electron fluence is shown to give an EOL efficiency of 12.7%; while a Ga0.51In0.49P/GaAs solar cell with 108 cm-2 dislocation density under 1016cm-2 electron fluence gives an EOL efficiency of 12.3%. The results suggest that by optimizing the device design, we can obtain nearly the same EOL efficiencies for high dislocation metamorphic solar cells and defect filtered metamorphic multijunction solar cells. The findings relax the need for thick or graded buffer used for defect filtering in metamorphic devices. It is found that device design optimization allows highly dislocated devices to be nearly as efficient as defect free devices for space applications.

Leukotriene D4 induces chemotaxis in human eosinophilc cell line, EoL-1 cells via CysLT1 receptor activation.

PubMed

Shirasaki, Hideaki; Kanaizumi, Etsuko; Himi, Tetsuo

2017-11-01

Numerous reports have shown that cysteinyl leukotrienes (CysLTs) contribute to tissue accumulation of eosinophils in allergic airway inflammation. To date, only a few studies have reported that CysLTs promote chemotactic activity of human eosinophils in vitro. The purpose of this study was to investigate whether CysLTs promote chemotaxis in the human eosinophilic cell line, EoL-1. EoL-1 cells were induced to differentiate into mature eosinophil-like cells via incubation with butyric acid and cytokines (IL-3, IL-5 and GM-CSF). The chemotactic activity of the differentiated EoL-1 cells was assessed using the commercial cell migration assay kit. LTD 4 elicited dose-related chemotactic activity in the differntiated EoL-1 cells in the range of 1-100 nM. A typical bell-shaped dose-response curve was observed with optimal activity at 10 nM. The chemotactic activity elicited by LTD 4 (10 nM) was significantly inhibited by montelukast (control, 345 ± 19.2 × 10 3 RFU; LTD 4 10 nM alone, 511 ± 39.2 × 10 3 RFU; LTD 4 10 nM plus montelukast 100 nM, 387 ± 28.2 × 10 3 RFU). LTD 4 induces migration in eosinophilic cells via activation of CysLT1 receptor. The present in vitro model may be useful for elucidation of the mechanism underlying CysLT-induced tissue eosinophilia.

Modeling and optimal designs for dislocation and radiation tolerant single and multijunction solar cells

NASA Astrophysics Data System (ADS)

Mehrotra, A.; Alemu, A.; Freundlich, A.

2011-02-01

Crystalline defects (e.g. dislocations or grain boundaries) as well as electron and proton induced defects cause reduction of minority carrier diffusion length which in turn results in degradation of efficiency of solar cells. Hetro-epitaxial or metamorphic III-V devices with low dislocation density have high BOL efficiencies but electron-proton radiation causes degradation in EOL efficiencies. By optimizing the device design (emitter-base thickness, doping) we can obtain highly dislocated metamorphic devices that are radiation resistant. Here we have modeled III-V single and multi junction solar cells using drift and diffusion equations considering experimental III-V material parameters, dislocation density, 1 Mev equivalent electron radiation doses, thicknesses and doping concentration. Thinner device thickness leads to increment in EOL efficiency of high dislocation density solar cells. By optimizing device design we can obtain nearly same EOL efficiencies from high dislocation solar cells than from defect free III-V multijunction solar cells. As example defect free GaAs solar cell after optimization gives 11.2% EOL efficiency (under typical 5x1015cm-2 1 MeV electron fluence) while a GaAs solar cell with high dislocation density (108 cm-2) after optimization gives 10.6% EOL efficiency. The approach provides an additional degree of freedom in the design of high efficiency space cells and could in turn be used to relax the need for thick defect filtering buffer in metamorphic devices.

Identification of Ponatinib as a potent inhibitor of growth, migration and activation of neoplastic eosinophils carrying FIP1L1-PDGFRA

PubMed Central

Sadovnik, Irina; Lierman, Els; Peter, Barbara; Herrmann, Harald; Suppan, Verena; Stefanzl, Gabriele; Haas, Oskar; Lion, Thomas; Pickl, Winfried; Cools, Jan; Vandenberghe, Peter; Valent, Peter

2015-01-01

In chronic eosinophilic leukemia (CEL), the transforming oncoprotein FIP1L1-PDGFRA is a major target of therapy. In most patients, the tyrosine kinase inhibitor (TKI) imatinib induces complete remission. For patients who are intolerant or resistant, novel TKI have been proposed. We examined the in vitro effects of 14 kinase blockers on growth and function of EOL-1 cells, a FIP1L1-PDGFRA+ eosinophil cell line. Major growth-inhibitory effects were seen with all PDGFR-blocking agents, with IC50 values in the low nM-range: ponatinib: 0.1-0.2 nM, sorafenib: 0.1-0.2 nM, masitinib: 0.2-0.5 nM, nilotinib: 0.2-1 nM, dasatinib: 0.5-2 nM, sunitinib: 1-2 nM, midostaurin: 5-10 nM. These drugs were also found to block activation of PDGFR-downstream signaling molecules, including Akt, S6, and STAT5 in EOL-1 cells. All effective TKI produced apoptosis in EOL-1 cells as determined by microscopy, Annexin-V/PI, and caspase-3-staining. In addition, PDGFR-targeting TKI were found to inhibit cytokine-induced migration of EOL-1 cells. In all bioassays employed, ponatinib was found to be the most potent compound in EOL-1 cells. In addition, ponatinib was found to downregulate expression of the activation-linked surface antigen CD63 on EOL-1 cells, and to suppress growth of primary neoplastic eosinophils. We also examined drug effects on Ba/F3 cells expressing two clinically relevant imatinib-resistant mutant-forms of FIP1L1-PDGFRA, namely T674I and D842V. Strong inhibitory effects on both mutants were only seen with ponatinib. In summary, novel PDGFR-targeting TKI may be alternative agents for the treatment of patients with imatinib-resistant CEL. Although several different PDGFR-targeting agents are effective, the most potent drug appears to be ponatinib. PMID:24407160

The impact of the Rasouli decision: a Survey of Canadian intensivists.

PubMed

Cape, David; Fox-Robichaud, Alison; Turgeon, Alexis F; Seely, Andrew; Hall, Richard; Burns, Karen; Singal, Rohit K; Dodek, Peter; Bagshaw, Sean; Sibbald, Robert; Downar, James

2016-03-01

In a landmark 2013 decision, the Supreme Court of Canada (SCC) ruled that the withdrawal of life support in certain circumstances is a treatment requiring patient or substitute decision maker (SDM) consent. How intensive care unit (ICU) physicians perceive this ruling is unknown. To determine physician knowledge of and attitudes towards the SCC decision, as well as the self-reported changes in practice attributed to the decision. We surveyed intensivists at university hospitals across Canada. We used a knowledge test and Likert-scale questions to measure respondent knowledge of and attitudes towards the ruling. We used vignettes to assess decision making in cases of intractable physician-SDM conflict over the management of patients with very poor prognoses. We compared management choices pre-SCC decision versus post-SCC decision versus the subjective, respondent-defined most appropriate choice. Responses were compared across predefined subgroups. We performed qualitative analysis on free-text responses. We received 82 responses (response rate=42%). Respondents reported providing high levels of self-defined inappropriate treatment. Although most respondents reported no change in practice, there was a significant overall shift towards higher intensity and less subjectively appropriate management after the SCC decision. Attitudes to the SCC decision and approaches to disputes over end-of-life (EoL) care in the ICU were highly variable. There were no significant differences among predefined subgroups. Many Canadian ICU physicians report providing a higher intensity of treatment, and less subjectively appropriate treatment, in situations of dispute over EoL care after the Supreme Court of Canada's ruling in Cuthbertson versus Rasouli. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Hospital policy on medical futility - does it help in conflict resolution and ensuring good end-of-life care?

PubMed

Joseph, Roy

2011-01-01

This paper aimed to ascertain if hospital policy on medical futility helps in conflict resolution, and in ensuring good end-of-life care. Literature on the subject published in the last 5 years was identified through Pubmed, and those with empirical data pertaining to the outcomes of interest were examined. A systematic analysis was not possible as papers varied greatly in aims, designs, outcomes and their measures. Instead, the outcomes of representative papers were described and discussed. There is a widespread use of policies and guidelines based on the concept of medical futility. Conflicts are rare and appear to arise primarily from the manner in which policies are implemented. End-of-life care appears to be improving as evidenced by a significant number of deaths occurring following: (i) discussions involving patient, family, healthcare team members; (ii) cessation of intensive care and (iii) cessation of institution of palliative care. Deaths are increasingly taking place in the presence of family and outside the intensive care wards. Finally, post mortem audit of processes and practices indicate (i) compliance but in a limited manner with policies and recommended guidelines, (ii) family satisfaction and (iii) identify areas where improvement in end-of-life (EOL) care can be effected. Key areas are in improving education of, communication with, and documentation by all stakeholders. Hospital policies on medical futility have helped to resolve conflicts and improve end-of-life care. Prospective, multicentre and controlled trials will be useful in determining the value of specific interventions, obtaining generalisable data and facilitating implementation of better end-of-life care models.

Mental health, treatment preferences, advance care planning, location, and quality of death in advanced cancer patients with dependent children.

PubMed

Nilsson, Matthew E; Maciejewski, Paul K; Zhang, Baohui; Wright, Alexi A; Trice, Elizabeth D; Muriel, Anna C; Friedlander, Robert J; Fasciano, Karen M; Block, Susan D; Prigerson, Holly G

2009-01-15

Clinicians observe that advanced cancer patients with dependent children agonize over the impact their death will have on their children. The objective of this study was to determine empirically whether advanced cancer patients with and without dependent children differ in treatment preferences, mental health, and end-of-life (EOL) outcomes. Coping with Cancer is a National Cancer Institute/National Institute of Mental Health-funded, multi-institutional, prospective cohort study of 668 patients with advanced cancer. Patients with and without dependent children were compared on rates of psychiatric disorders, advance care planning (ACP), EOL care, quality of their last week of life, and location of death. In adjusted analyses, patients with advanced cancer who had dependent children were more likely to meet panic disorder criteria (adjusted odds ratio [AOR], 5.41; 95% confidence interval [95% CI], 2.13-13.69), more likely to be worried (mean difference in standard deviations [delta], 0.09; P=.006), and more likely to prefer aggressive treatment over palliative care (AOR, 1.77; 95% CI, 1.07-2.93). Patients with dependent children were less likely to engage in ACP (eg, do not resuscitate orders: AOR, 0.44; 95% CI, 0.26-0.75) and had a worse quality of life in the last week of life (delta, 0.15; P=.007). Among spousal caregivers, those with dependent children were more likely to meet criteria for major depressive disorder (AOR, 4.53; 95% CI, 1.47-14) and generalized anxiety disorder (AOR, 3.95; 95% CI, 1.29-12.16). Patients with dependent children were more anxious, were less likely to engage in ACP, and were more likely to have a worse quality of life in their last week of life. Advanced cancer patients and spousal caregivers with dependent children represent a particularly distressed group that warrants further clinical attention, research, and support. Copyright (c) 2009 American Cancer Society.

Room for Death--International museum-visitors' preferences regarding the end of their life.

PubMed

Lindqvist, Olav; Tishelman, Carol

2015-08-01

Just as pain medications aim to relieve physical suffering, supportive surrounding for death and dying may facilitate well-being and comfort. However, little has been written of the experience of or preferences for the surroundings in which death and dying take place. In this study, we aim to complement our research from perspectives of patients, family members and staff, with perspectives from an international sample of the general public. Data derives from a project teaming artists and craftspeople together to create prototypes of space for difficult conversations in end-of-life (EoL) settings. These prototypes were presented in a museum exhibition, "Room for Death", in Stockholm in 2012. As project consultants, palliative care researchers contributed a question to the public viewing the exhibition, to explore their reflections: "How would you like it to be around you when you are dying?" Five-hundred and twelve responses were obtained from visitors from 46 countries. While preliminary analysis pointed to many similarities in responses across countries, continued analysis with a phenomenographic approach allowed us to distinguish different foci related to how preferences for surroundings for EoL were conceptualized. Responses were categorized in the following inductively-derived categories: The familiar death, The 'larger-than life' death, The lone death, The mediated death, The calm and peaceful death, The sensuous death, The 'green' death, and The distanced death. The responses could relate to a single category or be composites uniting different categories in individual combinations, and provide insight into different facets of contemporary reflections about death and dying. Despite the selective sample, these data give reason to consider how underlying assumptions and care provision in established forms for end-of-life care may differ from people's preferences. This project can be seen as an example of innovative endeavors to promote public awareness of issues related to death and dying, within the framework of health-promoting palliative care. Copyright © 2015 Elsevier Ltd. All rights reserved.

Uncertainty Representation and Interpretation in Model-based Prognostics Algorithms based on Kalman Filter Estimation

DTIC Science & Technology

2012-09-01

interpreting the state vector as the health indicator and a threshold is used on this variable in order to compute EOL (end-of-life) and RUL. Here, we...End-of-life ( EOL ) would match the true spread and would not change from one experiment to another. This is, however, in practice impossible to achieve

Development of an end-of-life vehicle recovery model using system dynamics and future research needs

NASA Astrophysics Data System (ADS)

Mohamad-Ali, N.; Ghazilla, R. A. R.; Abdul-Rashid, S. H.; Sakundarini, N.; Ahmad-Yazid, A.; Stephenie, L.

2017-06-01

The implementation of end-of-life vehicle (ELV) recovery policy in Malaysia has led vehicle manufacturers to look at different ways to improve design and development of vehicles. Nowadays, it is crucial to incorporate end-of-life (EOL) design strategies into the vehicle design in order to enhance the effectiveness of the ELV recovery network. Although recent studies have shown that product design has a significant effect on the product recovery rate, there is a lack of studies on how EOL design strategies affects the effectiveness of ELV recovery, particularly when there are dynamic changes in the behaviour of the product recovery network. Thus, in this study, we developed a preliminary model based on the system dynamics approach in order to predict the effectiveness of ELV recovery in response to dynamic changes of various factors (including EOL design strategies) in the business environment. We developed this model based on preliminary data that we had gathered from unstructured interviews with the key stakeholders of ELV management in Malaysia. We believe that our model will greatly benefit product designers in incorporating the appropriate EOL design strategies in order to boost ELV recovery effectiveness in Malaysia.

Effect of benzo[a]pyrene on the production of vascular endothelial growth factor by human eosinophilic leukemia EoL-1 cells.

PubMed

Gu, Jie; Chan, Lai-Sheung; Wong, Chris Kong-Chu; Wong, Ngok-Shun; Wong, Chun-Kwok; Leung, Kok-Nam; Mak, Naiki K

2011-01-01

Benzo[a]pyrene (BaP) has been shown to affect both the development and response of T and B cells in the immune system. However, the effect of BaP on other immune cells, such as eosionophils, is unknown. In this study, we investigated the effect of BaP on the production of vascular endothelial growth factor (VEGF) using an in vitro eosinophilic EoL-1 cell and human umbilical vein endothelial cell (HUVEC) co-culture system. EoL-1-conditioned medium was found to promote the growth of HUVEC in a time-dependent manner. The growth stimulating activity was due to the production of VEGF by the EoL-1 cells. The production of VEGF was correlated with the enhanced expression of the phosphorylated form of extracellular signal-regulated kinases (p-ERKs) and the upregulated expression of VEGF mRNA. Furthermore, BaP-induced expression of VEGF mRNA was reduced by the ERK inhibitor PD98059. Results from this study suggested that BaP might affect the growth of endothelial cells through the modulation of VEGF production by eosinophils.

Transitions in Prognostic Awareness Among Terminally Ill Cancer Patients in Their Last 6 Months of Life Examined by Multi-State Markov Modeling.

PubMed

Hsiu Chen, Chen; Wen, Fur-Hsing; Hou, Ming-Mo; Hsieh, Chia-Hsun; Chou, Wen-Chi; Chen, Jen-Shi; Chang, Wen-Cheng; Tang, Siew Tzuh

2017-09-01

Developing accurate prognostic awareness, a cornerstone of preference-based end-of-life (EOL) care decision-making, is a dynamic process involving more prognostic-awareness states than knowing or not knowing. Understanding the transition probabilities and time spent in each prognostic-awareness state can help clinicians identify trigger points for facilitating transitions toward accurate prognostic awareness. We examined transition probabilities in distinct prognostic-awareness states between consecutive time points in 247 cancer patients' last 6 months and estimated the time spent in each state. Prognostic awareness was categorized into four states: (a) unknown and not wanting to know, state 1; (b) unknown but wanting to know, state 2; (c) inaccurate awareness, state 3; and (d) accurate awareness, state 4. Transitional probabilities were examined by multistate Markov modeling. Initially, 59.5% of patients had accurate prognostic awareness, whereas the probabilities of being in states 1-3 were 8.1%, 17.4%, and 15.0%, respectively. Patients' prognostic awareness generally remained unchanged (probabilities of remaining in the same state: 45.5%-92.9%). If prognostic awareness changed, it tended to shift toward higher prognostic-awareness states (probabilities of shifting to state 4 were 23.2%-36.6% for patients initially in states 1-3, followed by probabilities of shifting to state 3 for those in states 1 and 2 [9.8%-10.1%]). Patients were estimated to spend 1.29, 0.42, 0.68, and 3.61 months in states 1-4, respectively, in their last 6 months. Terminally ill cancer patients' prognostic awareness generally remained unchanged, with a tendency to become more aware of their prognosis. Health care professionals should facilitate patients' transitions toward accurate prognostic awareness in a timely manner to promote preference-based EOL decisions. Terminally ill Taiwanese cancer patients' prognostic awareness generally remained stable, with a tendency toward developing higher states of awareness. Health care professionals should appropriately assess patients' readiness for prognostic information and respect patients' reluctance to confront their poor prognosis if they are not ready to know, but sensitively coach them to cultivate their accurate prognostic awareness, provide desired and understandable prognostic information for those who are ready to know, and give direct and honest prognostic information to clarify any misunderstandings for those with inaccurate awareness, thus ensuring that they develop accurate and realistic prognostic knowledge in time to make end-of-life care decisions. © AlphaMed Press 2017.

A New Observational Strategy for Monitoring the Tropical Cyclone Outflow Layer and its Relationship to Intensity and Structure Change

DTIC Science & Technology

2013-09-30

vertical structure of outflow layer jets for Hurricanes Leslie and Nadine in 2012 and Invest 97L in 2013 has been conducted using NCAR- EOL /Vaisala mini...generation of dropsonde, the Yankee, Inc HDSS and XDD sonde was intercompared during CIRPAS Twin Otter test flights on 24-25 June, 2011 with NCAR- EOL

Membrane receptor-mediated apoptosis and caspase activation in the differentiated EoL-1 eosinophilic cell line.

PubMed

Al-Rabia, Mohammed W; Blaylock, Morgan G; Sexton, Darren W; Walsh, Garry M

2004-06-01

Caspases are key molecules in the control of apoptosis, but relatively little is known about their contribution to eosinophil apoptosis. We examined caspase-3, -8, and -9 activities in receptor ligation-dependent apoptosis induction in the differentiated human eosinophilic cell line EoL-1. Differentiated EoL-1 exhibited bi-lobed nuclei, eosinophil-associated membrane receptors, and basic granule proteins. Annexin-V fluorescein isothiocyanate binding to EoL-1 revealed significant (P<0.01) apoptosis induction in cells cultured for 20 h with monoclonal antibodies (mAb) specific for CD45 (71%+/-4.3), CD45RA (58%+/-2.3), CD45RB (68%+/-2.4), CD95 (47%+/-2.6), and CD69 (52%+/-2.1) compared with control (23%+/-1.6) or CD45RO mAb (27%+/-3.9). The pan-caspase inhibitor Z-Val-Ala-Asp-fluoromethylketone (fmk) and inhibitors of caspase-8 (Z-Ile-Glu-Thr-Asp-fmk) and caspase-9 (Z-Leu-Glu-His-Asp-fmk) significantly inhibited mAb-induced apoptosis of EoL-1 but had no effect on constitutive (baseline) apoptosis at 16 and 20 h. Caspase activity was analyzed using the novel CaspaTag trade mark technique and flow cytometry. EoL-1 treated with pan-CD45, CD45RA, CD45RB, and CD95 mAb exhibited caspase-3 and -9 activation at 12 h post-treatment, which increased at 16 and 20 h. Activated caspase-8 was detected 12 and 16 h after ligation with CD45, CD45RA, CD45RB, and CD95 mAb followed by a trend toward basal levels at 20 h. CD69 ligation resulted in caspase-3 activation, a modest but significant activation of caspase-8, and a loss in mitochondrial transmembrane potential but had no significant effect on activation of caspase-9. Thus, the intrinsic and extrinsic caspase pathways are involved in controlling receptor ligation-mediated apoptosis induction in human eosinophils, findings that may aid the development of a more targeted, anti-inflammatory therapy for asthma.

Bioconversion of hybrid poplar to ethanol and co-products using an organosolv fractionation process: optimization of process yields.

PubMed

Pan, Xuejun; Gilkes, Neil; Kadla, John; Pye, Kendall; Saka, Shiro; Gregg, David; Ehara, Katsunobu; Xie, Dan; Lam, Dexter; Saddler, Jack

2006-08-05

An organosolv process involving extraction with hot aqueous ethanol has been evaluated for bioconversion of hybrid poplar to ethanol. The process resulted in fractionation of poplar chips into a cellulose-rich solids fraction, an ethanol organosolv lignin (EOL) fraction, and a water-soluble fraction containing hemicellulosic sugars, sugar breakdown products, degraded lignin, and other components. The influence of four independent process variables (temperature, time, catalyst dose, and ethanol concentration) on product yields was analyzed over a broad range using a small composite design and response surface methodology. Center point conditions for the composite design (180 degrees C, 60 min, 1.25% H(2)SO(4), and 60% ethanol), yielded a solids fraction containing approximately 88% of the cellulose present in the untreated poplar. Approximately 82% of the total cellulose in the untreated poplar was recovered as monomeric glucose after hydrolysis of the solids fraction for 24 h using a low enzyme loading (20 filter paper units of cellulase/g cellulose); approximately 85% was recovered after 48 h hydrolysis. Total recovery of xylose (soluble and insoluble) was equivalent to approximately 72% of the xylose present in untreated wood. Approximately 74% of the lignin in untreated wood was recovered as EOL. Other cooking conditions resulted in either similar or inferior product yields although the distribution of components between the various fractions differed markedly. Data analysis generated regression models that describe process responses for any combination of the four variables. (c) 2006 Wiley Periodicals, Inc.

Intensive procedure preferences at the end of life (EOL) in older Latino adults with end stage renal disease (ESRD) on dialysis.

PubMed

Gonzalez, Karla; Ulloa, Jesus G; Moreno, Gerardo; Echeverría, Oscar; Norris, Keith; Talamantes, Efrain

2017-10-23

Latinos in the U.S. are almost twice as likely to progress to End Stage Renal disease (ESRD) compared to non-Latino whites. Patients with ESRD on dialysis experience high morbidity, pre-mature mortality and receive intensive procedures at the end of life (EOL). This study explores intensive procedure preferences at the EOL in older Latino adults. Seventy-three community-dwelling Spanish- and English-Speaking Latinos over the age of 60 with and without ESRD participated in this study. Those without ESRD (n = 47) participated in one of five focus group sessions, and those with ESRD on dialysis (n = 26) participated in one-on-one semi-structured interviews. Focus group and individual participants answered questions regarding intensive procedures at the EOL. Recurring themes were identified using standard qualitative content-analysis methods. Participants also completed a brief survey that included demographics, language preference, health insurance coverage, co-morbidities, Emergency Department visits and functional limitations. The majority of participants were of Mexican origin with mean age of 70, and there were more female participants in the non-ESRD group, compared to the ESRD dialysis dependent group. The dialysis group reported a higher number of co-morbidities and functional limitations. Nearly 69% of those in the dialysis group reported one or more emergency department visits in the past year, compared to 38% in the non-ESRD group. Primary themes centered on 1) The acceptability of a "natural" versus "invasive" procedure 2) Cultural traditions and family involvement 3) Level of trust in physicians and autonomy in decision-making. Our results highlight the need for improved patient- and family-centered approaches to better understand intensive procedure preferences at the EOL in this underserved population of older adults.

Comparing aging of graphite/LiFePO4 cells at 22 °C and 55 °C - Electrochemical and photoelectron spectroscopy studies

NASA Astrophysics Data System (ADS)

Hellqvist Kjell, Maria; Malmgren, Sara; Ciosek, Katarzyna; Behm, Mårten; Edström, Kristina; Lindbergh, Göran

2013-12-01

Accelerated aging at elevated temperature is commonly used to test lithium-ion battery lifetime, but the effect of an elevated temperature is still not well understood. If aging at elevated temperature would only be faster, but in all other respects equivalent to aging at ambient temperature, cells aged to end-of-life (EOL) at different temperatures would be very similar. The present study compares graphite/LiFePO4-based cells either cycle- or calendar-aged to EOL at 22 °C and 55 °C. Cells cycled at the two temperatures show differences in electrochemical impedance spectra as well as in X-ray photoelectron spectroscopy (XPS) spectra. These results show that lithium-ion cell aging is a complex set of processes. At elevated temperature, the aging is accelerated in process-specific ways. Furthermore, the XPS results of cycle-aged samples indicate increased deposition of oxygenated LiPF6 decomposition products in both the negative and positive electrode/electrolyte interfaces. The decomposition seems more pronounced at elevated temperature, and largely accelerated by cycling, which could contribute to the observed cell impedance increase.

Medical practice and legal background of decisions for severely ill newborn infants: viewpoints from seven European countries.

PubMed

Sauer, P J J; Dorscheidt, J H H M; Verhagen, A A E; Hubben, J H

2013-02-01

To comparing attitudes towards end-of-life (EOL) decisions in newborn infants between seven European countries. One paediatrician and one lawyer from seven European countries were invited to attend a conference to discuss the practice of EOL decisions in newborn infants and the legal aspects involved. All paediatricians/neonatologists indicated that the best interest of the child should be the leading principle in all decisions. However, especially when discussing cases, important differences in attitude became apparent, although there are no significant differences between the involved countries with regard to national legal frameworks. Important differences in attitude towards neonatal EOL decisions between European countries exist, but they cannot be explained solely by medical or legal reasons. ©2012 The Author(s)/Acta Paediatrica ©2012 Foundation Acta Paediatrica.

Application of GRA for Sustainable Material Selection and Evaluation Using LCA

NASA Astrophysics Data System (ADS)

Jayakrishna, Kandasamy; Vinodh, Sekar; Sakthi Sanghvi, Vijayaselvan; Deepika, Chinadurai

2016-07-01

Material selection is identified as a successful key parameter in establishing any product to be sustainable, considering its end of life (EoL) characteristics. An accurate understanding of expected service conditions and environmental considerations are crucial in the selection of material plays a vital role with overwhelming customer expectations and stringent laws. Therefore, this article presents an integrated approach for sustainable material selection using grey relational analysis (GRA) considering the EoL disposal strategies with respect to an automotive product. GRA, an impact evaluation model measures the degree of similarity between the comparability (choice of material) sequence and reference (EoL strategies) sequence based on the relational grade. The ranking result shows that the outranking relationships in the order, ABS-REC > PP-INC > AL-REM > PP-LND > ABS-LND > ABS-INC > PU-LND > AL-REC > AL-LND > PU-INC > AL-INC. The best sustainable material selected was ABS and recycling was selected as the best EoL strategy with the grey relational value of 2.43856. The best material selected by this approach, ABS was evaluated for its viability using life cycle assessment and the estimated impacts also proved the practicability of the selected material highlighting the focus on dehumidification step in the manufacturing of the case product using this developed multi-criteria approach.

Data report of six free-drifting buoys tracked by the Eole satellite in the western North Atlantic Ocean in the autumn of 1972

NASA Technical Reports Server (NTRS)

Usry, J. W.; Wallace, J. W.

1972-01-01

The buoys were deployed on the Continental Shelf east of the Chesapeake Light and were tracked by the French EOLE satellite. Two buoys drifted for 11 days during the first mission and four buoys drifted for 14 days during the second mission. Trajectory and water temperature data are presented in tabular and graphical from with a discussion of the accuracy.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Habuer,, E-mail: habuer@env.t.u-tokyo.ac.jp; Nakatani, Jun; Moriguchi, Yuichi

Highlights: • We estimate the possession and obsolescence of household appliances (HAs) in China. • Over 4.8–5.1 billion units of major HAs will be discarded in the next 20 years. • We calculate the amounts of substances contained in end-of-life (EoL) TV sets. • Less common metals will tend to decrease in content in generation of EoL TV sets. • Precious metals will tend to increase in content in EoL TV sets in 2015–2030. - Abstract: Given the amounts of end-of-life electrical and electronic equipment (EoL-EEE) being generated and their contents of both harmful and valuable materials, the EoL-EEE issuemore » should be regarded not only as an emerging environmental problem but also as a resource management strategy in China. At present, in order to provide the basis for managing EoL-EEE at both product and substance levels in China, it is necessary to carry out a quantitative analysis on EoL-EEE and to determine how much of it will be generated and how much materials and substances it contains. In this study, the possession and obsolescence amounts of five types of household appliance (HA) including television (TV) sets and the amounts of substances contained in EoL TV sets were estimated using time-series product flow analysis (PFA) and substance flow analysis (SFA). The results of PFA indicated that the total possession amounts of those five types of HAs will exceed 3.1 billion units in 2030, which will be two times higher than those in 2010. In addition, it was estimated that cumulatively over 4.8–5.1 billion units of these five types of EoL HA would be obsoleted between 2010–2030. The results of SFA on TV sets indicated that the generated amounts of most of the less common metals and a part of common metals such as copper (Cu) would tend to decrease, whereas those of other common metals such as iron (Fe) as well as precious metals would tend to increase in EoL TV sets in 2015–2030. The results of this study provide a quantitative basis for helping decision makers develop strategic policies for the management of EoL-EEE considering both environmental and resource aspects. Moreover, a calculation scheme of obsolete HAs presented in this study can be applied to estimate other types of EoL durable good. Meanwhile, the frameworks of this study will help not only the policy decision makers in the Chinese government but also those in developing countries that are facing similar problems.« less

To the Geoportal and Beyond! Preparing the Earth Observing Laboratory's Datasets for Inter-Repository Discovery

NASA Astrophysics Data System (ADS)

Gordon, S.; Dattore, E.; Williams, S.

2014-12-01

Even when a data center makes it's datasets accessible, they can still be hard to discover if the user is unaware of the laboratory or organization the data center supports. NCAR's Earth Observing Laboratory (EOL) is no exception. In response to this problem and as an inquiry into the feasibility of inter-connecting all of NCAR's repositories at a discovery layer, ESRI's Geoportal was researched. It was determined that an implementation of Geoportal would be a good choice to build a proof of concept model of inter-repository discovery around. This collaborative project between the University of Illinois and NCAR is coordinated through the Data Curation Education in Research Centers program. This program is funded by the Institute of Museum and Library Services.Geoportal is open source software. It serves as an aggregation point for metadata catalogs of earth science datasets, with a focus on geospatial information. EOL's metadata is in static THREDDS catalogs. Geoportal can only create records from a THREDDS Data Server. The first step was to make EOL metadata more accessible by utilizing the ISO 19115-2 standard. It was also decided to create DIF records so EOL datasets could be ingested in NASA's Global Change Master Directory (GCMD). To offer records for harvest, it was decided to develop an OAI-PMH server. To make a compliant server, the OAI_DC standard was also implemented. A server was written in Perl to serve a set of static records. We created a sample set of records in ISO 19115-2, FGDC, DIF, and OAI_DC. We utilized GCMD shared vocabularies to enhance discoverability and precision. The proof of concept was tested and verified by having another NCAR laboratory's Geoportal harvest our sample set. To prepare for production, templates for each standard were developed and mapped to the database. These templates will help the automated creation of records. Once the OAI-PMH server is re-written in a Grails framework a dynamic representation of EOL's metadata will be available for harvest. EOL will need to develop an implementation of a Geoportal and point GCMD to the OAI-PMH server. We will also seek out partnerships with other earth science and related discipline repositories that can communicate by OAI-PMH or Geoportal so that the scientific community will benefit from more discoverable data.

Dynamic Stocks and Flows Analysis of Bisphenol A (BPA) in China: 2000-2014.

PubMed

Jiang, Daqian; Chen, Wei-Qiang; Zeng, Xianlai; Tang, Linbin

2018-03-20

Bisphenol A (BPA), a synthetic organic chemical, is creating a new category of ecological and human health challenges due to unintended leakage. Effectively managing the use and leakage of BPA can benefit from an understanding of the anthropogenic BPA cycles (i.e., the size of BPA flows and stocks). In this work, we provide a dynamic analysis of the anthropogenic BPA cycles in China for 2000-2014. We find that China's BPA consumption has increased 10-fold since 2000, to ∼3 million tonnes/year. With the increasing consumption, China's in-use BPA stock has increased 500-fold to 14.0 million tonnes (i.e., 10.2 kg BPA/capita). It is unclear whether a saturation point has been reached, but in 2004-2014, China's in-use BPA stock has been increasing by 0.8 kg BPA/capita annually. Electronic products are the biggest contributor, responsible for roughly one-third of China's in-use BPA stock. Optical media (DVD/VCD/CDs) is the largest contributor to China's current End-of-Life (EoL) BPA flow, totaling 0.9 million tonnes/year. However, the EoL BPA flow due to e-waste will increase quickly, and will soon become the largest EoL BPA flow. The changing quantities and sources of EoL BPA flows may require a shift in the macroscopic BPA management strategies.

Mechanism for the decrease in the FIP1L1-PDGFRalpha protein level in EoL-1 cells by histone deacetylase inhibitors.

PubMed

Ishihara, Kenji; Kaneko, Motoko; Kitamura, Hajime; Takahashi, Aki; Hong, Jang Ja; Seyama, Toshio; Iida, Koji; Wada, Hiroshi; Hirasawa, Noriyasu; Ohuchi, Kazuo

2008-01-01

Acetylation and deacetylation of proteins occur in cells in response to various stimuli, and are reversibly catalyzed by histone acetyltransferase and histone deacetylase (HDAC), respectively. EoL-1 cells have an FIP1L1-PDGFRA fusion gene that causes transformation of eosinophilic precursor cells into leukemia cells. The HDAC inhibitors apicidin and n-butyrate suppress the proliferation of EoL-1 cells and induce differentiation into eosinophils by a decrease in the protein level of FIP1L1-PDGFRalpha without affecting the mRNA level for FIP1L1-PDGFRA. In this study, we analyzed the mechanism by which the protein level of FIP1L1-PDGFRalpha is decreased by apicidin and n-butyrate. EoL-1 cells were incubated in the presence of the HDAC inhibitors apicidin, trichostatin A or n-butyrate. The protein levels of FIP1L1-PDGFRalpha and phosphorylated eIF-2alpha were determined by Western blotting. Actinomycin D and cycloheximide were used to block RNA synthesis and protein synthesis, respectively, in the chasing experiment of the amount of FIP1L1-PDGFRalpha protein. When apicidin- and n-butyrate-treated EoL-1 cells were incubated in the presence of actinomycin D, the decrease in the protein level of FIP1L1-PDGFRalpha was significantly enhanced when compared with controls. In contrast, the protein levels were not changed by cycloheximide among these groups. Apicidin and n-butyrate induced the continuous phosphorylation of eIF-2alpha for up to 8 days. The decrease in the level of FIP1L1-PDGFRalpha protein by continuous inhibition of HDAC may be due to the decrease in the translation rate of FIP1L1-PDGFRA. Copyright 2008 S. Karger AG, Basel.

Implementation of National Space Policy on US Air Force End of Life Operations and Orbital Debris Mitigation

DTIC Science & Technology

2012-06-01

procedures have been driven by the rising significance of the orbital debris problem in Low Earth Orbit (LEO). Therefore current EOL plans are...does not display a currently valid OMB control number. 1. REPORT DATE JUN 2012 2. REPORT TYPE 3. DATES COVERED 00-00-2012 to 00-00-2012 4...by the rising significance of the orbital debris problem in Low Earth Orbit (LEO). Therefore current EOL plans are written largely with the aim of

The EOLE experiment: Early results and current objectives

NASA Technical Reports Server (NTRS)

Morel, P.; Bandeen, W. R.

1972-01-01

The EOLE experiment with 480 constant level balloons released in the Southern Hemisphere is described. Each balloon floating freely at approximately the 200 mb level, is a precise tracer of the horizontal motion of air masses, the accuracy of which is limited only by the laminated structure of the stratospheric flow, within an RMS uncertainty of 1.5 m/sec. The balloons were found after 2 months to distribute at random over the whole hemisphere outside the tropics, irrespective of their original launching site. Early results of Eulerian and Lagrangian averages of the EOLE wind data are given for describing the mean 200 mb zonal and meridional circulations. The effect of the small scale eddies of two-dimensional turbulence has been studied with respect to the relative eddy diffusion of pairs of balloons and the relative dispersion of triangular clusters. New estimates of the RMS divergence of the 200 mb flow are given, together with their scale dependence which was found to be a logarithmic law.

End-of-life disposal of high elliptical orbit missions: The case of INTEGRAL

NASA Astrophysics Data System (ADS)

Armellin, Roberto; San-Juan, Juan F.; Lara, Martin

2015-08-01

Nowadays there is international consensus that space activities must be managed to minimize debris generation and risk. The paper presents a method for the end-of-life (EoL) disposal of spacecraft in high elliptical orbits (HEO). The time evolution of HEO is strongly affected by Earth's oblateness and luni-solar perturbation, and this can cause in the long-term to extended interferences with low Earth orbit (LEO) protected region and uncontrolled Earth re-entry. An EoL disposal concept that exploits the effect of orbital perturbations to reduce the disposal cost is presented. The problem is formulated as a multiobjective optimization problem, which is solved with an evolutionary algorithm. To explore at the best the search space a semi-analytical orbit propagator, which allows the propagation of the orbit motion for 100 years in few seconds, is adopted. The EoL disposal of the INTErnational Gamma-Ray Astrophysics Laboratory (INTEGRAL) mission is used as a practical test-case to show the effectiveness of the proposed methodology.

Are there regional tendencies toward controversial screening practices? A study of prostate and breast cancer screening in a Medicare population.

PubMed

Raffin, Eric; Onega, Tracy; Bynum, Julie; Austin, Andrea; Carmichael, Donald; Bronner, Kristen; Goodney, Philip; Hyams, Elias S

2017-10-01

Prostate and breast cancer screening in older patients continue to be controversial. Balancing the desire for early detection with avoidance of over-diagnosis has led to competing and contradictory guidelines for both practices. Despite similarities, it is not known how these screening practices are related at the regional level. In this study, we examined how screening PSA and mammography are related within healthcare regions, and, to better understand what may be driving these practices, whether they are associated with local intensity of care. We performed a retrospective cross-sectional study of fee-for-service Medicare beneficiaries in 2012. For each of 306 hospital referral regions (HRRs), we calculated rates of PSA screening for men aged ≥68 years, as well as rates of screening mammography for women aged ≥75 years, adjusted for age and race. Additionally, we determined regional rates of "healthcare intensity", including spending on tests and procedures, and intensity of end-of-life care. Pearson correlations of adjusted rates were calculated within HRRs. The mean adjusted rate of PSA screening was 22%. The mean age of screened and unscreened patients was 75.0 and 77.4 years, respectively (p<0.0001). The mean adjusted rate of screening mammography was 23%; mean ages of screened and non-screened women were 79.95 and 83.67, respectively (p<0.0001). HRR-level PSA screening rates were independent of screening mammography rates (r=0.06, p=0.31). PSA screening rates were associated with spending on testing and procedures (r=0.42, p<0.0001) and various measures of intensity of EOL care (e.g. r=0.40, p<0.0001 for mechanical ventilator use). Screening mammography had low correlation with both health care spending and EOL care intensity measures (all r-values <0.3). Regional rates of PSA screening rates were independent of screening mammography, thus these practices appear to be driven by different factors. Unlike mammography, PSA screening was associated with local enthusiasm for testing and treatment. Efforts to reduce over-testing should contemplate these practices differently, and future research should examine the factors motivating these screening practices. Copyright © 2017 Elsevier Ltd. All rights reserved.

Sustainability Impact of Nanomaterial Enhanced Lithium Ion Batteries

NASA Astrophysics Data System (ADS)

Ganter, Matthew

Energy storage devices are becoming an integral part of sustainable energy technology adoption, particularly, in alternative transportation (electric vehicles) and renewable energy technologies (solar and wind which are intermittent). The most prevalent technology exhibiting near-term impact are lithium ion batteries, especially in portable consumer electronics and initial electric vehicle models like the Chevy Volt and Nissan Leaf. However, new technologies need to consider the full life-cycle impacts from material production and use phase performance to the end-of-life management (EOL). This dissertation investigates the impacts of nanomaterials in lithium ion batteries throughout the life cycle and develops strategies to improve each step in the process. The embodied energy of laser vaporization synthesis and purification of carbon nanotubes (CNTs) was calculated to determine the environmental impact of the novel nanomaterial at beginning of life. CNTs were integrated into lithium ion battery electrodes as conductive additives, current collectors, and active material supports to increase power, energy, and thermal stability in the use phase. A method was developed to uniformly distribute CNT conductive additives in composites. Cathode composites with CNT additives had significant rate improvements (3x the capacity at a 10C rate) and higher thermal stability (40% reduction in exothermic energy released upon overcharge). Similar trends were also measured with CNTs in anode composites. Advanced free-standing anodes incorporating CNTs with high capacity silicon and germanium were measured to have high capacities where surface area reduction improved coulombic efficiencies and thermal stability. A thermal stability plot was developed that compares the safety of traditional composites with free-standing electrodes, relating the results to thermal conductivity and surface area effects. The EOL management of nanomaterials in lithium ion batteries was studied and a novel recycling technique, referred to as refunctionalization , for lithium ion cathode materials was developed. Refunctionalization is the treatment of active materials in order to regain electrochemical performance at EOL which eliminates the need to recycle to the elemental level and can lead to greater environmental and economic savings. The lithium ion capacity of EOL lithium iron phosphate (LiFePO4) nanomaterial cathode was regained through chemical and electrochemical re-lithiation techniques. The embodied energy of refunctionalized LiFePO4 was calculated to be 50% less than cathode synthesized from virgin materials. Overall, these results contribute to an improved understanding of the life cycle impacts for nanomaterials in batteries. The CNT embodied energy calculation established the first life cycle inventory for laser vaporization CNTs, whereas the novel refunctionalization strategies established a new EOL pathway to recover cathodes at a higher value state than traditional recycling. At the same time, CNT enhanced battery electrodes increased power and energy in the use phase while demonstrating the unique ability to engineer electrodes to control thermal stability, which enables better performing and safer batteries.

CentNet—A deployable 100-station network for surface exchange research

NASA Astrophysics Data System (ADS)

Oncley, S.; Horst, T. W.; Semmer, S.; Militzer, J.; Maclean, G.; Knudson, K.

2014-12-01

Climate, air quality, atmospheric composition, surface hydrology, and ecological processes are directly affected by the Earth's surface. Complexity of this surface exists at multiple spatial scales, which complicates the understanding of these processes. NCAR/EOL currently provides a facility to the research community to make direct eddy-covariance flux observations to quantify surface-atmosphere interactions. However, just as model resolution has continued to increase, there is a need to increase the spatial density of flux measurements to capture the wide variety of scales that contribute to exchange processes close to the surface. NCAR/EOL now has developed the CentNet facility, that is envisioned to have on the order of 100 surface flux stations deployable for periods of months to years. Each station would measure standard meteorological variables, all components of the surface energy balance (including turbulence fluxes and radiation), atmospheric composition, and other quantities to characterize the surface. Thus, CentNet can support observational research in the biogeosciences, hydrology, urban meteorology, basic meteorology, and turbulence. CentNet has been designed to be adaptable to a wide variety of research problems while keeping operations manageable. Tower infrastructure has been designed to be lightweight, easily deployed, and with a minimal set-up footprint. CentNet uses sensor networks to increase spatial sampling at each station. The data system saves every sample on site to retain flexibility in data analysis. We welcome guidance on development and funding priorities as we build CentNet.

Chromate conversion coating: Iridite 14-2 thermal/optical characterization

NASA Astrophysics Data System (ADS)

Rodriguez, Marcello

2012-10-01

Chromate Conversion Coating (CCC) BOL and EOL thermal properties (absorptance and emittance) have been unspecified throughout the industry and throughout its use here at GSFC. Being key values essential for thermal engineers to assess thermal space conditions, this study focuses on the current application process, its outputted properties and assess whether these properties can in turn be classified under proper documentation. The results show that wide variations in the process overcome any possibility in thermally classifying this coating. A new set of samples were fabricated (in preparation for space environmental studies) in which a more controlled approach to applying the CCC was made. The resulting thermal values continued to show variations indicating lack of bath agitation existing within the bath. From this study you can conclude that witness samples may not best represent the flight hardware for this coating. The study then turns to space environmental study testing samples to high temperature (80°C), high vacuum, and combination of both, and UV radiation totaling 1625 ESH. The results showed an extremely dynamic coating sensitive to every environmental condition it was exposed to. Though the initial changes to the coating are drastic, post initial changes appear to be minuscule making EOL predictions more attainable. These results show that the worst case alpha/emittance values are likely after ground processing and before space exposure. From the data obtained in this study greater understanding and more informed decisions can be made with respect to this coating.

Summary of Global Ozone Measurements Collected from Field Campaigns

NASA Astrophysics Data System (ADS)

Aguilera, J.; Salazar, V.

2013-12-01

The goal of the NCAR Earth Observing Laboratory data services is to advance science through delivering high-quality project data and meta data in ways that are as transparent, secure, and easily accessible as possible. By using EOL's existing infrastructure and applying data mining techniques, we explored global ozone measurements collected during EOL supported airborne field campaigns. This study highlights ozone concentrations addressing a diverse set of science objectives, and how these timed measurements contribute to the understanding of the state of the atmosphere and evolution of the different measuring techniques.

Model Comparisons For Space Solar Cell End-Of-Life Calculations

NASA Astrophysics Data System (ADS)

Messenger, Scott; Jackson, Eric; Warner, Jeffrey; Walters, Robert; Evans, Hugh; Heynderickx, Daniel

2011-10-01

Space solar cell end-of-life (EOL) calculations are performed over a wide range of space radiation environments for GaAs-based single and multijunction solar cell technologies. Two general semi-empirical approaches will used to generate these EOL calculation results: 1) the JPL equivalent fluence (EQFLUX) and 2) the NRL displacement damage dose (SCREAM). This paper also includes the first results using the Monte Carlo-based version of SCREAM, called MC- SCREAM, which is now freely available online as part of the SPENVIS suite of programs.

Opportunities for Palliative Care in Public Health.

PubMed

De Lima, Liliana; Pastrana, Tania

2016-01-01

In May 2014, the World Health Assembly, of the World Health Organization (WHO), unanimously adopted a palliative care (PC) resolution, which outlines clear recommendations to the United Nations member states, such as including PC in national health policies and in the undergraduate curricula for health care professionals, and highlights the critical need for countries to ensure that there is an adequate supply of essential PC medicines, especially those needed to alleviate pain. This resolution also carries great challenges: Every year over 20 million patients (of which 6% are children) need PC at the end of life (EOL). However, in 2011, approximately three million patients received PC, and only one in ten people in need is currently receiving it. We describe this public health situation and systems failure, the history and evolution of PC, and the components of the WHO public health model. We propose a role for public health for PC integration in community settings to advance PC and relieve suffering in the world.

Rumex L. species induce apoptosis in 1301, EOL-1 and H-9 cell lines.

PubMed

Wegiera, Magdalena; Smolarz, Helena D; Bogucka-Kocka, Anna

2012-01-01

The Rumex L. (dock) species for many centuries have been used in medical treatment, through their adstringent, spasmolitic or cholagogic action. In the present study, the in vitro screening of cytotoxic activities of ethanol extract from roots, leaves and fruits of six Rumex species: R. acetosa L., R. acetosella L., R. confertus Willd., R. crispus L., R. hydrolapathum Huds. and R. obtusifolius L. were performed. We found remarkable cytotoxic activities on leukemic 1301 and EOL-1 cell lines and T cell line at concentration dependent manners. Cytotoxic activity was determined in two ways: trypan blue test and annexin-V FITC and propidium iodide assay. Received IC50 values of investigated extracts on 1301, EOL-1 and H-9 cell lines ranged from 0.22, 0.17 and 0.04 to 2.56, 1.91 and 1.83 mg/mL, respectively. Analysis of morphological changes demonstrated that the extract exerted cell-death via apoptosis. The overall activities of Rumex species support the traditional use of the extract from the fruits of R. confertus, R. crispus, R. hydrolapathum and R. obtusifolius in the treatment of cancer.

EOL performance comparison of GaAs/Ge and Si BSF/R solar arrays

NASA Technical Reports Server (NTRS)

Woike, Thomas J.

1993-01-01

EOL power estimates for solar array designs are significantly influenced by the predicted degradation due to charged particle radiation. New radiation-induced power degradation data for GaAs/Ge solar arrays applicable to missions ranging from low earth orbit (LEO) to geosynchronous earth orbit (GEO) and compares these results to silicon BSF/R arrays. These results are based on recently published radiation damage coefficients for GaAs/Ge cells. The power density ratio (GaAs/Ge to Si BSF/R) was found to be as high as 1.83 for the proton-dominated worst-case altitude of 7408 km medium Earth orbit (MEO). Based on the EOL GaAs/Ge solar array power density results for MEO, missions which were previously considered infeasible may be reviewed based on these more favorable results. The additional life afforded by using GaAs/Ge cells is an important factor in system-level trade studies when selecting a solar cell technology for a mission and needs to be considered. The data presented supports this decision since the selected orbits have characteristics similar to most orbits of interest.

Technology requirements for GaAs photovoltaic arrays

NASA Technical Reports Server (NTRS)

Scott-Monck, J.; Rockey, D.

1981-01-01

An analysis based on percent GaAs solar cell weight and cost is performed to assess the utility of this cell for future space missions. It is shown that the GaAs substrate cost and the end-of-life (EOL) advantage the cell can provide over the space qualified silicon solar cell are the dominant factors determining potential use. Examples are presented to show that system level advantages resulting from reduction in solar panel area may warrant the use of GaAs at its current weight and projected initial cost provided the EOL advantage over silicon is at least 20 percent.

Leukotactin-1/CCL15 induces cell migration and differentiation of human eosinophilic leukemia EoL-1 cells through PKCdelta activation.

PubMed

Lee, Ji-Sook; Kim, In Sik

2010-06-01

Leukotactin-1 (Lkn-1)/CCL15 is a CC chemokine that binds to the CCR1 and CCR3. Lkn-1 functions as an essential factor in the migration of monocytes, lymphocytes, and neutrophils. Although eosinophils express both receptors, the role of Lkn-1 in immature eosinophils remains to be elucidated. In this present study, we investigated the contribution of the CCR1-binding chemokines to chemotactic activity and in the differentiation in the human eosinophilic leukemia cell line EoL-1. Lkn-1 induced the stronger migration of EoL-1 cells than other CCR1-binding chemokines such as RANTES/CCL5, MIP-1alpha/CCL3 and HCC-4/CCL16. Lkn-1-induced chemotaxis was inhibited by pertussis toxin, an inhibitor of G(i)/G(o) protein; U73122, an inhibitor of phospholipase C and rottlerin, an inhibitor of protein kinase C delta (PKCdelta). Lkn-1 increased PKCdelta activity, which was partially blocked by the pertussis toxin and U73122. Lkn-1 enhanced the butyric acid-induced differentiation via PKCdelta after binding to the increased CCR1 because Lkn-1 caused EoL-1 cells to change morphologically into mature eosinophil-like cells. Likewise, Lkn-1 increased the expression of both eosinophil peroxidase (EPO) and the major basic protein (MBP). PKCdelta activation due to Lkn-1 is involved in migration, as well as the butyric acid-induced differentiation. This finding contributes to an understanding of CC chemokines in eosinophil biology and to the development of novel therapies for the treatment of eosinophilic disorders. This study suggests the pivotal roles of Lkn-1 in the regulation of the movement and development of eosinophils.

Development and evaluation of the EOL-ICDQ as a measure of experiences, attitudes and knowledge in end-of-life in patients living with an implantable cardioverter defibrillator.

PubMed

Thylén, Ingela; Wenemark, Marika; Fluur, Christina; Strömberg, Anna; Bolse, Kärstin; Årestedt, Kristofer

2014-04-01

Due to extended indications and resynchronization therapy, many implantable cardioverter defibrillator (ICD) recipients will experience progressive co-morbid conditions and will be more likely to die of causes other than cardiac death. It is therefore important to elucidate the ICD patients' preferences when nearing end-of-life. Instead of avoiding the subject of end-of-life, a validated questionnaire may be helpful to explore patients' experiences and attitudes about end-of-life concerns and to assess knowledge of the function of the ICD in end-of-life. Validated instruments assessing patients' perspective concerning end-of-life issues are scarce. The purpose of this study was to develop and evaluate respondent satisfaction and measurement properties of the 'Experiences, Attitudes and Knowledge of End-of-Life Issues in Implantable Cardioverter Defibrillator Patients' Questionnaire' (EOL-ICDQ). The instrument was tested for validity, respondent satisfaction, and for homogeneity and stability in the Swedish language. An English version of the EOL-ICDQ was validated, but has not yet been pilot tested. The final instrument contained three domains, which were clustered into 39 items measuring: experiences (10 items), attitudes (18 items), and knowledge (11 items) of end-of-life concerns in ICD patients. In addition, the questionnaire also contained items on socio-demographic background (six items) and ICD-specific background (eight items). The validity and reliability properties were considered sufficient. The EOL-ICDQ has the potential to be used in clinical practice and future research. Further studies are needed using this instrument in an Anglo-Saxon context with a sample of English-speaking ICD recipients.

Management and Stewardship of Airborne Observational Data for the NSF/NCAR HIAPER (GV) and NSF/NCAR C-130 at the National Center for Atmospheric Research (NCAR) Earth Observing Laboratory (EOL)

NASA Astrophysics Data System (ADS)

Aquino, J.

2014-12-01

The National Science Foundation (NSF) provides the National Center for Atmospheric Research (NCAR) Earth Observing Laboratory (EOL) funding for the operation, maintenance and upgrade of two research aircraft: the NSF/NCAR High-performance Instrumented Airborne Platform for Environmental Research (HIAPER) Gulfstream V and the NSF/NCAR Hercules C-130. A suite of in-situ and remote sensing airborne instruments housed at the EOL Research Aviation Facility (RAF) provide a basic set of measurements that are typically deployed on most airborne field campaigns. In addition, instruments to address more specific research requirements are provided by collaborating participants from universities, industry, NASA, NOAA or other agencies. The data collected are an important legacy of these field campaigns. A comprehensive metadata database and integrated cyber-infrastructure, along with a robust data workflow that begins during the field phase and extends to long-term archival (current aircraft data holdings go back to 1967), assures that: all data and associated software are safeguarded throughout the data handling process; community standards of practice for data stewardship and software version control are followed; simple and timely community access to collected data and associated software tools are provided; and the quality of the collected data is preserved, with the ultimate goal of supporting research and the reproducibility of published results. The components of this data system to be presented include: robust, searchable web access to data holdings; reliable, redundant data storage; web-based tools and scripts for efficient creation, maintenance and update of data holdings; access to supplemental data and documentation; storage of data in standardized data formats; comprehensive metadata collection; mature version control; human-discernable storage practices; and procedures to inform users of changes. In addition, lessons learned, shortcomings, and desired upgrades will be discussed.

The Next Generation of Airborne Polarimetric Doppler Weather Radar: NCAR/EOL Airborne Phased Array Radar (APAR) Development

NASA Astrophysics Data System (ADS)

Moore, James; Lee, Wen-Chau; Loew, Eric; Vivekanandan, Jothiram; Grubišić, Vanda; Tsai, Peisang; Dixon, Mike; Emmett, Jonathan; Lord, Mark; Lussier, Louis; Hwang, Kyuil; Ranson, James

2017-04-01

The National Center for Atmospheric Research (NCAR) Earth observing Laboratory (EOL) is entering the third year of preliminary system design studies, engineering prototype testing and project management plan preparation for the development of a novel Airborne Phased Array Radar (APAR). This system being designed by NCAR/EOL will be installed and operated on the NSF/NCAR C-130 aircraft. The APAR system will consist of four removable C-band Active Electronically Scanned Arrays (AESA) strategically placed on the fuselage of the aircraft. Each AESA measures approximately 1.5 x 1.9 m and is composed of 3000 active radiating elements arranged in an array of line replaceable units (LRU) to simplify maintenance. APAR will provide unprecedented observations, and in conjunction with the advanced radar data assimilation schema, will be able to address the key science questions to improve understanding and predictability of significant and high-impact weather APAR, operating at C-band, allows the measurement of 3-D kinematics of the more intense portions of storms (e.g. thunderstorm dynamics and tornadic development, tropical cyclone rainband structure and evolution) with less attenuation compared with current airborne Doppler radar systems. Polarimetric measurements are not available from current airborne tail Doppler radars. However, APAR, with dual-Doppler and dual polarization diversity at a lesser attenuating C-band wavelength, will further advance the understanding of the microphysical processes within a variety of precipitation systems. The radar is sensitive enough to provide high resolution measurements of winter storm dynamics and microphysics. The planned APAR development that would bring the system to operational readiness for research community use aboard the C-130 is expected to take 8 years once major funding support is realized. The authors will review the overall APAR design and provide new details of the system based on our Technical Requirements Document, airflow studies and antenna aperture simulations We will further outline the next steps needed to bring this exceptional tool into full operation.

A potential utilization of end-of-life tyres as recycled carbon black in EPDM rubber.

PubMed

Sagar, M; Nibedita, K; Manohar, N; Kumar, K Raj; Suchismita, S; Pradnyesh, A; Reddy, A Babul; Sadiku, E Rotimi; Gupta, U N; Lachit, P; Jayaramudu, J

2018-04-01

End-of-life (EOL) tyres and their decomposition present severe environmental concern due to their resistance to moisture, oxygen, natural degradation, etc. Pyrolysis is considered to be the most effective and sustainable process for recycling, due to its eco-friendly process. The current work studied the effect of recycled carbon black (rCB), obtained from the pyrolysis of EOL tyres, on the properties of ethylene propylene diene rubber (EPDM). The rCB was characterized by scanning electron microscopy (SEM), thermogravimetric analysis (TGA) and chemical methods. rCB was incorporated solely, into a conventional EPDM formulation and also in combination with N550 carbon black. The physico-mechanical properties of the EPDM vulcanizates, before and after aging, were succinctly studied by SEM, TGA, Differential Scanning Calorimetry (DSC), tensile tests and cross-link density. The average particle size of rCB was observed to be 8 µm and the ash content was observed to be higher when compared to the conventional N550 carbon black, which was evident, by the TGA and SEM-EDX analyses. The reinforcing effect and the cross-link density of the rCB-filled vulcanizates were found to be marginally inferior in comparison to the conventional carbon black (N550). The morphology of the tensile- and tear-fractured surfaces were studied by SEM and it was observed that the breaking mechanism follows the rubber chain detachment from the surface mode. Copyright © 2018 Elsevier Ltd. All rights reserved.

Advance care planning: challenges and approaches for pediatricians.

PubMed

Heckford, Emma; Beringer, Antonia Jane

2014-09-01

There is increasing recognition of the value of advance care planning for children with life-limiting conditions. It is important that we acknowledge and reflect on the challenges that this work presents in order to optimize practice. Our aim was to review advance care planning for children with life-threatening or life-limiting conditions (LTLLCs) in our local area. We conducted a retrospective case note review. Study subjects were from two National Health Service (NHS) Trusts in Bristol in the United Kingdom. Cases were identified from Child Death Overview Panel data. Forty-two sets of case notes were reviewed in relation to 20 children. Measurements included quantitative and qualitative review of advance care planning in relation to standards set by The Association for Children's Palliative Care (ACT). In 25% of cases there was no documented discussion with families about the approach to end of life (EOL). In 25% of cases there was no evidence of an advance care plan, and the content and accessibility of those that did exist was variable. Forty-five percent of families were not offered a choice with regard to location of care (LOC) in the last months of life and 50% were not offered a choice about location of death (LOD). We hope that acknowledgement of some of the challenges, alongside recognition of the clear benefits, of planning will help pediatricians to deliver this important area of care.

A Comparative Analysis of Life-Cycle Assessment Tools for ...

EPA Pesticide Factsheets

We identified and evaluated five life-cycle assessment tools that community decision makers can use to assess the environmental and economic impacts of end-of-life (EOL) materials management options. The tools evaluated in this report are waste reduction mode (WARM), municipal solid waste-decision support tool (MSW-DST), solid waste optimization life-cycle framework (SWOLF), environmental assessment system for environmental technologies (EASETECH), and waste and resources assessment for the environment (WRATE). WARM, MSW-DST, and SWOLF were developed for US-specific materials management strategies, while WRATE and EASETECH were developed for European-specific conditions. All of the tools (with the exception of WARM) allow specification of a wide variety of parameters (e.g., materials composition and energy mix) to a varying degree, thus allowing users to model specific EOL materials management methods even outside the geographical domain they are originally intended for. The flexibility to accept user-specified input for a large number of parameters increases the level of complexity and the skill set needed for using these tools. The tools were evaluated and compared based on a series of criteria, including general tool features, the scope of the analysis (e.g., materials and processes included), and the impact categories analyzed (e.g., climate change, acidification). A series of scenarios representing materials management problems currently relevant to c

4D in situ visualization of electrode morphology changes during accelerated degradation in fuel cells by X-ray computed tomography

NASA Astrophysics Data System (ADS)

White, Robin T.; Wu, Alex; Najm, Marina; Orfino, Francesco P.; Dutta, Monica; Kjeang, Erik

2017-05-01

A four-dimensional visualization approach, featuring three dimensions in space and one dimension in time, is proposed to study local electrode degradation effects during voltage cycling in fuel cells. Non-invasive in situ micro X-ray computed tomography (XCT) with a custom fuel cell fixture is utilized to track the same cathode catalyst layer domain throughout various degradation times from beginning-of-life (BOL) to end-of-life (EOL). With this unique approach, new information regarding damage features and trends are revealed, including crack propagation and catalyst layer thinning being quantified by means of image processing and analysis methods. Degradation heterogeneities as a result of local environmental variations under land and channel are also explored, with a higher structural degradation rate under channels being observed. Density and compositional changes resulting from carbon corrosion and catalyst layer collapse and thinning are observed by changes in relative X-ray attenuation from BOL to EOL, which also indicate possible vulnerable regions where crack initiation and propagation may occur. Electrochemical diagnostics and morphological features observed by micro-XCT are correlated by additionally collecting effective catalyst surface area, double layer capacitance, and polarization curves prior to imaging at various stages of degradation.

Framing Effects on End-of-Life Preferences Among Latino Elders.

PubMed

Vélez Ortiz, Daniel; Martinez, Rubén O; Espino, David V

2015-01-01

This study compared how the presentation of end-of-life (EOL) choices influences responses by Latino and White older adults relative to resuscitation preferences. The authors apply prospect theory, which deals with decision making based on how choices are framed. Participants were presented with differently ordered questions framing a resuscitation scenario and asked to rate their preferences. Results show that Latino participants were significantly influenced by the framing order of treatment options with regard to resuscitation while Whites were not. Health professionals need to be aware that the ways they present EOL options are likely to affect the choices of Latino older adults. Further research is needed with Latino subgroups.

Going straight to the source: A pilot study of bereaved parent-facilitated communication training for pediatric subspecialty fellows.

PubMed

Snaman, Jennifer M; Kaye, Erica C; Cunningham, Melody J; Sykes, April; Levine, Deena R; Mahoney, Daniel; Baker, Justin N

2017-01-01

Medical trainees consistently report suboptimal instruction and poor self-confidence in communication skills. Despite this deficit, few established training programs provide comprehensive, pediatric-specific communication education, particularly in the provision of "bad news." To our knowledge, no programs currently use bereaved parent educators to facilitate communication training for pediatric subspecialty trainees. The authors designed and implemented a pilot communication training seminar in which bereaved parent educators and faculty facilitators led small groups in interactive, role-play scenarios. Surveys incorporating a retrospective preprogram assessment item to account for response-shift bias were used to assess short- and long-term changes in trainee comfort with delivering "bad news." Fifteen pediatric fellowship trainees participated in the communication seminar; complete data were available for 12 participants. After accounting for response-shift bias, participants reported significant improvement in overall preparedness, breaking bad news to a patient and family, and including the adolescent or young adult patient in conversations. Additionally, participants reported a significant improvement in their ability to address a patient and family's need for information, emotional suffering at the end of life (EOL), if and when a patient should be included in the conversation, and EOL care decisions. The participant's self-perceived improvement in comfort and preparedness persisted over time. Communication training for pediatric subspecialty trainees using bereaved parent educators is feasible and effective. Both medical trainee and bereaved parent participants benefited from involvement in this pilot study. Further iterations of this training will be modified to assess objective measures of improvement in trainees' communication skills. © 2016 Wiley Periodicals, Inc.

Are religion and religiosity important to end-of-life decisions and patient autonomy in the ICU? The Ethicatt study.

PubMed

Bülow, Hans-Henrik; Sprung, Charles L; Baras, Mario; Carmel, Sara; Svantesson, Mia; Benbenishty, Julie; Maia, Paulo A; Beishuizen, Albertus; Cohen, Simon; Nalos, Daniel

2012-07-01

This study explored differences in end-of-life (EOL) decisions and respect for patient autonomy of religious members versus those only affiliated to that particular religion (affiliated is a member without strong religious feelings). In 2005 structured questionnaires regarding EOL decisions were distributed in six European countries to ICUs in 142 hospital ICUs. This sub-study of the original data analyzed answers from Protestants, Catholics and Jews. A total of 304 physicians, 386 nurses, 248 patients and 330 family members were included in the study. Professionals wanted less treatment (ICU admission, CPR, ventilator treatment) than patients and family members. Religious respondents wanted more treatment and were more in favor of life prolongation, and they were less likely to want active euthanasia than those affiliated. Southern nurses and doctors favored euthanasia more than their Northern colleagues. Three quarters of doctors and nurses would respect a competent patient's refusal of a potentially life-saving treatment. No differences were found between religious and affiliated professionals regarding patient's autonomy. Inter-religious differences were detected, with Protestants most likely to follow competent patients' wishes and the Jewish respondents least likely to do so, and Jewish professionals more frequently accepting patients' wishes for futile treatment. However, these findings on autonomy were due to regional differences, not religious ones. Health-care professionals, families and patients who are religious will frequently want more extensive treatment than affiliated individuals. Views on active euthanasia are influenced by both religion and region, whereas views on patient autonomy are apparently more influenced by region.

The cultural context of patient's autonomy and doctor's duty: passive euthanasia and advance directives in Germany and Israel.

PubMed

Schicktanz, Silke; Raz, Aviad; Shalev, Carmel

2010-11-01

The moral discourse surrounding end-of-life (EoL) decisions is highly complex, and a comparison of Germany and Israel can highlight the impact of cultural factors. The comparison shows interesting differences in how patient's autonomy and doctor's duties are morally and legally related to each other with respect to the withholding and withdrawing of medical treatment in EoL situations. Taking the statements of two national expert ethics committees on EoL in Israel and Germany (and their legal outcome) as an example of this discourse, we describe the similarity of their recommendations and then focus on the differences, including the balancing of ethical principles, what is identified as a problem, what social role professionals play, and the influence of history and religion. The comparison seems to show that Israel is more restrictive in relation to Germany, in contrast with previous bioethical studies in the context of the moral and legal discourse regarding the beginning of life, in which Germany was characterized as far more restrictive. We reflect on the ambivalence of the cultural reasons for this difference and its expression in various dissenting views on passive euthanasia and advance directives, and conclude with a comment on the difficulty in classifying either stance as more or less restrictive.

Multi-kanban mechanism for appliance disassembly

NASA Astrophysics Data System (ADS)

Udomsawat, Gun; Gupta, Surendra M.

2005-11-01

The use of household appliances continues to rise every year. A significant number of End-Of-Life (EOL) appliances are generated because of the introduction of newer models that are more attractive, efficient and affordable. Others are, of course, generated when they become non-functional. Many regulations encourage recycling of EOL appliances to reduce the amount of waste sent to landfills. In addition, EOL appliances offer the appliance manufacturing and remanufacturing industries a source of less expensive raw materials and components. For this reason product recovery has become a subject of interest during the past decade. In this paper, we study the disassembly line for appliance disassembly. We discuss and incorporate some of the complications that are inherent in disassembly line including product arrival, demand arrival, inventory fluctuation and production control mechanisms. We show how to overcome such complications by implementing a multi-kanban system in the appliance disassembly line setting. The multi-kanban system (MKS) relies on dynamic routing of kanbans according to the state of the system. We investigate the multi-kanban mechanism using simulation and explore the effect of product mix on performance of the traditional push system (TPS) and MKS in terms of controlling the system's inventory while attempting to achieve a decent customer service level.

Use of real-time tools to support field operations of NSF's Lower Atmosphere Observing Facilities

NASA Astrophysics Data System (ADS)

Daniels, M.; Stossmeister, G.; Johnson, E.; Martin, C.; Webster, C.; Dixon, M.; Maclean, G.

2012-12-01

NCAR's Earth Observing Laboratory (EOL) operates Lower Atmosphere Observing Facilities (LAOF) for the scientific community, under sponsorship of the National Science Foundation. In order to obtain the highest quality dataset during field campaigns, real-time decision-making critically depends on the availability of timely data and reliable communications between field operations staff and instrument operators. EOL incorporates the latest technologies to monitor the health of instrumentation, facilitate remote operations of instrumentation and keep project participants abreast of changing conditions in the field. As the availability of bandwidth on mobile communication networks and the capabilities of their associated devices (smart phone, tablets, etc.) improved, so has the ability of researchers to respond to rapidly changing conditions and coordinate ever more detailed measurements from multiple remote fixed, portable and airborne platforms. This presentation will describe several new tools that EOL is making available to project investigators and how these tools are being used in a mobile computing environment to support enhanced data collection during field campaigns. LAOF platforms such as radars, aircraft, sondes, balloons and surface stations all rely on displays of real-time data for their operations. Data from sondes are ingested into the Global Telecommunications System (GTS) for assimilation into regional forecasting models that help guide project operations. Since many of EOL's projects occur around the globe and at the same time instrument complexity has increased, automated monitoring of instrumentation platforms and systems has become essential. Tools are being developed to allow remote instrument control of our suite of observing systems where feasible. The Computing, Data and Software (CDS) Facility of EOL develops and supports a Field Catalog used in field campaigns for nearly two decades. Today, the Field Catalog serves as a hub for the collection and browsing of field research products, related operational and forecast imagery, project documentation as well as tools for real-time decision-making, communication, mission planning and post analysis. Incorporation of new capabilities into the Field Catalog to support the mobile computing environment and devices has led to the development of new tools which will be described. EOL/CDS has also developed a customized Internet Relay Chat (IRC) chat system to enable communication between all project participants distributed across various land-based, shipboard and airborne remote sites. The CDS chat system has incorporated aspects of fault tolerance in order to handle intermittent communications links. NOAA and NASA have used this chat system for their field missions as well. These new tools were recently deployed in support of the Deep Convective Clouds and Chemistry (DC3) field campaign that took place May - June 2012 in the Central United States. This presentation will show examples of these real-time tools from recent projects. We will also describe some of the challenges, problems and surprises, as well as improvements that have been made to the tools. The capabilities of this system continue to advance, taking advantage of new technology and guided by our experience and feedback from users participating in field campaigns.

Probing platinum degradation in polymer electrolyte membrane fuel cells by synchrotron X-ray microscopy.

PubMed

Berejnov, Viatcheslav; Martin, Zulima; West, Marcia; Kundu, Sumit; Bessarabov, Dmitri; Stumper, Jürgen; Susac, Darija; Hitchcock, Adam P

2012-04-14

Synchrotron-based scanning transmission X-ray spectromicroscopy (STXM) was used to characterize the local chemical environment at and around the platinum particles in the membrane (PTIM) which form in operationally tested (end-of-life, EOL) catalyst coated membranes (CCMs) of polymer electrolyte membrane fuel cells (PEM-FC). The band of metallic Pt particles in operationally tested CCM membranes was imaged using transmission electron microscopy (TEM). The cathode catalyst layer in the beginning-of-life (BOL) CCMs was fabricated using commercially available catalysts created from Pt precursors with and without nitrogen containing ligands. The surface composition of these catalyst powders was measured by X-ray Photoelectron Spectroscopy (XPS). The local chemical environment of the PTIM in EOL CCMs was found to be directly related to the Pt precursor used in CCM fabrication. STXM chemical mapping at the N 1s edge revealed a characteristic spectrum at and around the dendritic Pt particles in CCMs fabricated with nitrogen containing Pt-precursors. This N 1s spectrum was identical to that of the cathode and different from the membrane. For CCM samples fabricated without nitrogen containing Pt-precursors the N 1s spectrum at the Pt particles was indistinguishable from that of the adjacent membrane. We interpret these observations to indicate that nitrogenous ligands in the nitrogen containing precursors, or decomposition product(s) from that source, are transported together with the dissolved Pt from the cathode into the membrane as a result of the catalyst degradation process. This places constraints on possible mechanisms for the PTIM band formation process.

Using life cycle assessment to address stakeholders' potential for improving municipal solid waste management.

PubMed

de Andrade Junior, Milton Aurelio Uba; Zanghelini, Guillherme Marcelo; Soares, Sebastião Roberto

2017-05-01

Because the consumption of materials is generally higher than their recovery rate, improving municipal solid waste (MSW) management is fundamental for increasing the efficiency of natural resource use and consumption in urban areas. More broadly, the characteristics of a MSW management system influence the end-of-life (EOL) impacts of goods consumed by households. We aim to indicate the extent to which greenhouse gas emissions from a MSW management system can be reduced by increasing waste paper recycling. We also address the stakeholders' contribution for driving transition towards an improved scenario. Life cycle assessment (LCA) addresses the EOL impacts of the paper industry, driven by the characteristics of MSW management in Florianópolis, Brazil, by varying the level of stakeholders' commitment through different recycling scenarios. The results show that 41% of the climate change impacts from waste paper management could be reduced when increasing the waste paper recycling rates and reducing waste paper landfilling. To achieve such emissions reduction, the industry contribution to the MSW management system would have to increase from 17% in the business-as-usual scenario to 74% in the target scenario. We were able to measure the differences in stakeholders' contribution by modelling the MSW management system processes that are under the industry's responsibility separately from the processes that are under the government's responsibility, based on the Brazilian legal framework. The conclusions indicate that LCA can be used to support policy directions on reducing the impacts of MSW management by increasing resource recovery towards a circular economy.

Describing Spirituality at the End of Life.

PubMed

Stephenson, Pam Shockey; Berry, Devon M

2015-09-01

Spirituality is salient to persons nearing the end of life (EOL). Unfortunately, researchers have not been able to agree on a universal definition of spirituality reducing the effectiveness of spiritual research. To advance spiritual knowledge and build an evidence base, researchers must develop creative ways to describe spirituality as it cannot be explicitly defined. A literature review was conducted to determine the common attributes that comprise the essence of spirituality, thereby creating a common ground on which to base spiritual research. Forty original research articles (2002 to 2012) focusing on EOL and including spiritual definitions/descriptions were reviewed. Analysis identified five attributes that most commonly described the essence of spirituality, including meaning, beliefs, connecting, self-transcendence, and value. © The Author(s) 2014.

Pricing end-of-life components

NASA Astrophysics Data System (ADS)

Vadde, Srikanth; Kamarthi, Sagar V.; Gupta, Surendra M.

2005-11-01

The main objective of a product recovery facility (PRF) is to disassemble end-of-life (EOL) products and sell the reclaimed components for reuse and recovered materials in second-hand markets. Variability in the inflow of EOL products and fluctuation in demand for reusable components contribute to the volatility in inventory levels. To stay profitable the PRFs ought to manage their inventory by regulating the price appropriately to minimize holding costs. This work presents two deterministic pricing models for a PRF bounded by environmental regulations. In the first model, the demand is price dependent and in the second, the demand is both price and time dependent. The models are valid for single component with no inventory replenishment sale during the selling horizon . Numerical examples are presented to illustrate the models.

A I-V analysis of irradiated Gallium Arsenide solar cells

NASA Technical Reports Server (NTRS)

Heulenberg, A.; Maurer, R. H.; Kinnison, J. D.

1991-01-01

A computer program was used to analyze the illuminated I-V characteristics of four sets of gallium arsenide (GaAs) solar cells irradiated with 1-MeV electrons and 10-MeV protons. It was concluded that junction regions (J sub r) dominate nearly all GaAs cells tested, except for irradiated Mitsubishi cells, which appear to have a different doping profile. Irradiation maintains or increases the dominance by J sub r. Proton irradiation increases J sub r more than does electron irradiation. The U.S. cells were optimized for beginning of life (BOL) and the Japanese for end of life (EOL). I-V analysis indicates ways of improving both the BOL and EOL performance of GaAs solar cells.

3D interconnect metrology in CMS/ITRI

NASA Astrophysics Data System (ADS)

Ku, Y. S.; Shyu, D. M.; Hsu, W. T.; Chang, P. Y.; Chen, Y. C.; Pang, H. L.

2011-05-01

Semiconductor device packaging technology is rapidly advancing, in response to the demand for thinner and smaller electronic devices. Three-dimensional chip/wafer stacking that uses through-silicon vias (TSV) is a key technical focus area, and the continuous development of this novel technology has created a need for non-contact characterization. Many of these challenges are novel to the industry due to the relatively large variety of via sizes and density, and new processes such as wafer thinning and stacked wafer bonding. This paper summarizes the developing metrology that has been used during via-middle & via-last TSV process development at EOL/ITRI. While there is a variety of metrology and inspection applications for 3D interconnect processing, the main topics covered here are via CD/depth measurement, thinned wafer inspection and wafer warpage measurement.

Attitudes towards end-of-life issues in intensive care unit among Italian anesthesiologists: a nation-wide survey.

PubMed

Cortegiani, Andrea; Russotto, Vincenzo; Raineri, Santi Maurizio; Gregoretti, Cesare; Giarratano, Antonino; Mercadante, Sebastiano

2018-06-01

The aim of this paper is to collect data on the practice of palliative care, withholding and withdrawal of life-sustaining therapies, and management of end of life (EOL) in Italian intensive care units (ICUs). Web-based survey among Italian anesthesiologists endorsed by the Italian Society of Anesthesiology Analgesia Reanimation and Intensive Care (SIAARTI). The survey consists of 27 close-ended and 2 open-ended questions. Eight hundred and five persons responded to the full list of questions. The highest proportion of respondents was of 36-45 years of age (34%) and catholic (66%). Almost 70% of responders declared that palliative/supportive care are applied in their ICU in case of futility of intensive treatments. Decision on withdrawing/withholding of life-sustaining treatments resulted from team consensus in most cases (58%). In more than 70% of responders' ICUs, there is no collaboration with palliative/supportive care experts. Systematic recording of most frequent symptoms experienced by critically ill patients (e.g., pain, dyspnea, thirst) was not common. Vasopressors, extracorporeal therapies, blood component transfusions and invasive monitoring were the most commonly modified/interrupted measures in case of futility. Almost 85% of respondents have not received training in palliative/supportive care. The proportion of respondents whose institution has a palliative care team and who had training in palliative care was not homogenous across the country. These data suggest that training in palliative care and its clinical application should be implemented in Italy. Efforts should be made to improve and homogenize the management of dying patients in ICU.

Simultaneous material flow analysis of nickel, chromium, and molybdenum used in alloy steel by means of input-output analysis.

PubMed

Nakajima, Kenichi; Ohno, Hajime; Kondo, Yasushi; Matsubae, Kazuyo; Takeda, Osamu; Miki, Takahiro; Nakamura, Shinichiro; Nagasaka, Tetsuya

2013-05-07

Steel is not elemental iron but rather a group of iron-based alloys containing many elements, especially chromium, nickel, and molybdenum. Steel recycling is expected to promote efficient resource use. However, open-loop recycling of steel could result in quality loss of nickel and molybdenum and/or material loss of chromium. Knowledge about alloying element substance flow is needed to avoid such losses. Material flow analyses (MFAs) indicate the importance of steel recycling to recovery of alloying elements. Flows of nickel, chromium, and molybdenum are interconnected, but MFAs have paid little attention to the interconnected flow of materials/substances in supply chains. This study combined a waste input-output material flow model and physical unit input-output analysis to perform a simultaneous MFA for nickel, chromium, and molybdenum in the Japanese economy in 2000. Results indicated the importance of recovery of these elements in recycling policies for end-of-life (EoL) vehicles and constructions. Improvement in EoL sorting technologies and implementation of designs for recycling/disassembly at the manufacturing phase are needed. Possible solutions include development of sorting processes for steel scrap and introduction of easier methods for identifying the composition of secondary resources. Recovery of steel scrap with a high alloy content will reduce primary inputs of alloying elements and contribute to more efficient resource use.

Automatic detection and classification of EOL-concrete and resulting recovered products by hyperspectral imaging

NASA Astrophysics Data System (ADS)

Palmieri, Roberta; Bonifazi, Giuseppe; Serranti, Silvia

2014-05-01

The recovery of materials from Demolition Waste (DW) represents one of the main target of the recycling industry and the its characterization is important in order to set up efficient sorting and/or quality control systems. End-Of-Life (EOL) concrete materials identification is necessary to maximize DW conversion into useful secondary raw materials, so it is fundamental to develop strategies for the implementation of an automatic recognition system of the recovered products. In this paper, HyperSpectral Imaging (HSI) technique was applied in order to detect DW composition. Hyperspectral images were acquired by a laboratory device equipped with a HSI sensing device working in the near infrared range (1000-1700 nm): NIR Spectral Camera™, embedding an ImSpector™ N17E (SPECIM Ltd, Finland). Acquired spectral data were analyzed adopting the PLS_Toolbox (Version 7.5, Eigenvector Research, Inc.) under Matlab® environment (Version 7.11.1, The Mathworks, Inc.), applying different chemometric methods: Principal Component Analysis (PCA) for exploratory data approach and Partial Least Square- Discriminant Analysis (PLS-DA) to build classification models. Results showed that it is possible to recognize DW materials, distinguishing recycled aggregates from contaminants (e.g. bricks, gypsum, plastics, wood, foam, etc.). The developed procedure is cheap, fast and non-destructive: it could be used to make some steps of the recycling process more efficient and less expensive.

The cultural context of patient’s autonomy and doctor’s duty: passive euthanasia and advance directives in Germany and Israel

PubMed Central

Raz, Aviad; Shalev, Carmel

2010-01-01

The moral discourse surrounding end-of-life (EoL) decisions is highly complex, and a comparison of Germany and Israel can highlight the impact of cultural factors. The comparison shows interesting differences in how patient’s autonomy and doctor’s duties are morally and legally related to each other with respect to the withholding and withdrawing of medical treatment in EoL situations. Taking the statements of two national expert ethics committees on EoL in Israel and Germany (and their legal outcome) as an example of this discourse, we describe the similarity of their recommendations and then focus on the differences, including the balancing of ethical principles, what is identified as a problem, what social role professionals play, and the influence of history and religion. The comparison seems to show that Israel is more restrictive in relation to Germany, in contrast with previous bioethical studies in the context of the moral and legal discourse regarding the beginning of life, in which Germany was characterized as far more restrictive. We reflect on the ambivalence of the cultural reasons for this difference and its expression in various dissenting views on passive euthanasia and advance directives, and conclude with a comment on the difficulty in classifying either stance as more or less restrictive. PMID:20680469

An evaluation of the potential yield of indium recycled from end-of-life LCDs: A case study in China.

PubMed

Wang, Hengguang; Gu, Yifan; Wu, Yufeng; Zhang, Yi-Nan; Wang, Wei

2015-12-01

With the advances in electronics and information technology, China has gradually become the largest consumer of household appliances (HAs). Increasingly, end-of-life (EOL) HAs are generated in China. EOL recycling is a promising strategy to reduce dependence on virgin production, and indium is one of the recycled substances. The potential yield of indium recycling has not been systematically evaluated in China thus far. This paper estimates the potential yield of recycled indium from waste liquid crystal displays (LCDs) in China during the period from 2015 to 2030. The quantities of indium that will be used to produce LCDs are also predicted. The estimates focus on the following three key LCD waste sources: LCD TVs, desktop computers and portable computers. The results show that the demand for indium will be increasing in the near future. It is expected that 350 tonnes of indium will be needed to produce LCDs in China in 2035. The indium recycled from EOL LCDs, however, is much less than the demand and only accounts for approximately 48% of the indium demand. The sustainable index of indium is always less than 0.5. Therefore, future indium recycling efforts should focus on the development of recycling technology and the improvement of the relevant policy. Copyright © 2015 Elsevier Ltd. All rights reserved.

Challenges in the Management and Stewardship of Airborne Observational Data at the National Center for Atmospheric Research (NCAR) Earth Observing Laboratory (EOL)

NASA Astrophysics Data System (ADS)

Aquino, J.; Daniels, M. D.

2015-12-01

The National Science Foundation (NSF) provides the National Center for Atmospheric Research (NCAR) Earth Observing Laboratory (EOL) funding for the operation, maintenance and upgrade of two research aircraft: the NSF/NCAR High-performance Instrumented Airborne Platform for Environmental Research (HIAPER) Gulfstream V and the NSF/NCAR Hercules C-130. A suite of in-situ and remote sensing airborne instruments housed at the EOL Research Aviation Facility (RAF) provide a basic set of measurements that are typically deployed on most airborne field campaigns. In addition, instruments to address more specific research requirements are provided by collaborating participants from universities, industry, NASA, NOAA or other agencies (referred to as Principal Investigator, or PI, instruments). At the 2014 AGU Fall Meeting, a poster (IN13B-3639) was presented outlining the components of Airborne Data Management included field phase data collection, formats, data archival and documentation, version control, storage practices, stewardship and obsolete data formats, and public data access. This talk will cover lessons learned, challenges associated with the above components, and current developments to address these challenges, including: tracking data workflows for aircraft instrumentation to facilitate identification, and correction, of gaps in these workflows; implementation of dataset versioning guidelines; and assignment of Digital Object Identifiers (DOIs) to data and instrumentation to facilitate tracking data and facility use in publications.

Thermodynamic Considerations of Contamination by Alloying Elements of Remelted End-of-Life Nickel- and Cobalt-Based Superalloys

NASA Astrophysics Data System (ADS)

Lu, Xin; Matsubae, Kazuyo; Nakajima, Kenichi; Nakamura, Shinichiro; Nagasaka, Tetsuya

2016-06-01

Cobalt and nickel are high-value commodity metals and are mostly used in the form of highly alloyed materials. The alloying elements used may cause contamination problems during recycling. To ensure maximum resource efficiency, an understanding of the removability of these alloying elements and the controllability of some of the primary alloying elements is essential with respect to the recycling of end-of-life (EoL) nickel- and cobalt-based superalloys by remelting. In this study, the distribution behaviors of approximately 30 elements that are usually present in EoL nickel- and cobalt-based superalloys in the solvent metal (nickel, cobalt, or nickel-cobalt alloy), oxide slag, and gas phases during the remelting were quantitatively evaluated using a thermodynamic approach. The results showed that most of the alloying elements can be removed either in the slag phase or into the gas phase. However, the removal of copper, tin, arsenic, and antimony by remelting is difficult, and they remain as tramp elements during the recycling. On the other hand, the distribution tendencies of iron, molybdenum, and tungsten can be controlled by changing the remelting conditions. To increase the resource efficiency of recycling, preventing contamination by the tramp elements and identifying the alloying compositions of EoL superalloys are significantly essential, which will require the development of efficient prior alloy-sorting systems and advanced separation technologies.

Inhibitory effect of turmeric curcuminoids on FLT3 expression and cell cycle arrest in the FLT3-overexpressing EoL-1 leukemic cell line.

PubMed

Tima, Singkome; Ichikawa, Hideki; Ampasavate, Chadarat; Okonogi, Siriporn; Anuchapreeda, Songyot

2014-04-25

Leukemia is a hematologic malignancy with a frequent incidence and high mortality rate. Previous studies have shown that the FLT3 gene is overexpressed in leukemic blast cells, especially in acute myeloid leukemia. In this study, a commercially available curcuminoid mixture (1), pure curcumin (2), pure demethoxycurcumin (3), and pure bisdemethoxycurcumin (4) were investigated for their inhibitory effects on cell growth, FLT3 expression, and cell cycle progression in an FLT3-overexpressing EoL-1 leukemic cell line using an MTT assay, Western blotting, and flow cytometry, respectively. The mixture (1) and compounds 2-4 demonstrated cytotoxic effects with IC50 values ranging from 6.5 to 22.5 μM. A significant decrease in FLT3 protein levels was found after curcuminoid treatment with IC20 doses, especially with mixture 1 and compound 2. In addition, mixture 1 and curcumin (2) showed activity on cell cycle arrest at the G0/G1 phase and decreased the FLT3 and STAT5A protein levels in a dose-dependent manner. Compound 2 demonstrated the greatest potential for inhibiting cell growth, cell cycle progression, and FLT3 expression in EoL-1 cells. This investigation has provided new findings regarding the effect of turmeric curcuminoids on FLT3 expression in leukemic cells.

Older patients’ attitudes towards and experiences of patient-physician end-of-life communication: a secondary analysis of interviews from British, Dutch and Belgian patients

PubMed Central

2012-01-01

Background Older patients often experience sub-standard communication in the palliative phase of illness. Due to the importance of good communication in patient-centred end-of-life care, it is essential to understand the factors which influence older patients’ communication with physicians. This study examines older patients’ attitudes towards, and experiences of, patient-physician end-of-life (EoL) communication in three European countries. Methods A secondary analysis of interviews from British, Dutch and Belgian patients over the age of 60 with a progressive terminal illness was conducted. Cross-cutting themes were identified using a thematic approach. Results Themes from 30 interviews (Male n = 20, Median age 78.5) included: confidence and trust; disclosure and awareness; and participation in decision-making. Confidence and trust were reinforced by physicians’ availability, time and genuine attention and hindered by misdiagnoses and poor communication style. Most participants preferred full disclosure, though some remained deliberately ill-informed to avoid distress. Patients expressed a variety of preferences for and experiences of involvement in medical EoL decision-making and a few complained that information was only provided about the physician's preferred treatment. Conclusions A variety of experiences and attitudes regarding disclosure and participation in decision-making were reported from each country, suggesting that communication preferences are highly individual. It is important that physicians are sensitive to this diversity and avoid stereotyping. In regard to communication style, physicians are advised to provide clear explanations, avoid jargon, and continually check understanding. Both the ‘informed’ and the ‘shared’ patient-physician decision-making models assume patients make rational choices based on a clear understanding of treatment options. This idealized situation was often not reflected in patients’ experiences. PMID:23186392

Scale dependence of the 200-mb divergence inferred from EOLE data.

NASA Technical Reports Server (NTRS)

Morel, P.; Necco, G.

1973-01-01

The EOLE experiment with 480 constant-volume balloons distributed over the Southern Hemisphere approximately at the 200-mb level, has provided a unique, highly accurate set of tracer trajectories in the general westerly circulation. The trajectories of neighboring balloons are analyzed to estimate the horizontal divergence from the Lagrangian derivative of the area of one cluster. The variance of the divergence estimates results from two almost comparable effects: the true divergence of the horizontal flow and eddy diffusion due to small-scale, two-dimensional turbulence. Taking this into account, the rms divergence is found to be of the order of 0.00001 per sec and decreases logarithmically with cluster size. This scale dependence is shown to be consistent with the quasi-geostrophic turbulence model of the general circulation in midlatitudes.

Developments in life cycle assessment applied to evaluate the environmental performance of construction and demolition wastes.

PubMed

Bovea, M D; Powell, J C

2016-04-01

This paper provides a review of the literature that applies the life cycle assessment (LCA) methodology to the assessment of the environmental performance of the life cycle of construction and demolition waste (CDW) management systems. This article is focused on generating a general mapping of the literature and on identifying the best practices in compliance with LCA framework and proposing directions for future LCA studies in this field. The temporal evolution of the research in this field and the aim of the studies have grown in parallel with the legal framework related to waste and energy efficiency of buildings. Most studies have been published in Europe, followed by USA. Asia and Australia, being at an incipient application stage to the rest of the world. Topics related to "LCA of buildings, including their EoL" and "LCA of general CDW management strategies" are the most frequently analysed, followed by "LCA of EoL of construction elements" and "LCA of natural material vs recycled material". Regarding the strategies, recycling off-site and incineration, both combined with landfill for the rejected fractions, are the most commonly applied. Re-use or recycling on-site is the strategy least applied. The key aspect when LCA is applied to evaluate CDW management systems is the need to normalise which processes to include in the system boundary and the functional unit, the use of inventory data adapted to the context of the case study and the definition of a common set of appropriate impact assessment categories. Also, it is important to obtain results disaggregated by unit processes. This will allow the comparison between case studies. Copyright © 2016 Elsevier Ltd. All rights reserved.

VIVO Open Source Software: Connecting Facilities to Promote Discovery and Further Research.

NASA Astrophysics Data System (ADS)

Gross, M. B.; Rowan, L. R.; Mayernik, M. S.; Daniels, M. D.; Stott, D.; Allison, J.; Maull, K. E.; Krafft, D. B.; Khan, H.

2016-12-01

EarthCollab (http://earthcube.org/group/earthcollab), a National Science Foundation (NSF) EarthCube Building Block project, has adapted an open source semantic web application, VIVO, for use within the earth science domain. EarthCollab is a partnership between UNAVCO, an NSF facility supporting research through geodetic services, the Earth Observing Laboratory (EOL) at the National Center for Atmospheric Research (NCAR), and Cornell University, where VIVO was created to highlight the scholarly output of researchers at universities. Two public sites have been released: Connect UNAVCO (connect.unavco.org) and Arctic Data Connects (vivo.eol.ucar.edu). The core VIVO software and ontology have been extended to work better with concepts necessary for capturing work within UNAVCO's and EOL's province such as principal investigators for continuous GPS/GNSS stations at UNAVCO and keywords describing cruise datasets at EOL. The sites increase discoverability of large and diverse data archives by linking data with people, research, and field projects. Disambiguation is a major challenge when using VIVO and open data when "anyone can say anything about anything." Concepts and controlled vocabularies help to build consistent and easily searchable connections within VIVO. We use aspects of subject heading services such as FAST and LOC, as well as AGU and GSA fields of research and subject areas to reveal connections, especially with VIVO instances at other institutions. VIVO works effectively with persistent IDs and the projects strive to utilize publication and data DOIs, ORCIDs for people, and ISNI and GRID for organizations. ORCID, an open source project, is very useful for disambiguation and unlike other identifier systems for people developed by publishers, makes public data available via an API. VIVO utilizes Solr and Freemarker, which are open source search engine and templating technologies, respectively. Additionally, a handful of popular open source libraries and applications are being used in the project such as D3.js, jQuery, Leaflet, and Elasticsearch. Our implementation of these open source projects within VIVO is available for adaptation by other institutions using VIVO via GitHub (git.io/vG9AJ).

Earth Observation from space taken during Mission STS-111 UF-2

NASA Image and Video Library

2002-06-05

STS111-719-061 (5-19 June 2002) --- This photo showing the Manicouagan Reservoir in Quebec, Canada, was photographed by the STS-111 crewmembers aboard the Space Shuttle Endeavour. Manicouagan Reservoir marks the site of an impact crater, 60 miles (100 km) wide, which, according to scientists, was formed 212 million years ago when a meteorite crashed into this area. Scientists say that over millions of years the many advancing and retreating glaciers and other erosional processes have worn down the crater. The Gateway to Astronaut Photography of Earth (link to http://eol.jsc.nasa.gov/sseop/) provides searchable access to other photographs of Earth taken by astronauts.

Amorphous silicon thin films: The ultimate lightweight space solar cell

NASA Technical Reports Server (NTRS)

Vendura, G. J., Jr.; Kruer, M. A.; Schurig, H. H.; Bianchi, M. A.; Roth, J. A.

1994-01-01

Progress is reported with respect to the development of thin film amorphous (alpha-Si) terrestrial solar cells for space applications. Such devices promise to result in very lightweight, low cost, flexible arrays with superior end of life (EOL) performance. Each alpha-Si cell consists of a tandem arrangement of three very thin p-i-n junctions vapor deposited between film electrodes. The thickness of this entire stack is approximately 2.0 microns, resulting in a device of negligible weight, but one that must be mechanically supported for handling and fabrication into arrays. The stack is therefore presently deposited onto a large area (12 by 13 in), rigid, glass superstrate, 40 mil thick, and preliminary space qualification testing of modules so configured is underway. At the same time, a more advanced version is under development in which the thin film stack is transferred from the glass onto a thin (2.0 mil) polymer substrate to create large arrays that are truly flexible and significantly lighter than either the glassed alpha-Si version or present conventional crystalline technologies. In this paper the key processes for such effective transfer are described. In addition, both glassed (rigid) and unglassed (flexible) alpha-Si cells are studied when integrated with various advanced structures to form lightweight systems. EOL predictions are generated for the case of a 1000 W array in a standard, 10 year geosynchronous (GEO) orbit. Specific powers (W/kg), power densities (W/sq m) and total array costs ($/sq ft) are compared.

Weather Radars and Lidar for Observing the Atmosphere

NASA Astrophysics Data System (ADS)

(Vivek) Vivekanandan, J.

2010-05-01

The Earth Observing Laboratory (EOL) at the National Center for Atmospheric Research (NCAR) in Boulder, Colorado develops and deploys state-of-the-art ground-based radar, airborne radar and lidar instruments to advance scientific understanding of the earth system. The ground-based radar (S-Pol) is equipped with dual-wavelength capability (S-band and Ka-band). S-Pol is the only transportable radar in the world. In order to capture faster moving weather events such as tornadoes and record observations of clouds over rugged mountainous terrain and ocean, an airborne radar (ELDORA) is used. It is the only airborne Doppler meteorological radar that is able to detect motions in the clear air. The EOL is in the process of building the first phase of a three phase dual wavelength W/Ka-band airborne cloud radar to be called the HIAPER Cloud Radar (HCR). This phase is a pod based W-band radar system with scanning capability. The second phase will add pulse compression and polarimetric capability to the W-band system, while the third phase will add complementary Ka-band radar. The pod-based radar is primarily designed to fly on the Gulfstream V (GV) and C-130 aircraft. The envisioned capability of a millimeter wave radar system on GV is enhanced by coordination with microwave radiometer, in situ probes, and especially by the NCAR GV High-Spectral Resolution Lidar (HSRL) which is also under construction. The presentation will describe the capabilities of current instruments and also planned instrumentation development.

Passivating Window/First Layer AR Coating for Space Solar Cells

NASA Technical Reports Server (NTRS)

Faur, Mircea; Faur, Maria; Bailey, S. G.; Flood, D. J.; Brinker, D. J.; Alterovitz, S. A.; Wheeler, D. R.; Matesscu, G.; Goradia, C.; Goradia, M.

2004-01-01

Chemically grown oxides, if well designed, offer excellent surface passivation of the emitter surface of space solar cells and can be used as effective passivating window/first layer AR coating. In this paper, we demonstrate the effectiveness of using a simple room temperature wet chemical technique to grow cost effective passivating layers on solar cell front surfaces after the front grid metallization step. These passivating layers can be grown both on planar and porous surfaces. Our results show that these oxide layers: (i) can effectively passivate the from the surface, (ii) can serve as an effective optical window/first layer AR coating, (iii) are chemically, thermally and UV stable, and (iv) have the potential of improving the BOL and especially the EOL efficiency of space solar cells. The potential of using this concept to simplify the III-V based space cell heterostructures while increasing their BOL and EOL efficiency is also discussed.

Gravitational Lens: Deep Space Probe Design

DTIC Science & Technology

2012-03-01

Lieutenant, USAF Approved: Timothy Lawrence, Col, USAF (Chairman) Date Carl Hartsfield, Lt Col, USAF (Member) Date Marc G. Millis (Member) Date Abstract A...23 RTG Radioisotope Thermoelectric Generators . . . . . . . . . . . . . . . . . 26 EOL End of Life...26 ASRG Advanced Stirling Radioisotope Generator . . . . . . . . . . . . . . . . 26 GPHS

The role of radiation hard solar cells in minimizing the costs of global satellite communications systems

NASA Technical Reports Server (NTRS)

Summers, Geoffrey P.; Walters, Robert J.; Messenger, Scott R.; Burke, Edward A.

1995-01-01

An analysis embodied in a PC computer program is presented which quantitatively demonstrates how the availability of radiation hard solar cells can minimize the cost of a global satellite communication system. The chief distinction between the currently proposed systems, such as Iridium Odyssey and Ellipsat, is the number of satellites employed and their operating altitudes. Analysis of the major costs associated with implementing these systems shows that operation within the earth's radiation belts can reduce the total system cost by as much as a factor of two, so long as radiation hard components including solar cells, can be used. A detailed evaluation of several types of planar solar cells is given, including commercially available Si and GaAs/Ge cells, and InP/Si cells which are under development. The computer program calculates the end of life (EOL) power density of solar arrays taking into account the cell geometry, coverglass thickness, support frame, electrical interconnects, etc. The EOL power density can be determined for any altitude from low earth orbit (LEO) to geosynchronous (GEO) and for equatorial to polar planes of inclination. The mission duration can be varied over the entire range planned for the proposed satellite systems. An algorithm is included in the program for determining the degradation of cell efficiency for different cell technologies due to proton and electron irradiation. The program can be used to determine the optimum configuration for any cell technology for a particular orbit and for a specified mission life. Several examples of applying the program are presented, in which it is shown that the EOL power density of different technologies can vary by an order of magnitude for certain missions. Therefore, although a relatively radiation soft technology can be made to provide the required EOL power by simply increasing the size of the array, the impact on the total system budget could be unacceptable, due to increased launch and hardware costs. In aggregate these factors can account for more than a 10% increase in the total system cost. Since the estimated total costs of proposed global coverage systems range from $1 Billion to $9 Billion, the availability of radiation hard solar cells could make a decisive difference in the selection of a particular constellation architecture.

Object-Oriented Simulation of EW Systems.

DTIC Science & Technology

1987-12-01

elix.- r’UATO. SY - ~ ow W ." --N I -SEL’ TD DEEICESESEC ETBLISKM - 1Eol~P7 TEST National Defense Deec ationale OBJECT-ORIENTED SIMULATION OF EW...C C- _ _ _4- 0 E (4. I o 0 ~1 . __ _ L c 0 0 i EnE- L-C( 1*c 0~~ N1 Ld 0- E, U, E 0 cu a 0* L L L C:c0 Yc 0 c aja, it) oO -.zz - VV1V 41-4- ia. ca...will retain a simultaneous capability to simulate signal processing at the pulse level. 10 ?1( N 0 .0O Ldk rW% o N1 0 4’-V - 54 - " As discussed

Dehalococcoides abundance and alternate electron acceptor effects on large, flow-through trichloroethene dechlorinating columns.

PubMed

Mirza, Babur S; Sorensen, Darwin L; Dupont, R Ryan; McLean, Joan E

2016-03-01

Trichloroethene (TCE) in groundwater is a major health concern and biostimulation/bioaugmentation-based strategies have been evaluated to achieve complete reductive dechlorination with varying success. Different carbon sources were hypothesized to stimulate different extents of TCE reductive dechlorination. Ecological conditions that developed different dechlorination stages were investigated by quantitating Dehalococcoides 16S rRNA (Dhc) and reductive dehalogenase gene abundance, and by describing biogeochemical properties of laboratory columns in response to this biostimulation. Eight large columns (183 cm × 15.2 cm), packed with aquifer material from Hill AFB, Utah, that were continuously fed TCE for 7.5 years. Duplicate columns were biostimulated with whey or one of two different Newman Zone® emulsified oil formulations containing either nonionic surfactant (EOLN) or standard surfactant (EOL). Two columns were non-stimulated controls. Complete (whey amended), partial (EOLN amended), limited (EOL), and non-TCE dehalogenating systems (controls) developed over the course of the study. Bioaugmentation of half of the columns with Bachman Road culture 3 years prior to dismantling did not influence the extent of TCE dehalogenation. Multivariate analysis clustered samples by biostimulation treatments and extent of TCE dehalogenation. Dhc, tceA, and bvcA gene concentrations did not show a consistent relationship with TCE dehalogenation but the vcrA gene was more abundant in completely dehalogenating, whey-treated columns. The whey columns developed strongly reducing conditions producing Fe(II), sulfide, and methane. Biostimulation with different carbon and energy sources can support high concentrations of diverse Dhc, but carbon addition has a major influence on biogeochemical processes effecting the extent of TCE dehalogenation.

Teaching Residents How to Talk About Death and Dying: A Mixed-Methods Analysis of Barriers and Randomized Educational Intervention.

PubMed

Miller, David C; Sullivan, Amy M; Soffler, Morgan; Armstrong, Brett; Anandaiah, Asha; Rock, Laura; McSparron, Jakob I; Schwartzstein, Richard M; Hayes, Margaret M

2018-01-01

We present a pilot study exploring the effects of a brief, 30-minute educational intervention targeting resident communication surrounding dying in the intensive care unit (ICU). We sought to determine whether simulation or didactic educational interventions improved resident-reported comfort, preparation, and skill acquisition. We also sought to identify resident barriers to using the word "dying." In this mixed-methods prospective study, second- and third-year medical residents were randomized to participate in a simulation-based communication training or a didactic session. Residents completed a pre-post survey after the sessions evaluating the sessions and reflecting on their use of the word "dying" in family meetings. Forty-five residents participated in the study. Residents reported increases in comfort (Mean [M]-pre = 3.3 [standard deviation: 0.6], M-post = 3.7 [0.7]; P < .01, Cohen d = 0.75) and preparation (M-pre = 3.4 [0.7], M-post = 3.9 [0.6]; P < .01, d = 1.07) using the word "dying" after both the simulation and didactic versions. Residents randomized to the simulation reported they were more likely to have learned new skills as compared to residents in the didactic (M-simulation = 2.2 [0.4], M-didactic = 1.9 [0.3]; P = .015, d = 0.80). They estimated that they used the word "dying" in 50% of their end-of-life (EOL) conversations and identified uncertain prognosis as the main barrier to explicitly stating the word "dying." A 30-minute educational intervention improves internal medicine residents' self-reported comfort and preparation in talking about death and dying in the ICU. Residents in simulation-based training were more likely to report they learned new skills as compared to the didactic session. Residents report multiple barriers to using the word "dying" EOL conversations.

Advanced cancer patients' reported wishes at the end of life: a randomized controlled trial.

PubMed

Delgado-Guay, Marvin O; Rodriguez-Nunez, Alfredo; De la Cruz, Vera; Frisbee-Hume, Susan; Williams, Janet; Wu, Jimin; Liu, Diane; Fisch, Michael J; Bruera, Eduardo

2016-10-01

Conversations about end-of-life (EOL) wishes are challenging for many clinicians. The Go Wish card game (GWG) was developed to facilitate these conversations. Little is known about the type and consistency of EOL wishes using the GWG in advanced cancer patients. We conducted a randomized controlled trial to assess the EOL wishes of 100 patients with advanced cancer treated at The University of Texas MD Anderson Cancer Center. The purpose of this study was to determine the EOL wishes of patients with advanced cancer and to compare patients' preference between the GWG and List of wishes/statements (LOS) containing the same number of items. Patients were randomized into four groups and completed either the GWG or a checklist of 35 LOS and one opened statement found on the GWG cards; patients were asked to categorize these wishes as very, somewhat, or not important. After 4-24 h, the patients were asked to complete the same or other test. Group A (n = 25) received LOS-LOS, group B (n = 25) received GWG-GWG, group C (n = 26) received GWG-LOS, and group D (n = 24) received LOS-GWG. All patients completed the State-Trait Anxiety Inventory (STAI) for adults before and after the first test. Median age (interquartile range = IQR): 56 (27-83) years. Age, sex, ethnicity, marital status, religion, education, and cancer diagnosis did not differ significantly among the four groups. All patients were able to complete the GWG and/or LOS. The ten most common wishes identified as very important by patients in the first and second test were to be at peace with God (74 vs. 71 %); to pray (62 vs. 61 %); and to have family present (57 vs. 61 %). to be free from pain (54 vs. 60 %); not being a burden to my family (48 vs. 49 %); to trust my doctor (44 vs. 45 %); to keep my sense of humor (41 vs. 45 %); to say goodbye to important people in my life (41 vs. 37 %); to have my family prepared for my death (40 vs. 49 %); and to be able to help others (36 vs. 31 %). There was significant association among the frequency of responses of the study groups. Of the 50 patients exposed to both tests, 43 (86 %) agreed that the GWG instructions were clear, 45 (90 %) agreed that the GWG was easy to understand, 31 (62 %) preferred the GWG, 39 (78 %) agreed that the GWG did not increase their anxiety and 31 (62 %) agreed that having conversations about EOL priorities was beneficial. The median STAI score after GWG was 48 (interquartile range, 39-59) vs. 47 (interquartile range, 27-63) after LOS (p = 0.2952). Patients with advanced cancer assigned high importance to spirituality and the presence/relationships of family, and these wishes were consistent over the two tests. The GWG did not worsen anxiety.

The status of lightweight photovoltaic space array technology based on amorphous silicon solar cells

NASA Technical Reports Server (NTRS)

Hanak, Joseph J.; Kaschmitter, Jim

1991-01-01

Ultralight, flexible photovoltaic (PV) array of amorphous silicon (a-Si) was identified as a potential low cost power source for small satellites. A survey was conducted of the status of the a-Si PV array technology with respect to present and future performance, availability, cost, and risks. For existing, experimental array blankets made of commercial cell material, utilizing metal foil substrates, the Beginning of Life (BOL) performance at Air Mass Zero (AM0) and 35 C includes total power up to 200 W, power per area of 64 W/sq m and power per weight of 258 W/kg. Doubling of power per weight occurs when polyimide substrates are used. Estimated End of Life (EOL) power output after 10 years in a nominal low earth orbit would be 80 pct. of BOL, the degradation being due to largely light induced effects (-10 to -15 pct.) and in part (-5 pct.) to space radiation. Predictions for the year 1995 for flexible PV arrays, made on the basis of published results for rigid a-Si modules, indicate EOL power output per area and per weight of 105 W/sq m and 400 W/kg, respectively, while predictions for the late 1990s based on existing U.S. national PV program goals indicate EOL values of 157 W/sq m and 600 W/kg. Cost estimates by vendors for 200 W ultralight arrays in volume of over 1000 units range from $100/watt to $125/watt. Identified risks include the lack of flexible, space compatible encapsulant, the lack of space qualification effort, recent partial or full acquisitions of US manufacturers of a-Si cells by foreign firms, and the absence of a national commitment for a long range development program toward developing of this important power source for space.

Prognostics for Ground Support Systems: Case Study on Pneumatic Valves

NASA Technical Reports Server (NTRS)

Daigle, Matthew; Goebel, Kai

2011-01-01

Prognostics technologies determine the health (or damage) state of a component or sub-system, and make end of life (EOL) and remaining useful life (RUL) predictions. Such information enables system operators to make informed maintenance decisions and streamline operational and mission-level activities. We develop a model-based prognostics methodology for pneumatic valves used in ground support equipment for cryogenic propellant loading operations. These valves are used to control the flow of propellant, so failures may have a significant impact on launch availability. Therefore, correctly predicting when valves will fail enables timely maintenance that avoids launch delays and aborts. The approach utilizes mathematical models describing the underlying physics of valve degradation, and, employing the particle filtering algorithm for joint state-parameter estimation, determines the health state of the valve and the rate of damage progression, from which EOL and RUL predictions are made. We develop a prototype user interface for valve prognostics, and demonstrate the prognostics approach using historical pneumatic valve data from the Space Shuttle refueling system.

On the Prediction of Solar Cell Degradation in Space

NASA Astrophysics Data System (ADS)

Bourgoin, J. C.; Boizot, B.; Khirouni, K.; Khorenko, V.

2014-08-01

We discuss the validity of the procedure which is used to predict End Of Life performances of a solar cell in space. This procedure consists to measure the performances of the cell after it has been irradiated at the EOL fluence during a time ti very short compared to the duration tm of the mission in space, i.e. with a considerably larger flux. We show that this procedure is valid only when the defects created by the irradiation do not anneal (thermally or by carrier injection) with a time constant shorter than tm or larger than ti. This can be a common situation since annealing of irradiation induced defects occurs in all type of cells, at least in specific conditions (temperature, intensity of illumination, flux and nature of irradiating particles). Using modeling, we illustrate the effect of injection or thermal annealing on EOL prediction in the case GaInP, material at the heart of modern high efficiency space solar cells.

Nilotinib and Imatinib Are Comparably Effective in Reducing Growth of Human Eosinophil Leukemia Cells in a Newly Established Xenograft Model

PubMed Central

Salamon, Johannes; Thamer, Mohammed; Herrmann, Harald; Valent, Peter; Schumacher, Udo; Ullrich, Sebastian

2012-01-01

We developed a xenograft model of human Chronic Eosinophilic Leukemia (CEL) to study disease progression and remission-induction under therapy with tyrosine kinase inhibitors using imatinib and nilotinib as examples. The FIP1L1/PDGFRA+ human CEL cell lineEOL-1 was injected intravenously into scid mice, and MR imaging and FACS analysis of mouse blood samples were performed to monitor disease development and the effects of imatinib and nilotinib. Organ infiltration was analyzed in detail by immunohistochemistry after sacrifice. All animals developed CEL and within one week of therapy, complete remissions were seen with both imatinib and nilotinib, resulting in reduced total tumor volumes by MR-imaging and almost complete disappearance of EOL-1 cells in the peripheral blood and in tissues. The new model system is feasible for the evaluation of new tyrosine kinase inhibitors and our data suggest that nilotinib may be a valuable additional targeted drug active in patients with FIP1L1/PDGFRA+ CEL. PMID:22348015

Large-scale kinetic energy spectra from Eulerian analysis of EOLE wind data

NASA Technical Reports Server (NTRS)

Desbois, M.

1975-01-01

A data set of 56,000 winds determined from the horizontal displacements of EOLE balloons at the 200 mb level in the Southern Hemisphere during the period October 1971-February 1972 is utilized for the computation of planetary- and synoptic-scale kinetic energy space spectra. However, the random distribution of measurements in space and time presents some problems for the spectral analysis. Two different approaches are used, i.e., a harmonic analysis of daily wind values at equi-distant points obtained by space-time interpolation of the data, and a correlation method using the direct measurements. Both methods give similar results for small wavenumbers, but the second is more accurate for higher wavenumbers (k above or equal to 10). The spectra show a maximum at wavenumbers 5 and 6 due to baroclinic instability and then decrease for high wavenumbers up to wavenumber 35 (which is the limit of the analysis), according to the inverse power law k to the negative p, with p close to 3.

Investigation of the environmental implications of the CNT switch through its life cycle

NASA Astrophysics Data System (ADS)

Dahlben, Lindsay Johanna

Carbon nanotubes (CNTs) are unique allotropes of carbon that have high tensile strength, a high Young's modulus, good thermal conductivity, and depending on the CNT chirality can be metallic or semiconducting. These mechanical, thermal, and electrical properties make CNTs an attractive element in electronic applications such as conductive films, photovoltaics, non-volatile memory devices, batteries, sensors, and displays. Although commercialization of CNT-enabled products is increasing, there remains a significant lack of information regarding the health effects and environmental impacts of CNTs. Some studies have even shown that the behavior, toxicity, and persistence of CNTs may differ from bulk heterogeneous carbon. Given these uncertainties, it is prudent to assess the environmental attributes of CNT products and processes now to discover and potentially prevent adverse effects. This study investigates the environmental implications of a non-volatile bi-stable electromechanical CNT switch through its life cycle. Life cycle assessment (LCA) methodology is used to track the environmental impacts of the CNT switch through its fabrication and expected use and end-of-life (EOL) stages. Process parameters, energy consumption, input materials, output emissions, and yield efficiencies are determined for the laboratory and full-scale manufacture environments. The Ecoinvent(TM) inventory database and Eco-indicator 1999(TM) method are utilized for the impact assessment. Results for the fabrication stage are reported for highest contributions to environmental impact such as airborne inorganics, land use, and fossil fuels due to Au refining processes and electricity consumption. Extension of the LCA scope is evaluated for the potential replacement of CNT switches to current field-effect transistors (FETs) in flash memory for a cellular phone application. First-order predictions are made for the functionality and performance of the CNT switch during the use stage through an environmental perspective. Existing cellular phone EOL management options including recycling and direct disposal to landfill and incineration are evaluated for potential limitations, concerns, and environmental releases that may occur from the assimilation of CNT switch-enabled phones into the waste stream. In this manner, potential environmental effects of the CNT switch throughout its life cycle stages can be addressed alongside its technological development to ensure safe, sustainable, and successful CNT products.

Using a public health approach to improve end-of-life care: results and discussion of a health needs assessment undertaken in a large city in northern England.

PubMed

Ingold, Kathryn; Hicks, Fiona

2015-06-01

A detailed health needs assessment (HNA) for end-of-life care (EoLC) services was led by public health in Leeds to inform a commissioning strategy. To answer the question: are we delivering the best possible EoLC services within the resources available? Mixed methods were used with three approaches: epidemiological, corporate and comparative. More people from deprived communities die in hospital. 18% of people who die each year are on a palliative care register, reflecting a lack of recognition and planning for EoLC given that 75% of people who die need EoLC. Over 100 staff, patients and carers were interviewed and over 200 staff returned questionnaires. Staff highlighted concerns about capacity of services; pressure on out-of-hospital care; problems at physical and electronic interfaces between services; suboptimal hospital discharge; need for earlier recognition of the EoL stage for patients. Patients and carers stressed the importance of communication, coordination and continuity of care; full involvement in care planning; honesty and support for the bereaved; an advocate for patients and families; accessible information; improved urgent care; integrated team working; pain relief, dignity and respect. Issues from comparator sites included the need for sustainable leadership for change, lack of interoperability between IT systems; building advance care planning into working culture; gaps in psychological services, bereavement and pastoral support; integration within all clinical areas; lack of district nurses; few investment opportunities; getting home care support right; concerns about 111; incentives for general practitioners to deliver EoLC; variability in service and the Liverpool Care Pathway controversy. Ethical approval was not sought as the HNA was undertaken as a service evaluation. Local policy is that ethical approval is not required for service evaluation. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Changes in health-related quality of life and quality of care among terminally ill cancer patients and survival prediction: Multicenter prospective cohort study.

PubMed

Lee, Myung Kyung; Lee, Woo Jin; Do, Young Rok; Lee, Keun Seok; Jung, Kyung Hae; Heo, Dae Seog; Kim, Sam Yong; Park, Sang Yoon; Jeong, Hyun Sik; Kang, Jung Hun; Kim, Si-Young; Park, Sook Ryun; Yun, Young Ho

2015-08-01

This study examined changes in health-related quality of life (HRQoL) and quality of care (QoC) as perceived by terminally ill cancer patients and a stratified set of HRQoL or QoC factors that are most likely to influence survival at the end of life (EoL). We administered questionnaires to 619 consecutive patients immediately after they were diagnosed with terminal cancer by physicians at 11 university hospitals and at the National Cancer Center in Korea. Subjects were followed up over 161.2 person-years until their deaths. We measured HRQoL using the core 30-item European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, and QoC using the Quality Care Questionnaire-End of Life (QCQ-EoL). We evaluated changes in HRQoL and QoC issues during the first three months after enrollment, performing sensitivity analysis by using data generated via four methods (complete case analysis, available case analysis, the last observation carried forward, and multiple imputation). Emotional and cognitive functioning decreased significantly over time, while dyspnea, constipation, and pain increased significantly. Dignity-conserving care, care by healthcare professionals, family relationships, and QCQ-EoL total score decreased significantly. Global QoL, appetite loss, and Eastern Cooperative Oncology Group Performance Status (ECOG-PS) scores were significantly associated with survival. Future standardization of palliative care should be focused on assessment of these deteriorated types of quality. Accurate estimates of the length of life remaining for terminally ill cancer patients by such EoL-enhancing factors as global QoL, appetite loss, and ECOG-PS are needed to help patients experience a dignified and comfortable death.

Toward Improving Quality of End-of-Life Care: Encoding Clinical Guidelines and Standing Orders Using the Omaha System.

PubMed

Slipka, Allison F; Monsen, Karen A

2018-02-01

End-of-life care (EOLC) relieves the suffering of millions of people around the globe each year. A growing body of hospice care research has led to the creation of several evidence-based clinical guidelines for EOLC. As evidence for the effectiveness of timely EOLC swells, so does the increased need for efficient information exchange between disciplines and across the care continuum. The purpose of this study was to investigate the feasibility of using the Omaha System as a framework for encoding interoperable evidence-based EOL interventions with specified temporality for use across disciplines and settings. Four evidence-based clinical guidelines and one current set of hospice standing orders were encoded using the Omaha System Problem Classification Scheme and Intervention Scheme, as well as Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT). The resulting encoded guideline was entered on a Microsoft Excel spreadsheet and made available for public use on the Omaha System Guidelines website. The resulting EOLC guideline consisted of 153 interventions that may enable patients and their surrogates, clinicians, and ancillary providers to communicate interventions in a universally comprehensible way. Evidence-based interventions from diverse disciplines involved in EOLC are described within this guideline using the Omaha System. Because the Omaha System and clinical guidelines are maintained in the public domain, encoding interventions is achievable by anyone with access to the Internet and basic Excel skills. Using the guideline as a documentation template customized for unique patient needs, clinicians can quantify and track patient care across the care continuum to ensure timely evidence-based interventions. Clinical guidelines coded in the Omaha System can support the use of multidisciplinary evidence-based interventions to improve quality of EOLC across settings and professions. © 2017 Sigma Theta Tau International.

Image fusion algorithm based on energy of Laplacian and PCNN

NASA Astrophysics Data System (ADS)

Li, Meili; Wang, Hongmei; Li, Yanjun; Zhang, Ke

2009-12-01

Owing to the global coupling and pulse synchronization characteristic of pulse coupled neural networks (PCNN), it has been proved to be suitable for image processing and successfully employed in image fusion. However, in almost all the literatures of image processing about PCNN, linking strength of each neuron is assigned the same value which is chosen by experiments. This is not consistent with the human vision system in which the responses to the region with notable features are stronger than that to the region with nonnotable features. It is more reasonable that notable features, rather than the same value, are employed to linking strength of each neuron. As notable feature, energy of Laplacian (EOL) is used to obtain the value of linking strength in PCNN in this paper. Experimental results demonstrate that the proposed algorithm outperforms Laplacian-based, wavelet-based, PCNN -based fusion algorithms.

A Comparative Analysis of Life-Cycle Assessment Tools for End-of-Life Materials Management Systems

EPA Science Inventory

We identified and evaluated five life-cycle assessment tools that community decision makers can use to assess the environmental and economic impacts of end-of-life (EOL) materials management options. The tools evaluated in this report are waste reduction mode (WARM), municipal s...

English Language Learners and English-Only Learners' Response to Direct Vocabulary Instruction

ERIC Educational Resources Information Center

Crevecoeur, Yvel C.; Coyne, Michael D.; McCoach, D. Betsy

2014-01-01

We examined data from an 18-week kindergarten vocabulary intervention study to determine whether treatment outcomes had differential effects that favored English language learners (ELLs) or English-only learners (EOLs) and whether the relationship between initial English general receptive vocabulary knowledge and response to vocabulary…

The Bering Sea Project Archive: a Prototype for Improved Discovery and Access

NASA Astrophysics Data System (ADS)

Stott, D.; Mayernik, M. S.; Daniels, M. D.; Moore, J. A.; Williams, S. F.; Allison, J.

2015-12-01

The Bering Sea Project was a research program from 2007 through 2012 that sought to understand the impacts of climate change and dynamic sea ice cover on the eastern Bering Sea ecosystem. More than 100 scientists engaged in field data collection, original research, and ecosystem modeling to link climate, physical oceanography, plankton, fishes, seabirds, marine mammals, humans, traditional knowledge and economic outcomes. Over the six-year period of the program hundreds of multidisciplinary datasets coming from a variety of instrumentation and measurement platforms within thirty-one categories of research were processed and curated by the National Center for Atmospheric Research (NCAR) Earth Observing Laboratory (EOL). For the investigator proposing a field project, the researcher performing synthesis, or the modeler seeking data for verification, the easy discovery and access to the most relevant data is of prime importance. The heterogeneous products of oceanographic field programs such as the Bering Sea Project challenge the ability of researchers to identify which data sets, people, or tools might be relevant to their research, and to understand how certain data, instruments, or methods were used to produce particular results.EOL, as a partner in the NSF funded EarthCollab project, is using linked open data to permit the direct interlinking of information and data across platforms and projects. We are leveraging an existing open-source semantic web application, VIVO, to address connectivity gaps across distributed networks of researchers and resources and identify relevant content, independent of location. We will present our approach in connecting ontologies and integrating them within the VIVO system, using the Bering Sea Project datasets as a case study, and will provide insight into how the geosciences can leverage linked data to produce more coherent methods of information and data discovery across large multi-disciplinary projects.

Real-time data and communications services of NCAR's Earth Observing Laboratory

NASA Astrophysics Data System (ADS)

Webster, C. J.; Daniels, M.; Stossmeister, G.

2011-12-01

Near real-time information is critical for mission management of atmospheric observing systems. Advances in satellite communications and Internet distribution have allowed the Earth Observing Laboratory (EOL) of NCAR to provide data, information and imagery to the scientists during evolving weather situations. Real-time data are necessary for updating interactive displays that show products from forecast models and many disparate observation systems (e.g. satellite, soundings, surface radars and aircraft in-situ observations). At the same time, network-based collaborative tools such as chat and web conferencing facilitate interactive participation between remote groups of scientists, engineers, operations centers and the observing platforms. In the recent PREDICT deployment of the NSF/NCAR GV research aircraft, dropsondes were released from the aircraft at 45,000 ft over a 1000 km x 1000 km area to give profiles of pressure, temperature, humidity and wind below the aircraft. Real-time data from the sondes was collected by the aircraft and relayed by satcom into the Global Telecommunications System (GTS) and assimilated into forecast models. The model forecast results were then fed back into ground-based and airborne displays (along with a multitude of observations) for enhanced decision-making and mission guidance. This environment of streaming data in real-time also allows more experts to look at data and compare it with other measurements. One particular benefit is that it alerts instrument operators on the ground and in the air to instrument problems, which can then be addressed very rapidly. The resulting communications and collaborations infrastructure results in unprecedented improvements to our data quality and rapid targeting of mission resources to important weather events. Using several examples, this presentation will provide an overview of current tools and processes in use at EOL, and future needs will be discussed.

Doctors' learning experiences in end-of-life care - a focus group study from nursing homes.

PubMed

Fosse, Anette; Ruths, Sabine; Malterud, Kirsti; Schaufel, Margrethe Aase

2017-01-31

Doctors often find dialogues about death difficult. In Norway, 45% of deaths take place in nursing homes. Newly qualified medical doctors serve as house officers in nursing homes during internship. Little is known about how nursing homes can become useful sites for learning about end-of-life care. The aim of this study was to explore newly qualified doctors' learning experiences with end-of-life care in nursing homes, especially focusing on dialogues about death. House officers in nursing homes (n = 16) participated in three focus group interviews. Interviews were audiotaped and transcribed verbatim. Data were analysed with systematic text condensation. Lave & Wenger's theory about situated learning was used to support interpretations, focusing on how the newly qualified doctors gained knowledge of end-of-life care through participation in the nursing home's community of practice. Newly qualified doctors explained how nursing home staff's attitudes taught them how calmness and acceptance could be more appropriate than heroic action when death was imminent. Shifting focus from disease treatment to symptom relief was demanding, yet participants comprehended situations where death could even be welcomed. Through challenging dialogues dealing with family members' hope and trust, they learnt how to adjust words and decisions according to family and patient's life story. Interdisciplinary role models helped them balance uncertainty and competence in the intermediate position of being in charge while also needing surveillance. There is a considerable potential for training doctors in EOL care in nursing homes, which can be developed and integrated in medical education. This practice based learning arena offers newly qualified doctors close interaction with patients, relatives and nurses, teaching them to perform difficult dialogues, individualize medical decisions and balance their professional role in an interdisciplinary setting.

OA57 The digitalisation of dying, loss and grief on social media channels.

PubMed

Taubert, Mark; Norris, James

2015-04-01

The internet and birth of social media channels have changed the way in which we deal with death, loss and grief forever. Our photo albums are now saved digitally and shared on Facebook. Our private thoughts are now relayed on Twitter. Each year we spend more of our lives online, this workshop will address what happens as we approach death and when we switch off. After building a relationship digitally they recently presented together at the Macmillan Primary Care Conference on the subject 'Can we Palliate Social media'. The outcome of the workshop can be viewed below: 'Can we Palliate Social Media' workshop (about) - http://deadsocial.org/blog/222-macmillan-primary-care-conference BMJ review/results of workshop - http://blogs.bmj.com/spcare/2014/12/04/palliating-social-media-a-seminar-workshop-at-the-macmillan-professionals-conference-in-london/ We will highlight how the digital landscape has changed to help evoke thought and discussion around the subject of digitising death. They will explore the ethical and moral questions regarding end of life within the digital context. The role of the HCP will be examined in relation to social media and patient practice. All attendees will be provided with a number of simple tasks to carryout online. This will again provide a better understanding around the conversations that are occurring online and the digitisation of death. An interactive 40 min workshop will be directed by us. This will conclude with a 20-minute discussion. Leaflets containing relevant tasks for HCPs to carryout online can be carried out after the workshop. Understanding of the main social and digital channels that we (in the UK) use today. Understanding of how online channels have changed how we communicate and behave. The different ways grieving, remembering and mourning occurs online How death, grief and loss is different online Examination of how social media is breaking down the notion of death Reflect on how could/should HCPs and EOL professionals engage online in relation to EOL matters. Understanding how our digital footprint will ultimately become our digital legacy. Each participant/attendee will have a basic understanding of how death, grief and loss are addressed online within the UK. Examples of how different patients (especially children) are using social media in hospitals will be provided to help highlight the catalyst for change that social media has become. © 2015, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

History and perspectives of scientific ballooning

NASA Astrophysics Data System (ADS)

Lefevre, Frank

2001-08-01

Prehistory: Robertson, Biot and Gay-Lussac; Glaisher and the first studies of the atmosphere; Flammarion. The rebirth of scientific ballooning: polyethylene and mylar vehicles at Minneapolis. Super-pressurized balloons. The CNES and the Nasa programs; meteorology, aeronomy and astronomy, The Eole program. The Venus and Mars balloons in the French-Soviet space program. The future.

A structural model decomposition framework for systems health management

NASA Astrophysics Data System (ADS)

Roychoudhury, I.; Daigle, M.; Bregon, A.; Pulido, B.

Systems health management (SHM) is an important set of technologies aimed at increasing system safety and reliability by detecting, isolating, and identifying faults; and predicting when the system reaches end of life (EOL), so that appropriate fault mitigation and recovery actions can be taken. Model-based SHM approaches typically make use of global, monolithic system models for online analysis, which results in a loss of scalability and efficiency for large-scale systems. Improvement in scalability and efficiency can be achieved by decomposing the system model into smaller local submodels and operating on these submodels instead. In this paper, the global system model is analyzed offline and structurally decomposed into local submodels. We define a common model decomposition framework for extracting submodels from the global model. This framework is then used to develop algorithms for solving model decomposition problems for the design of three separate SHM technologies, namely, estimation (which is useful for fault detection and identification), fault isolation, and EOL prediction. We solve these model decomposition problems using a three-tank system as a case study.

A Structural Model Decomposition Framework for Systems Health Management

NASA Technical Reports Server (NTRS)

Roychoudhury, Indranil; Daigle, Matthew J.; Bregon, Anibal; Pulido, Belamino

2013-01-01

Systems health management (SHM) is an important set of technologies aimed at increasing system safety and reliability by detecting, isolating, and identifying faults; and predicting when the system reaches end of life (EOL), so that appropriate fault mitigation and recovery actions can be taken. Model-based SHM approaches typically make use of global, monolithic system models for online analysis, which results in a loss of scalability and efficiency for large-scale systems. Improvement in scalability and efficiency can be achieved by decomposing the system model into smaller local submodels and operating on these submodels instead. In this paper, the global system model is analyzed offline and structurally decomposed into local submodels. We define a common model decomposition framework for extracting submodels from the global model. This framework is then used to develop algorithms for solving model decomposition problems for the design of three separate SHM technologies, namely, estimation (which is useful for fault detection and identification), fault isolation, and EOL prediction. We solve these model decomposition problems using a three-tank system as a case study.

IO-MFA and Thermodynamic Approach for Metal Recycling

NASA Astrophysics Data System (ADS)

Nakajima, Kenichi; Matsubae, Kazuyo; Kondo, Yasushi; Nakamura, Shinichiro; Nagasaka, Tetsuya

Recently, the issue of sustainable resource management has been increasingly recognized. In order to increase resource efficiency, Castro et al. (2004) pointed out an importance to understand the interconnections between the materials' processing routes and their thermodynamic constraints, and discussed losses due to contaminations during recycling. One of the dominant solutions to avoid such losses or contaminants is knowledge about the substance flows in material cycles. Material flow analysis (MFA) is a powerful tool to understand the resource consumption and material cycle in the national economy. Some advanced MFA studies discussed the complex web of metal flows and their linkages (Nakamura et al. 2007, 2008). Discussions on the limitations of impurity removal and the recoverability of elements in the recycling of EoL metal products, however, have been insufficient even in conventional MFA studies.

Quantitative Evaluation of Heavy Duty Machine Tools Remanufacturing Based on Modified Catastrophe Progression Method

NASA Astrophysics Data System (ADS)

shunhe, Li; jianhua, Rao; lin, Gui; weimin, Zhang; degang, Liu

2017-11-01

The result of remanufacturing evaluation is the basis for judging whether the heavy duty machine tool can remanufacture in the EOL stage of the machine tool lifecycle management.The objectivity and accuracy of evaluation is the key to the evaluation method.In this paper, the catastrophe progression method is introduced into the quantitative evaluation of heavy duty machine tools’ remanufacturing,and the results are modified by the comprehensive adjustment method,which makes the evaluation results accord with the standard of human conventional thinking.Using the catastrophe progression method to establish the heavy duty machine tools’ quantitative evaluation model,to evaluate the retired TK6916 type CNC floor milling-boring machine’s remanufacturing.The evaluation process is simple,high quantification,the result is objective.

The status of lightweight photovoltaic space array technology based on amorphous silicon solar cells

NASA Astrophysics Data System (ADS)

Hanak, J. J.; Kaschmitter, J. L.

1991-05-01

An ultralight, flexible photovoltaic (PV) array of amorphous silicon (a-Si) has been identified as a potential low-cost power source for small satellites. We have conducted a survey of the status of the a-Si PV array technology with respect to present and future performance, availability, cost and risks. For existing, experimental array 'blankets' made of commercial cell material, utilizing metal foil substrates, the BOL performance at AM0 and 35 C includes total power up to 200 W, power per area of 64 W/sq m and power per weight of 258 W/kg. Doubling of power per weight occurs when polyimide substrates are used. Estimated EOL power output after 10 years in a nominal low-earth orbit would be 80 percent of BOL, the degradation being due to largely light-induced effects (minus 10 to minus 15 percent) and in part (minus 5 percent) to space radiation. Predictions for the year 1995 for flexible PV arrays, made on the basis of published results for rigid a-Si modules, indicate EOL power output per area and per weight of 105 W/sq m and 400 W/kg, respectively, while predictions for the late 1990s based on existing US national PV program goals indicate EOL values of 157 W/sq m and 600 W/kg. cost estimates by vendors for 200 W ultralight arrays in volume of over 1000 units range from $100/watt to $125/watt. Identified risks include the lack of flexible, space compatible encapsulant, the lack of space qualification effort, recent partial or full acquisitions of US manufacturers of a-Si cells by foreign firms, and the absence of a national commitment for a long-range development program toward developing of this important power source for space. One new US developer has emerged as a future potential supplier of a-Si PV devices on thin, polyimide substrates.

End-of-Life in the railway sector: Analysis of recyclability and recoverability for different vehicle case studies.

PubMed

Delogu, Massimo; Del Pero, Francesco; Berzi, Lorenzo; Pierini, Marco; Bonaffini, Davide

2017-02-01

The railway system represents one of the most resource-efficient answer to our ever-growing demand for transport service and the development trends for the following years forecast a substantial increase in this sector. Considering the European Union, rolling stock realizes a significant share of both goods and passengers carriage while it is responsible for a derisory quota of environmental impact and energy consumption involved by transportation. Contrary to the low environmental impact, the amount of End-of-Life (EoL) waste generated by rolling stocks in relation to the number of vehicles is notable, much greater than in the case of road vehicles. As railway vehicles are constituted by many heterogeneous components, the EoL rolling stock is a precious source of materials, whose recycling brings measurable economic benefits and needs to be appropriately debated. The paper presents calculation of recoverability/recyclability rate for different typologies of vehicles representative of railway transport; calculation is performed on the basis of primary data and according to the recyclability and recoverability calculation method issued by UNIFE in the context of Product Category Rules (PCR). The typologies of railway vehicles taken into account are electric metro, diesel commuter train and high-speed electric train. The analysis envisages also to replicate the calculation in case innovative materials and manufacturing technologies are adopted in the construction of car-body structure. Results show that recyclability/recoverability rates are abundantly over the quota of 90% for each one of the three trains, these latter being made in major part of metals that benefit from very efficient recovery processes. The adoption of innovative materials and manufacturing technologies for car-body structure involves a scarce reduction of recyclability and recoverability rates (about 2% and 0.2% respectively) due to the introduction of components and materials characterized by critical dismantlability and low efficiency recovery processes; recoverability results less affected by lightweighting because post-shredding thermal recovery treatments are roughly independent with respect to dismantlability. A sensitivity analysis based on different dismantling scenarios reveals that the effectiveness of dismantling has a moderate influence on recyclability/recoverability rate (the variation does not exceed 3%). The low variability of recyclability/recoverability rate can be explained by the following reasons: predominance of metals in trains material composition, efficiency of metals separation processes close to 100%, post-shredding recycling processes of metals characterized by recovery factors equal to the ones of post-dismantling recycling processes. Copyright © 2016 Elsevier Ltd. All rights reserved.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Carl Irwin; Rakesh Gupta; Richard Turton

The Mid-Atlantic Recycling Center for End-of-Life Electronics (MARCEE) was set up in 1999 in response to a call from Congressman Alan Mollohan, who had a strong interest in this subject. A consortium was put together which included the Polymer Alliance Zone (PAZ) of West Virginia, West Virginia University (WVU), DN American and Ecolibrium. The consortium developed a set of objectives and task plans, which included both the research issues of setting up facilities to demanufacture End-of-Life Electronics (EoLE), the economics of the demanufacturing process, and the infrastructure development necessary for a sustainable recycling industry to be established in West Virginia.more » This report discusses the work of the MARCEE Project Consortium from November 1999 through March 2005. While the body of the report is distributed in hard-copy form the Appendices are being distributed on CD's.« less

Verification and extension of the MBL technique for photo resist pattern shape measurement

NASA Astrophysics Data System (ADS)

Isawa, Miki; Tanaka, Maki; Kazumi, Hideyuki; Shishido, Chie; Hamamatsu, Akira; Hasegawa, Norio; De Bisschop, Peter; Laidler, David; Leray, Philippe; Cheng, Shaunee

2011-03-01

In order to achieve pattern shape measurement with CD-SEM, the Model Based Library (MBL) technique is in the process of development. In this study, several libraries which consisted by double trapezoid model placed in optimum layout, were used to measure the various layout patterns. In order to verify the accuracy of the MBL photoresist pattern shape measurement, CDAFM measurements were carried out as a reference metrology. Both results were compared to each other, and we confirmed that there is a linear correlation between them. After that, to expand the application field of the MBL technique, it was applied to end-of-line (EOL) shape measurement to show the capability. Finally, we confirmed the possibility that the MBL could be applied to more local area shape measurement like hot-spot analysis.

Optimizing decision making at the end of life of a product

NASA Astrophysics Data System (ADS)

Gonzalez-Torre, Beatriz; Adenso-Diaz, Belarmino

2004-02-01

European environmental legislation has significantly evolved over the last few years, forcing manufacturers to be more environmentally aware and to introduce ecological criteria in their traditional practices. One of the most important goals of this set of regulations is to reduce the amount of solid waste generated per unit of time by promoting recycling, repair, reuse and other recovery strategies at the product end of life (EOL). However, one of the most difficult steps for manufacturers is that of deciding which of these options or which combination of them should be implemented to get the maximum recovery value taking into account the specific characteristics of each product. In this paper, a recurrent algorithm is proposed to determine the optimal end-of-life strategy. On the basis of the product bill of materials and its graphical CAD/CAM representation, the model will determine to what extent the product should be disassembled and what the final end of each disassembled part should be (reuse, recycling or disposal). The paper starts by presenting an overview of the model, to then focus on the CAD-integrated algorithm for determining the optimum disassembly sequence, a necessary step in EOL decision-making.

Optimal Earth's reentry disposal of the Galileo constellation

NASA Astrophysics Data System (ADS)

Armellin, Roberto; San-Juan, Juan F.

2018-02-01

Nowadays there is international consensus that space activities must be managed to minimize debris generation and risk. The paper presents a method for the end-of-life (EoL) disposal of spacecraft in Medium Earth Orbit (MEO). The problem is formulated as a multiobjective optimisation one, which is solved with an evolutionary algorithm. An impulsive manoeuvre is optimised to reenter the spacecraft in Earth's atmosphere within 100 years. Pareto optimal solutions are obtained using the manoeuvre Δv and the time-to-reentry as objective functions to be minimised. To explore at the best the search space a semi-analytical orbit propagator, which can propagate an orbit for 100 years in few seconds, is adopted. An in-depth analysis of the results is carried out to understand the conditions leading to a fast reentry with minimum propellant. For this aim a new way of representing the disposal solutions is introduced. With a single 2D plot we are able to fully describe the time evolution of all the relevant orbital parameters as well as identify the conditions that enables the eccentricity build-up. The EoL disposal of the Galileo constellation is used as test case.

Irradiation campaign in the EOLE critical facility of fiber optic Bragg gratings dedicated to the online temperature measurement in zero power research reactors

DOE Office of Scientific and Technical Information (OSTI.GOV)

Mellier, Frederic; Cheymol, Guy; Destouches, Christophe

2015-07-01

The control of temperature during operation of zero power research reactors participates to the overall control of experimentation conditions and reveals itself of a major importance more especially when measuring small multiplication factor variations. Within the framework of the refurbishment of the MASURCA facility, the development of a new temperature measurement system based on the optical fiber Bragg grating (FBG) technology is under consideration. In a first step, a series of FBGs is irradiated in the EOLE critical facility with the aim to select the most appropriate. Online temperature measurements are performed during a set of irradiations that should allowmore » reaching a fast neutron fluence of some 10{sup 14} n.cm{sup -2}. The results obtained, more especially the Bragg wavelength shifts during the irradiation campaign, are discussed in this paper and compared to data from standard PT100 temperature sensors to highlight possible radiation effects on sensor performances. Work to be conducted during the second step of the project, aiming to a feasibility demonstration using a MASURCA assembly, is also presented. (authors)« less

Life cycle assessment of second generation (2G) and third generation (3G) mobile phone networks.

PubMed

Scharnhorst, Wolfram; Hilty, Lorenz M; Jolliet, Olivier

2006-07-01

The environmental performance of presently operated GSM and UMTS networks was analysed concentrating on the environmental effects of the End-of-Life (EOL) phase using the Life Cycle Assessment (LCA) method. The study was performed based on comprehensive life cycle inventory and life cycle modelling. The environmental effects were quantified using the IMPACT2002+ method. Based on technological forecasts, the environmental effects of forthcoming mobile telephone networks were approximated. The results indicate that a parallel operation of GSM and UMTS networks is environmentally detrimental and the transition phase should be kept as short as possible. The use phase (i.e. the operation) of the radio network components account for a large fraction of the total environmental impact. In particular, there is a need to lower the energy consumption of those network components. Seen in relation to each other, UMTS networks provide an environmentally more efficient mobile communication technology than GSM networks. In assessing the EOL phase, recycling the electronic scrap of mobile phone networks was shown to have clear environmental benefits. Under the present conditions, material recycling could help lower the environmental impact of the production phase by up to 50%.