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The architect of Oregon’s vaccine lottery on using games for social good
The tagline is pretty easy to understand: Get a vaccine, get a chance to win a million bucks.
That was the scheme cooked up by Ashby Monk when Oregon State Treasurer Tobias Reed gave him a call in April.
Monk is the executive and research director at the Stanford Global Projects Center. He’d spent much of his career studying institutional investing before turning his attention to a thornier question: how to motivate people to make smarter long-term personal finance decisions.
On the phone, Reed was looking for creative ways to convince more people to get vaccinated. Oregon’s vaccination rate had been strong for several months, but demand was beginning to taper off as the most vaccine-hungry Oregonians had already scheduled their appointments. The state still had a long way to go to hit its aim of a 70% vaccination rate by July 4, President Joe Biden’s target.
How do you help the vaccine-ambivalent get off the fence and get their shots, quickly?
Monk’s answer was also elegant in its simplicity: make it a game.
Monk said convincing the vaccine-hesitant to sign up for a shot carries a lot of the same challenges he saw when he was researching how to motivate people to begin saving money. In both cases, there are a lot of up-front challenges, and the long-term payoff is hard to visualize.
“Many people are intimidated by personal finance,” he said. “There’s tons of misunderstanding, there’s high cost, you have to put money away.”
With COVID-19, the combination of uncertainty about the vaccine itself, an unwieldy scheduling process and competing obligations for personal time was preventing many individuals from prioritizing their vaccine appointments.
Monk said the one thing that wouldn’t work, though, was telling people what’s best for them.
“There’s a whole world in the personal finance space that’s focused on financial literacy,” Monk said, “which is another way of saying ‘Let’s just try to teach everybody how to behave.’”
Research shows that the approach doesn’t really do much. A 2013 meta-analysis in the journal Management Science found traditional financial literacy programs only result in a 0.1% change in individual financial behaviors.
“You could almost say the takeaway from all these financial literacy programs is they don’t make you worse at personal finance,” Monk said.
Monk found a solution in prize-linked savings accounts. He started a company to motivate people to save money by incentivizing them with the chance to win cash prizes as long as their money stays in the bank. The practice was signed into law by President Barack Obama in 2014, and it has proven to be a success: A recent study from the Kellogg School of Management at Northwestern University found that 110 bank branches with prize-link savings programs saw a 41% increase in new personal savings accounts being opened.
“Look: This is the era of games,” Monk recently told OPB’s Weekend Edition.
With the omnipresent rise of smartphones, more and more of our daily decisions are being gamified. Want to eat better or work out faster? There’s an app for that. We use games to sleep better, to track our steps, even to meet new people: Just look at the swipe-culture of online dating.
Monk said the trick is providing people extrinsic motivation to make better decisions based on the hope of an uncertain but potentially huge payoff.
“People play for the chance to change their lives with luck,” Monk said. “It’s like, ‘If I win, the change is just going to be astounding. And I’m not really feeling the cost.’”
In designing Oregon’s vaccine lottery, he pushed the governor’s team to focus on three priorities. First, there needed to be a variable reward prize.
“It’s a type of game prize where not everybody wins,” he said.
That big million dollar prize would motivate people to opt in, even generating a bit of fear of missing out (yes, he used the term “FOMO”). Why play if there’s no big reward?
Second, there needed to be a chance to feel some proximity to the winner. That’s why he urged a smaller $10,000 prize in each of Oregon’s 36 counties.
“We wanted every community and region to have winners so that maybe somebody you know won,” Monk said, “so you could really visualize yourself winning this thing.”
Finally, it needed to be risk-free for participants. Monk acknowledges this is one of the biggest problems for conventional lotteries. “I can find you losers,” he said. “These are people who often struggle to make the money they’re holding in their hand and sadly, it goes away.”
Initial findings suggest the incentive may be working here in Oregon. Daily vaccinations are up in several rural counties: Marion County is reporting a 2.3% increase, Sherman County is up 2.5%, Gilliam County up 2.1% since before the lottery was announced. These are places where previous trends had anticipated a decreasing vaccination rate.
On Friday, Oregon Gov. Kate Brown announced we’re closer than ever to reaching the 70% vaccination threshold that will allow the state’s economy to reopen, and that we’re even running ahead of schedule. The Oregon Health Authority estimates that we will reach that goal by June 21 at the latest.
But Monk said the biggest change might come once governments wrap their heads around how effective games are as a motivator.
“It’s a carrot,” he said. “For those freedom loving folks out there, there’s something here that’s pretty interesting because there’s no mandate, right? It’s about building an incentive and allowing you to choose.”
One of the major tensions in American life this year has been the friction between well-intentioned government regulation and the bristling of individuals and communities who feel their rights are being trampled. Monk hypothesizes there are countless ways governments could create more systems that incentivize people to opt-in to healthier, more productive behaviors, rather then penalizing them for opting out.
“I’d love to see it applied to education, maybe welfare-to-work or personal health. What if instead of a healthcare mandate there were healthcare prizes?”
Listen to Ashby Monk’s full conversation with OPB Weekend Edition host John Notarianni using the audio player above
Copyright 2021 Oregon Public Broadcasting | <urn:uuid:88070544-5ba4-411f-94a8-0f117ec66cab> | CC-MAIN-2022-33 | https://www.khsu.org/regional-interests/2021-06-05/the-architect-of-oregons-vaccine-lottery-on-using-games-for-social-good | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571056.58/warc/CC-MAIN-20220809155137-20220809185137-00672.warc.gz | en | 0.963598 | 1,449 | 1.828125 | 2 |
Rasmalai is one of the most popular Indian milk based sweets. Soft, juicy, melt in mouth with a heady flavor of saffron and cardamom, what’s not to love :). Ras malai is a Bengali milk sweet that is a super hit with everyone.
Here is how to make soft and juicy rasmalai recipe at home easily with few ridiculously simple ingredients, yup all you need are milk and sugar 🙂 This is a keeper recipe that you can easily make even if you are novice in kitchen.
Of all these sweets rasgulla and rasmalai sweet are my all time favorite. I can easily loose count and keep gobbling these little melt in mouth treat!
It is easy to make rasmalai recipe at home is really easy, a bit time consuming though if you make rasgulla from scratch. However there is an easy shortcut to make this recipe in 15 minutes. Here I am sharing with you both the methods.
When ever I have leftover milk, rasgulla and rasmalai recipe are my go to choices. Here I am sharing my easy keeper recipe that yields best rasmalai every time, enjoy!
So What Is Rasmalai?
Rasmalai or rosh malai or rossomalai is a popular Indian milk sweet from West Bengal. Ras means juice and malai means milk cream. So the literal meaning would be juicy milk cream.
Rasmalai is a classic Indian dessert made for festivals and celebrations. It is made of full cream milk, an acidic ingredient like lemon juice, vinegar or yogurt to curdle the milk, cardamom, saffron and some nuts to garnish.
To make rasmalaai you need very basic and minimum ingredients . All you need are
- whole milk
- acidic agent to curdle the milk like lemon juice, yogurt or citric acid
- few saffron strands, cardamom
- chopped nuts for garnish
Can’t you tell this sweet is rich and royal already by one look at the ingredients?
As I have mentioned above, making rasmalai is easy but a bit tricky to make it super soft, melt in mouth and juicy. It all starts with making perfect rasgulla. If that is tackled, half the work is done 🙂
In this post I am sharing all the tips and tricks I have learnt over the years along with this dessert easy rasmalai recipe that has been perfected with many trials. This is an absolute favorite with my husband and daughter 🙂
I assure you if you follow these steps with a bit of patience you can easily recreate halwai or mithai shop style rasmalai at home easily.
Can’t you tell how soft and juicy these are by looking at these ras malai pics 🙂
This sweet tastes excellent when served super cold. I usually make this and refrigerate overnight for next days dessert after lunch.
This Rasmalai Recipe Is
Soft, juicy melt in mouth- seriously the best
All tips, tricks and trouble shooting covered
broke down in easy steps, simple to follow
Rich and creamy
flavored with saffron and cardamom
a sweet that is truly royal
Before we begin with this Indian dessert rasmalai recipe recipe set aside plenty of time and be prepared for some good stirring and kneading.
While the steps are fairly simple like boiling, reducing the milk etc, you need to take some time with all the steps to make rasmalai that is perfectly spongy and melt in mouth.
Also use heavy bottomed deep pan big enough for boiling rasgulla as well as making ras malai. I use big pressure cooked base for both steps.
Now you are armed up with initial tips, let us take a detailed look on ingredients for rasmalai.
Ingredients For Ras Malai
Milk– whole cream and we shall not have it any other way :).
If you want to make best full bodied rasmali that does not fall flat while boiling or tastes super rich and creamy use full fat or whole cream cow’s milk or buffalo milk. Also if possible source non homogenized non pasteurized milk for best texture and taste.
Again for making reduced flavored milk or rabdi for rasmalai recipe, we need full fat milk. Here in this step you can also add some condensed milk for richer and creamier taste. I always use whole cow’s milk to make rasmalai recipe.
You can use lemon juice or curd or vinegar to curdle the milk. I prefer to use curd as it yields more soft chenna. Also if using lemon juice you need to rinse the strained milk solids with cold water to remove sour after taste. You can also use a pinch of citric acid.
Sugar- Use granulated white sugar or raw organic sugar. If you use organic sugar, the color of rasgulla and rasmalai will be a bit darker.
cardamom, saffron strands and nuts- for flavor and garnishing. You can use cardamom powder or crushed cardamom pods. I like to use slivered almonds and pistachios for garnishing this dessert.
Making rasmalai at home can be divided into three steps.
- make the chenna or milk solid balls. These are also called as paneer balls or cottage cheese balls.
- make the ras (reduced sweetened milk) and simmer the balls in it.
- third step would be refrigerating it for at least 6 hours before serving.
How To Make Rasmalai Recipe
Since this is long process and takes quite some time, I take two days to make this Indian dessert. I usually prepare the rasgulla a day before and make ras malai next day.
Making chenna or milk solids – Preparation For Rasmalai
Heat milk in a pan. Bring the whole milk to a boil in a wide pan.
As it starts to boil, lower the flame and add lemon juice. mix well and keep stirring until the milk curdles completely. Once the milk curdles completely and all whey is separated, remove from flame.
Next to separate all the whey from chenna, line a colander with two layers of cheesecloth or cotton cloth. Pour the curdled milk into the prepared colander. Set aside for 5 minutes.
Now bring the edges of the cloth together rinse under cold water several times. This step will remove any sour taste from lemon juice.
Now hang this over a hook or tap as seen in the photo for around 30-45 minutes.
once all the whey is drained collect the milk solid from the cloth.
step 2- Shaping chenna balls and boiling in sugar syrup
Now we will knead the prepared chenna and make it soft and smooth.
Take the chenna mass in a wide plate and start kneading. Knead for around 5-6 minutes by stretching and bringing it back. Knead until it starts to release a bit of fat. but do not over knead as it will result in chewy rasmalai balls.
Now make around 20 small balls from the kneaded chenna and set aside.
In the meanwhile combine 1 3/4 cup sugar and 4 cups water in a big pan.
Cook until the sugar is completely dissolved and the syrup starts to boil. At this stage add 1 tsp cardamom powder and rose water. Mix well. Now slide the prepared rasmalai balls to the boiling sugar syrup and cover the pan.
Cook for around 12-14 minutes or until the chenna balls soak up sugar syrup and doubles in size.
Remove from sugar syrup gently and let cool thoroughly.
You can make these rasgullas a day ahead and refrigerate and continue making ras malai the other day.
Making Sweetened Milk Or Ras
The final step of this soft rasmalai recipe is to make sweetened reduced milk or ras.
Soak a bog pinch of saffron in1/4 cup warm milk for 15 minutes.
Bring 2 cups full fat milk to a boil. You can also use 1 cup milk and 1 cup condensed milk. In that case avoid sugar.
While the milk is boiling add the saffron milk to it and mix well. Now add sugar and mix.
Once done maintain medium flame and cook till the milk condneses and reaches 1/3 of its quantity. Make sure to scrape the malai or cream that sediments in the walls of the vessel. Malai is what makes the ras or sweetened milk super creamy and results in creamiest ras malai.
Now add the chilled ramalai balls we prepared earlier and simmer for 2 minutes. Do note that the milk should be reduced but not super thick. The paneer balls will be able to absorb the milk only if it is a bit thin.
Remove from flame and cool thoroughly. Once it reaches room temperature, refrigerate for at least three hours before serving ras malai. Serve chilled rasmalai along with ras, garnished with slivered nuts.
Easy Rasmalai Recipe In 10 Minutes
This is a super quick and easy recipe of making soft rasmalai in 10 mins with store bought rasgullas.
First of all prepare rasgullas as mentioned here. You can also use store bought rasgullas.
Gently squeeze the rasgullas to remove excess sugar syrup and set aside. If there is more syrup, then the rasgullas will not absorb the rabdi.
Now take 1 cup milk in a thick pan and add a 400 grams of condensed milk to it. Now add the other 1/2 cup milk. Mix well and bring to a boil. Simmer for 10 minutes until the rabri thickens. Add crushed saffron and cardamom powder. Mix well. You can also make this saffron milk and add condensed milk to it.
Next add the squeezed rasgullas gently to the thickened milk and close the pan. Simmer for 2 minutes.
Let the rasgullas come to room temperature and then refrigerate at least for 2 hours before serving. While serving serve ras malai along with rabri, topped with nuts.
Serve rasmalai chilled with sliced nuts.
Tips To Make Soft Rasmalai
To make rasmalai recipe that melts in mouth and soft , making super soft chenna is the key. The milk solids you get by straining the curdled milk is called chenna. This is also the base for making paneer or cottage cheese.
- Now as the chenna balls are nothing but milk solids, do use full fat whole milk for soft chenna.
- Try to use non homogenized milk that is milk locally sourced without additives or pasteurization. This milk contains more fat and yields really best rasmalai. My mom always uses non homogenized milk to make this recipe.
- You can also use packed milk but use only whole milk.
- As soon the milk comes to a boil, switch off the flame and add lemon juice.
- After adding lemon juice, mix gently and wait for few minutes for whey to separate fully.
- Then strain the milk solids from whey using a muslin cloth placed over a strainer.
- Rest for 30 minutes and there you have perfect chenna for ras malai sweet.
Next stage in our recipe is kneading chenna. Once you have drained the whey from milk solids for around 30 minutes, knead the milk solids well for 5-6 minutes.
I don’t prefer to add milk powder or corn starch or maida with chenna, that is what they do in shops and we don’t have to in homemade rasmalai. Just stretch and knead the chenna for 5-6 minutes but not more than that. As you knead some fat will release from chenna and that’s when you stop.
After kneading make small balls and they will be boiled in sugar syrup. I don’t prefer to make flat discs from chenna as mentioned in few recipes. I just make small balls like traditional rasgulla as they swell up and doubled in size.
If you make flat discs sometimes they turn hard and rubbery unlike chenna balls.
Making ras or reduced milk-
use a heavy bottomed pan like pressure cooker base or non stick pan.
- you can cook this reduced milk in high flame itself but keep stirring and keep a watch to avoid burning.
- You can reduce sugar but rasmalai tastes best when it is made on the sweeter side.
- Before soaking chenna balls in this sweet milk, squeeze out as much syrup as possible.
- Make very sure the sweetened chenna balls is cold while adding to the sweet milk.
Frequently Asked Questions
If the chenna balls break while boiling in sugar syrup, chances are
1. the whey was not separated completely from the milk solids
2. you did not roll the balls very smooth. If there are cracks in shaped balls, water will get inside and they will dissolve in sugar syrup.
If you knead the chenna balls for a long time than required, the balls will be dense and hard on cooking in sugar syrup. Knead the chenna for not more than 6 minutes. Also do not exert too much pressure while kneading the chenna.
This is an important tip as over kneaded chenna will result in rubbery discs instead of soft melt in mouth ones.
Usually it takes anywhere around 30-45 minutes for the whey to drain from milk solids or chenna completely. After that time the chenna will be crumbly, grainly and has very less moisture.
If is very sticky like a dough, you need to let it sit for few more minutes.
If you knead the chenna more than required or boil them for long time in sugar syrup will result in hard rasgulla. On the other hand if you simmer the discs in sweetened milk for long time, the ras malai will turn hard on refrigerating.
It tastes best thoroughly chilled as dessert. It tastes best thoroughly chilled as dessert, generously topped with sweetened thickened milk.
I would not recommend using store bought paneer for this recipe.
More Indian Sweets
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Soft Rasmalai Recipe
1 CUP = 250 ml
For Making chenna and sugar syrup
- 4 cups Milk full fat
- 3 tablespoons lemon juice or yogurt
- 1 3/4 cups sugar
- 3-4 green cardamoms pounded
- 2 teaspoons pure rose water
For making ras for rasmalai
- 2.5 cups Milk
- 1/2 cup sugar
- few saffron strands
- 1/2 teaspoon pounded cardamom peel and crush 4-5 green cardamoms
- 1/4 cup pistachios and amonds mixed and slivered
Making chenna or milk solids
- Bring measured whole milk or full cream milk to a boil in a wide pan.
- As it starts to boil, lower the flame and add lemon juice. mix well and keep stirring until the milk completely curdles. Once the milk is curdles and all when is separated remove from flame.
- Next to separate all the whey from milk solids, line a colander with two layers of cheese cloth or cotton cloth. Pour the curdles milk into the prepared colander. Set aside for 5 minutes
- Now bring the edges of the cloth together rinse under cold water several times. This step will remove any sour taste from lemon juice.
- once all the whey is drained collect the milk solid from the cloth.
Preparing ras malai balls and boiling in sugar syrup
- Now we will knead the prepared chenna and make it soft and smooth
- Take the chenna mass in a wide plate and start kneading. Knead for around 5-6 minutes by stretching and bringing it back. Knead until it starts to release a bit of fat. but do not over knead as it will result in chewy rasmalai balls.
- Now make around 20 small balls from the kneaded chenna and set aside.
- In the meanwhile combine 1 3/4 cup sugar and 4 cups water in a big pan. Cook until the sugar is completely dissolved and the sugar syrup starts to boil. At this stage add cardamom powder and rose water. Mix well.
- Now slide the prepared ras malai balls and cover the pan.
- Cook for around 12-14 minutes or until the chenna balls soak up sugar syrup and doubles in size.
- Remove from sugar syrup gently and let cool thoroughly. You can make these rasgullas a day ahead and refrigerate and continue making ras malai next day.
How to make rasmalai
- Soak A big pinch of saffron in 1/4 warm milk for 15 minutes
- Bring 2 cups full fat milk to a boil.
- While the milk is boiling add the saffron milk to it and mix well.
- Now add sugar and mix.
- Once done maintain medium flame and cook till the milk is condensed to half quantity. Make sure to scrap the malai or cream that sediments in the walls of the vessel. Now add the chilled ramalai balls we prepared earlier and simmer for 2 minutes.
- Remove from flame and cool thoroughly.
- Once it reaches room temperature, refrigerate for at least three hours before serving rasmalai. Serve chilled ras malai along with ras, garnished with slivered nuts.
- You can double the recipe | <urn:uuid:df8fe271-7952-4132-ae55-9b113d4ad6d0> | CC-MAIN-2022-33 | https://www.cookclickndevour.com/rasmalai-recipe/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571222.74/warc/CC-MAIN-20220810222056-20220811012056-00672.warc.gz | en | 0.916696 | 3,903 | 1.648438 | 2 |
Domenico Vitale owns and runs an advertising and film production company in DUMBO, Brooklyn called PI&C and wants to expand, but those plans are on hold because of the partial federal government shutdown.
Vitale says he was days away from closing on a refinancing loan backed by the federal government's Small Business Administration when the government shutdown, "The SBA closed before the actual loan closed. It's put us in a situation. We've been waiting for a month. Of course, we have put a lot of plans in place in terms of cash flow so you know it start to hurt, he said."
The plans on hold are to hire at least three more people and buy new equipment, which Vitale says could have potentially pulled in hundreds of thousands of dollars in new business. He says he feels helpless, "it's not allowing us to put in place a lot of the investments we had planned."
"Everything is stuck up right now," said Rohit Arora, the owner of Biz2Credit in midtown Manhattan. Biz2Credit works to get small and medium size businesses access to financing. Arora says he has at least 50 clients around the country with applications stalled in the Small Business Administration, often with loan values of more than a million dollars each.
Arora explains, "Typically the SBA every year guarantees loans worth almost $35 to $40 billion. So right now it's almost $100 million a week of money that is not flowing to main street businesses in the U.S."
He thinks that even if the shutdown ended this week, the SBA will still face at least a two month backlog of loan applications, leaving loan delays that grow each day the government is shutdown.
Vitale says he's been in business for 10 years and has 50 employees at several locations. He says his employment numbers will have to stay the same, at least for now, and that means lost jobs and tax revenue for government. He's worried though, the full impact on his business might not be known until the end of the year.
He explains, ''Instead of having a year with 12 months, we have a year with 11 months of potential investments and growth that we could have achieved just doing the normal course of business." | <urn:uuid:64d2e2f5-7242-4bd9-95e9-fbc12520db50> | CC-MAIN-2022-33 | https://www.ny1.com/nyc/all-boroughs/news/2019/01/17/how-the-partial-government-shutdown-is-slowing-down-small-businesses | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.982751 | 466 | 1.5 | 2 |
Miracle Aussie baby beats rare condition in world first
A "miracle" Australian baby has become the first person cured of a rare and deadly brain-melting condition after doctors gambled on an experimental drug tested only on mice, they said Thursday.
The child, known only as "Baby Z", was facing a painful death of seizures and brain damage from molybdenum cofactor deficiency, a genetic defect which causes a build-up of toxic sulphite and usually kills in months.
But she made an amazing recovery just three days after first being given the untested treatment which was flown in from Germany and rushed through the courts.
"We are looking at her now and she is just an absolute miracle -- she has defied everybody," her mother, who cannot be named for legal reasons, told reporters.
Baby Z started having seizures within 60 hours of her birth in May 2008, prompting her family to appeal to biochemist Rob Gianello to help beat the previously incurable condition which affects just one in a million Australians.
"There was courage and there was death -- we opted for courage," the mother said. "If she wasn't treated she would die a very painful death."
Baby Z's doctor Alex Veldman said Gianello discovered an experimental drug which had been successfully used on mice by Germany's Gunther Schwarz, but had never been tested on humans.
As Schwarz couriered his entire stock of the compound from Cologne to Melbourne, doctors were in a race against time to get ethics approval from the hospital and a court order clearing its use, with Baby Z worsening by the hour.
"The team ... managed to get this therapy from bench to bedside in about two weeks, a process which normally takes several years," Veldman said.
Within hours of receiving her first dose of the drug, cyclic pyranopterin monophosphate (cPMP), Baby Z's sulphite levels plunged by more than two-thirds and were at normal levels within about three days.
Veldman said Baby Z's alertness improved and her twitching slowed rapidly, with her seizures dropping by 90 percent in three weeks.
"The response was just amazing," he told AFP.
"We can treat this in humans for the first time in (the history of) mankind. It has the potential to save lives all around the world."
Baby Z's development has been slowed by the brain damage she suffered before the treatment, and Veldman said she would need a cPMP injection every day for the rest of her life.
But her mother said the baby, now 18 months old, had started speaking and was physically active.
"Every day just gets better and better. We look at her every day and just think, 'Wow'," she said. "(The procedure) was a tiny bit of hope but, when you have nothing, that is a lot of hope."
Veldman said a second child, "Baby P", had since started cPMP treatment in Germany and was "improving rapidly".
The cases were now being analysed ahead of a planned international human trial of the medication at Melbourne's Monash Medical Centre, he said.
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Sovetskaya str., 50
The two-storey building has an asymmetrical facade, the plastic of which is built on the division of blades and pilasters vertically and belts and cornices horizontally. The plinth of the facade is decorated with niches that match the rhythm of the window openings. The plinth is separated from the first floor by a semicircular rod. The rhythm of the first floor of the main facade is formed by niches separated by rusticated shoulder blades. The niches contain arched windows decorated with profiled archivolts with a keystone.
On the right side of the facade, the blades are wider, between them there are double window openings. A narrow draft serves as the visual boundary between the floors. The rhythm of the second floor of the main façade is set by Doric pilasters, which also outline shallow niches. The niches contain rectangular windows with molded lintels and window sills. On the right side of the facade there is a balcony with double window openings, flanked by two pairs of pilasters. At the level of the roof, they end with a rectangular attic on which a triangular stucco pediment is placed. The entire building is surrounded by a profiled cornice under the roof. Sovetskaya Street (formerly Rumyantsevskaya) is one of the main thoroughfares of Gomel. It was formed in the second half of the 20th - early 20th centuries, when it became the main street of the city.
Apart from the owners' apartments, 2-3-storey apartment buildings belonging to private individuals housed trade and economic enterprises on the ground floor, and the premises of the remaining floors were rented out as apartments. This function could be performed by the house number 50 on the street. Soviet, erected at the beginning of the twentieth century. After the establishment of Soviet power in the city, many houses were nationalized. House number 50 in the 1920s-1940s. belonged to the "Engine of the Revolution" plant, the shops of which were located on the present Knizhnaya street. During the Great Patriotic War until 1942, an underground group of workers operated in the house under the leadership of the Hero of the SSR T.S. Borodin and R. I. Timofeenko, which is immortalized with a memorial plaque on the building. As evidenced by a photograph of the 1940s from the funds of the museum of the Gomel Palace and Park Ensemble, the building received minor damage and was restored in 1948. After restoration, it housed a police stronghold (until 2009), a radio class, a schoolchild's room, a DOSAAF center, and a city special medical examination. Since the 1990s. the building housed the administration of the Gomel regional employment service. Today the state institution "Gomel City Orchestras" is located here.
50, Sovetskaya Street. Photo of 1948. From the funds of the State Artistic Cultural Establishment “The Museum “Gomel Palace and Park Ensemble”.
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(click/touch triangles for details)
- he scarcely tried to refute his evidenceBook 12 — A Judicial Error (14% in)
refute = argue against
- The lawyers and experts were lost in admiration, and were only at a loss to understand what good purpose could be served by it, for all, I repeat, felt that the case for the prosecution could not be refuted, but was growing more and more tragically overwhelming.Book 12 — A Judicial Error (15% in)
- His speech might be divided into two parts, the first consisting of criticism in refutation of the charge, sometimes malicious and sarcastic.Book 12 — A Judicial Error (70% in)
There are no more uses of "refute" in The Brothers Karamazov.
Typical Usage (best examples) | <urn:uuid:f82e5bd2-d05f-4fb5-9b86-0bfe7dbd7884> | CC-MAIN-2022-33 | https://www.verbalworkout.com/u/u110/u416803.htm | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.971591 | 170 | 2.625 | 3 |
Does Heartburn During Pregnancy Mean My Baby Will Be Born With Hair
Suffering from severe heartburn? You may want to stock up on baby shampoo. Research has backed up the superstition that, on average, the more heartburn you have during pregnancy, the more likely your baby will be born with a full head of hair.
From the What to Expect editorial team and Heidi Murkoff, author of What to Expect When You’re Expecting. What to Expect follows strict reporting guidelines and uses only credible sources, such as peer-reviewed studies, academic research institutions and highly respected health organizations. Learn how we keep our content accurate and up-to-date by reading our medical review and editorial policy.
Can Gerd Cause Asthma
We dont know the exact relationship between GERD and asthma. More than 75% of people with asthma have GERD. They are twice as likely to have GERD as people without asthma. GERD may make asthma symptoms worse, and asthma drugs may make GERD worse. But treating GERD often helps to relieve asthma symptoms.
The symptoms of GERD can injure the lining of the throat, airways and lungs, making breathing difficult and causing a persistent cough, which may suggest a link. Doctors mostly look at GERD as a cause of asthma if:
- Asthma begins in adulthood.
- Asthma symptoms get worse after a meal, exercise, at night and after lying down.
- Asthma doesnt get better with standard asthma treatments.
If you have asthma and GERD, your healthcare provider can help you find the best ways to handles both conditions the right medications and treatments that wont aggravate symptoms of either disease.
Dangers Of Frequent Heartburn
Heartburn occurs when stomach juices backflow up into the esophagusthe food pipe to your stomach. Most people experience heartburn some time in their life others experience regularly. If you’re having frequent heartburn, talk to your doctor. Heartburn can cause serious problems and it may be a symptom of a more serious condition called gastrointestinal reflux disease also known as acid reflux. Here are several reasons not to ignore your heartburn.
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If Your Heartburn Lasts Longer Than Two Weeks
Occasional heartburn may not require a visit to the doctor, but if you have heartburn that occurs several times a week, for more than two weeks, then its time to go to the doctor. For most people, the symptom can be controlled with either over-the-counter or prescription medications. However, in rare instances, that constant heartburn can indicate a far more serious condition. Because heartburn damages the esophagus tissue, you may be at risk for a precancerous condition known as Barretts esophagus. That, in turn, puts a person at risk for esophageal cancer, which is the fastest-growing in the United States . To determine the extent of esophageal damage, a doctor will perform an endoscopy, in which a tube is slid down the throat to the esophagus. In some cases, surgery to reinforce the esophageal sphincter may be recommended, so if you suffer from heartburn very frequently, consult your doctor.
Indigestion And Heartburn In Pregnancy
Many women experience indigestion and heartburn while they are pregnant, which can be painful or uncomfortable. There are ways to help avoid or treat indigestion and heartburn, especially if it is mild. Sometimes the feeling of heartburn can be confused with a more serious condition called pre-eclampsia.
Indigestion, also called ‘dyspepsia’, is a feeling of pain or discomfort in the stomach . This mostly occurs after eating or drinking but can happen some time after.
If you have indigestion in the early stage of your pregnancy, this may be caused by changes in your hormone levels. In the second or third trimester, indigestion becomes more common and may be caused by your baby pushing up against your stomach. As many as 8 in 10 women may have indigestion during their pregnancy.
Symptoms of indigestion may include:
- reflux or regurgitation
- feeling heavy, bloated or full
- feeling sick
Heartburn is a burning pain in the throat or chest, behind the breastbone, caused by stomach acid coming up the oesophagus and irritating the lining.
In pregnant women, indigestion and heartburn can be caused by:
- eating a big meal
- drinking fruit juice or caffeinated beverages
- doing physical activity soon after eating
- bending over
- feeling anxious
It’s a good idea to take note of the particular foods, drinks or activities that give you indigestion while you are pregnant.
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What Kinds Of Complications Are Caused By Frequent Heartburn
- Excess stomach acid in the esophagus can cause ulcers, damage to the inner layers of the esophageal wall, and narrowing .
- Very rarely, the esophagus may bleed or tear completely because it is so damaged. In severe cases, a person may vomit blood or have small amounts of blood in bowel movements, found only on testing the stool.
- Regurgitated stomach acid can damage the respiratory tract, causing asthma, hoarseness, chronic cough, sore throat, or tooth damage . A person may feel as if he or she has a lump in the throat.
- If the acid exposure continues for long periods of time, the esophagus becomes thick and damaged. A person may then have difficulty swallowing and food becomes stuck.
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What Are My Options If These Treatments Don’t Work
If a person continues to have heartburn, a health care professional may recommend adding a drug such as metoclopramide . This drug empties food and acid quickly from the stomach so less can back up into the esophagus. Reglan also helps tighten the lower esophageal sphincter.
If a person still have symptoms, a health care professional will then recommend one of the drugs called proton pump inhibitors. Examples of these drugs are omeprazole , lansoprazole , esomeprazole , rabeprazole , and pantoprazole . These tablets prevent the stomach from secreting acid. They are very effective and are typically taken only once a day. These drugs usually are prescribed if other drugs have not helped. They may have to be used indefinitely.
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What Lifestyle Changes Relieve Heartburn
There are several ways to treat and avoid heartburn with lifestyle changes .
Lose weight and maintain your ideal weight. Excess weight increases the pressure on the stomach, increasing the chance of acid reflux into the esophagus.
Avoid foods that aggravate heartburn and replace them with healthy foods. Avoid foods that trigger heartburn . Consider keeping a food journal to alert you to foods that make your heartburn worse. Decrease the amount of food you eat.
Elevate the head of the bed: If you are experiencing heartburn at night, elevating the head of the bed will decrease reflux.
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Check If You Have Acid Reflux
The main symptoms of acid reflux are:
- heartburn a burning sensation in the middle of your chest
- an unpleasant sour taste in your mouth, caused by stomach acid
You may also have:
- a cough or hiccups that keep coming back
- a hoarse voice
Your symptoms will probably be worse after eating, when lying down and when bending over.
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How Is Heartburn Treated
In most cases, heartburn can be treated at home with over-the-counter medications and changes to lifestyle habits that cause the feeling. Occasional heartburn is common and is typically not serious. However, if you have frequent and severe heartburn, reach out to your healthcare provider. This could be a sign of a chronic condition like GERD. GERD can lead to other serious conditions like esophagitis, Barretts esophagus and even cancer. Sometimes, your doctor may want to do an endoscopy to check for underlying medication conditions. An endoscopy is the examination of your digestive tract with a lighted flexible instrument.
Over-the-counter medications for heartburn typically include antacids and acid blockers.
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What Can Trigger Heartburn
Heartburn can be triggered by many different things that are a part of your daily life. For many people, heartburn can be caused by certain eating and lifestyle habits. These habits can involve things like eating large portions of food, eating too close to bedtime or even having high stress levels.
Certain foods and drinks can also trigger heartburn for some people. Some foods and drinks that could trigger your heartburn can include:
- Caffeinated beverages.
- Carbonated beverages.
Your lifestyle habits can also play a part in why you might experience heartburn. These everyday factors often contribute to medical conditions that cause heartburn, like GERD or hiatal hernia. Some lifestyle habits that can trigger your heartburn include:
- Being overweight.
- Having a high stress level.
- Wearing tight clothes and belts.
Read Also: Is Heartburn A Sign Of Heart Disease
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How Is Heartburn Diagnosed
In most cases, your doctor will be able to diagnose heartburn by asking questions about your symptoms and what triggers those symptoms.
If you have heartburn more than 2 times a week, it could be a symptom of gastro-oesophageal reflux disease or other gastrointestinal diseases. These are usually diagnosed by endoscopy, which uses a tube with a camera passed through the mouth into the stomach.
How Do I Know Im Having Heartburn And Not A Heart Attack
Chest pain caused by heartburn may make you afraid youre having a heart attack. Heartburn has nothing to do with your heart, but since the discomfort is in your chest it may be hard to know the difference while its going on. But symptoms of a heart attack are different than heartburn.
Heartburn is that uncomfortable burning feeling or pain in your chest that can move up to your neck and throat. A heart attack can cause pain in the arms, neck and jaw, shortness of breath, sweating, nausea, dizziness, extreme fatigue and anxiety, among other symptoms.
If your heartburn medication doesnt help and your chest pain is accompanied by these symptoms, call for medical attention right away.
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What Does It Mean When You Have Heartburn
The term heartburn can be misleading at times as it has nothing to do with the heart, even though it contains the word heart. The symptoms of heartburn may appear to be like the symptoms of heart diseases. It is also referred as acid indigestion. Chronic or regular long lasting heartburn takes the form of gastro esophageal reflux disease .
Childhood Heartburn A Warning Sign For Your Childs Future Health
It goes without saying that no one wants their child to have heartburn. But I believe the most important aspect of this problem is that a child with heartburn is a child that is progressing towards more serious illnesses in early adulthood.
High blood pressure, diabetes, heart disease, polycystic ovarian disease, gout, obesity, sleep apnea and all triggered by excessive carbohydrates consumption. These are all illnesses associated with insulin resistance a disorder known to be triggered by excess carbohydrate consumption. Coincidentally, these conditions are becoming increasingly more common in young adults.
Your childs lifelong eating habits and taste preferences are formed when they are young. If your child has heartburn, they are on the fast track to develop these other illnesses as well.
It is imperative you change their eating habits by controlling the foods that come into the house, their choices when eating out and the foods they eat at school. You must take charge because no one else is looking out for them.
Its not too late to change their future. Start today by pledging not to bring any more soda, juices, chips, cookies, fruit rollups, donuts or ice cream into the house. These should be foods that are eaten only infrequently. Save them for the rare celebration.
Your kids dont NEED these foods. Sure they will gripe and complain. But in time, they will adapt and in the process, you will literally save their life in adulthood.
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When Gerd Progresses To Esophageal Cancer
GERD develops when acid that digests food in the stomach washes up into the esophagus. Often it occurs in people who overeat or who lie down too soon after eating. It may also be caused by defects in the valve that connects the esophagus to the stomach or by a condition called hiatal hernia, which is when the upper part of the stomach pushes up through the diaphragm and into the chest.
After someone has had GERD for many years, it can advance to a condition called Barretts esophagus. Barretts is a defensive mechanism of your esophagus, Dr. Molena explains. When the esophagus is bathed in acid all the time, it wants to protect itself, and so the cells in the lining begin to change. These changes can advance to become cancer.
When patients develop Barretts esophagus, their GERD symptoms often disappear. Its typical for patients with esophageal cancer to tell me that they suffered from GERD for years, but then it went away and they stopped taking their GERD medications, which would have actually reduced their cancer risk, Dr. Molena says.
Not everyone with GERD has the typical symptoms, which are heartburn and regurgitation soon after eating. Up to 20% may have different symptoms, such as coughing or chest pain, a sore throat or hoarse voice, or even frequent sinus infections. Its important to talk to your doctor about any of these.
Heartburn Or Heart Attack
Symptoms of severe heartburn and those of a heart attack can often overlap, but you can usually tell you have heartburn if you experience a burning sensation in your upper abdomen and chest, accompanied by a sour taste in your mouth. The most common and similar symptom of heartburn and a heart attack is the chest pain or discomfort. Other symptoms that may be a more likely indication of heart attack are listed below:
- Cold sweat
- Sudden lightheadedness
- Pressure or pain in your chest, arms, neck, jaw or back
With heartburn, you may feel like food is coming up into your mouth. Its a different sensation than vomiting, but severe heartburn can also cause you to vomit. If youre not sure if youre experiencing heartburn or a heart attack, seek immediate medical care.
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If I Have Heartburn Should I See My Health Care Professional
That depends. If a person has heartburn more than three times a week for at least two weeks, he or she should see a health care professional. On the other hand, if a person only has occasional bouts of heartburn, he or she may find that taking nonprescription antacids and making some simple changes in lifestyle can resolve the heartburn. If these measures do not help, then a visit to a health care professional is warranted.
If a person has any of these symptoms, with or without heartburn, call a doctor or go to a hospital emergency department right away:
- Throwing up blood or passing blood in bowel movements
- Severe pain, dizziness, or lightheadedness
- Difficulty swallowing
With proper understanding of the condition and treatment, relief can be attained.
When I have chest pain, how can I tell whether it is my heart or just heartburn?
Sometimes a person can’t tell the difference. Just like chest pain from the heart, heartburn sometimes spreads from the chest to the jaw, shoulders, arms, or back. If a person has chest pain for any reason, seek medical care immediately.
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Cdhf Talks: Gerd And Barretts Esophagus
Gastroesophageal reflux disease is the result of a disordered valve mechanism between the esophagus and the stomach. The valve, or lower esophageal sphincter , opens during swallowing to allow food to enter the stomach and then closes to prevent food and stomach secretions from moving backward into the esophagus. When the LES fails to close correctly, the stomach contentswhich are acidic and contain digestive secretionscan flow back into the esophagus. This reverse flow of food, acids and the digestive enzyme pepsin, can cause damage to the esophageal lining and resulting heartburn. When diagnosis and treatment are delayed, chronic GERD can increase the risk for serious health complications, including Barretts esophagus and esophageal cancer. Barretts esophagus describes a condition where the cells lining the lower esophagus change. The esophagus is the swallowing tube that carries food from the mouth to the stomach.
In this series of videos, Dr. Jeff Mosko and Dr. Gail Darling go over all things GERD, its relationship to Barretts esophagus, the benefits of getting screened early, what are some of the treatment options, and advocating for your own health! Watch the full version or skip to each section to find the answers you are looking for.
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What Causes Acid Reflux
Acid reflux is caused by weakness or relaxation of the lower esophageal sphincter . Normally this valve closes tightly after food enters your stomach. If it relaxes when it shouldnt, your stomach contents rise back up into the esophagus.
Stomach acids flow back up into the esophagus, causing reflux.
Factors that can lead to this include:
- Too much pressure on the abdomen. Some pregnant women experience heartburn almost daily because of this increased pressure.
- Particular types of food and eating habits.
- Medications that include medicines for asthma, high blood pressure and allergies as well as painkillers, sedatives and anti-depressants.
- A hiatal hernia. The upper part of the stomach bulges into the diaphragm, getting in the way of normal intake of food. | <urn:uuid:33845bb6-83f1-4eb8-b02f-68e44f295428> | CC-MAIN-2022-33 | https://www.heartburntalk.net/what-does-having-constant-heartburn-mean/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882570793.14/warc/CC-MAIN-20220808092125-20220808122125-00672.warc.gz | en | 0.928537 | 3,997 | 2.6875 | 3 |
The knowledge of CPR (cardiopulmonary resuscitation) and AED (automated external defibrillator) can add to survival rate of a cardiac arrest patient. Performing these skills in emergency conditions will certainly give every bystander the power to confidently rescue the cardiac arrest sufferer even after getting collapsed on the spot. There are many First Aid Certification courses offered online including CPR & AED training to impart life saving skills to people and make them react fast whenever required.
The success in acquiring these essential life-saving skills depends on selection of the best courses and skipping the various online courses that are frauds or don’t include the right techniques and training materials to let you walk away with a professional CPR certification and make yourself prepared for emergency situations. This write up will give you necessary clues on how to weigh CPR and First Aid Certification providers and which factors you should consider before joining for their training courses. In this way, you can pick up the course that best suits your certification needs. So, follow the details we are sharing with you regarding First Aid Certification including CPR/AED training classes and use the recommended tips to find the best CPR certification program for your learning.
What is CPR & AED Certification?
CPR certification is about learning a life saving technique that is used to manually induce heart pumping and aid in circulation of blood carrying oxygen to the body organs which has stopped due to a cardiac arrest. When there is no heart beat, the pumping of blood to the major organs in body, including the liver, kidneys and brain stops automatically. These organs get starved of oxygen and give rise to risk of severe damage to brain cells, causing ultimate death of victim within 10 minutes of attack. The faster a bystander reacts to the situation and performs CPR correctly; the more likely is the survival of the victim. CPR can’t alone initiate the beat of heart which stops immediately after a cardiac arrest. It is the combined use of AED device and CPR that would help the heart start beat and pump blood again. AED certification will teach you about different steps of using the device on the victim and make him breath normal.
The most important thing is the course duration is not stretched. The average participant takes 1-3 hours to complete a course which is easy to attend and learn.
How to Recognize the Best CPR & First Aid Certification Provider?
The resolution to become CPR & First Aid qualified is a noble desire. Not only it will add to your first aid knowledge but also makes you ready to save a life even when it looks impossible. There are lots of options for CPR/First Aid certification courses for which you may face difficulty in getting a course that perfectly suits you and ensures you optimal value. You need to consider a few important things that would lead your way to the best CPR or First Aid course. Follow the list which includes different criteria to be considered in the selection of CPR/AED/First Aid certification programs.
1. Credibility of the course material –
If the CPR/AED certification material is of high quality and designed with precise details by experienced medical professionals or instructors and made compliant to the AHA standards, then it will be reliable and useful for saving the life of a victim.
2. Accredited or Approved Certification
Not all CPR/AED certification programs are accredited, and very few of them are internationally acknowledged. For all of you who need CPR certification for professional qualification, joining officially accredited programs is necessary.
3. Complimentary Courses
There are First Aid Certification courses which are offered in combination with CPR and AED training. A quality certification provider will allow you to join courses that include two or more topics of your interest, so that you can carry on your training without the need to separately register for each course.
4. Flexibility & Convenience
You must be able to continue your CPR/First Aid training at your own pace. Convenience of accessing a class at anywhere at your spare time will bring down hassle in your life. Online First Aid certification courses are perfect for those who don’t want to abide by time limitations or need more flexibility than conventional class room training.
5. Affordable Pricing
A quality course provider will ensure AHA standard compliant online CPR/AED/First Aid certification without the risk of overpayment. As a result you will get the best value training for saving life of people in emergency situations.
No matter for personal or professional reasons, there is always a requirement for CPR/ First Aid certification which will enable you to save cardiac sufferers from death. Don’t postpone your training any more – the perfect opportunity to add to your personal skill and ability to save lives is now available with First Aid Certification course of CPR Professor. We offer certification courses designed to the latest training standards that are all nationally recognized. Our CPR & First Aid Certification courses can be accomplished in just one or multiple sittings. You can consider registering for our CPR Certification and continue it the way you want. | <urn:uuid:51170744-6626-40e7-8eea-0461eec5bc31> | CC-MAIN-2022-33 | https://www.cprprofessor.com/blog/2017/06/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.940138 | 1,019 | 2.453125 | 2 |
We define as an Interaction any kind of specific communication between one Customer and one Agent.
The customer can engage communication choosing several interaction points and channels, like voice or video calls, mail, chat, social media messages and more.
The following are some examples of interaction between your organization agents and a customer:
- Email thread about a topic
- Web Chat Transcript communication
- Voice call
- Video call
- Social Media Message exchange
Each interaction is managed by one specific agent owner at any specific time. Such owner can also change during the interaction (in case of timeouts, unmanaged messages etc… etc…) however only one agent is the interaction owner considering any specific time. | <urn:uuid:cd43a33c-3e98-4fd2-bd36-b7455e945ec9> | CC-MAIN-2022-33 | https://helpdesk.xcallyusa.com/dt_articles/interaction/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.933836 | 140 | 1.992188 | 2 |
KORG MS-20 v2.2.0 WIN
The analog monophonic synthesizer with the potential for patching that went on sale in 1978: the MS-20.
The entirety of the MS-20 is reproduced with its two oscillators (which can be ring-modulated), high-pass/low-pass self-oscillating filters with unique distortion, and a patch section with an external signal processor that can accommodate external audio input.
For the software, 32 voices of polyphony and up to 16-voice unison (with detune/spread function) were added. Flexible external modulation settings and MIDI clock synchronization have also been introduced, allowing for sound production with a high level of flexibility and freedom.
In the further designed and refined MS-20 of KORG Collection 2 there are now two additional multi-effect units, a new sound browser, and new preset programs. | <urn:uuid:b105ef80-3a9a-4040-a834-301a9d5e9da4> | CC-MAIN-2022-33 | https://audiobar.info/korg-ms-20-v2-2-0-win/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571222.74/warc/CC-MAIN-20220810222056-20220811012056-00672.warc.gz | en | 0.928876 | 187 | 1.5 | 2 |
Does anyone know how to plot a displacement-time graph that will give the average velocity of a bouncing ball? The ball bounces 5 times and I would like to know it's average velocity. What equations would I use?
The Attempt at a Solution
I simply plotted displacement vs time graph but I get a quadratic (or exponential) function. I just want to confirm if I am doing this right. Thank you. | <urn:uuid:eabeb2c1-cf19-4873-83eb-d75ef3f548db> | CC-MAIN-2022-33 | https://www.physicsforums.com/threads/displacement-time-graph-of-a-bouncing-ball.871155/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571222.74/warc/CC-MAIN-20220810222056-20220811012056-00672.warc.gz | en | 0.952911 | 116 | 2.28125 | 2 |
The Eternities Before the Saints—The Sublimity of the Gospel, Etc.
I am pleased to have another opportunity of meeting with you on this the first Sabbath of the New Year; and I will add to all the faithful, ten thousand more of them. For we, as Latter-day Saints, do not consider that our existence ends with time, as we generally term it, but that it reaches into eternity. And that while we are here in a state of probation to fulfil the various duties devolving upon us, as Saints of the living God; while we come into the world and exist in it for a time and then leave it, we have hopes and aspirations beyond the grave, and anticipate that, as ages and cycles shall pass along and generation succeeds generation, if we are true to our trust and live our religion, keeping the commandments of God and fulfilling the various covenants devolving upon us to attend to, that we shall associate with the just in the eternities to come! Therefore we are living, and hoping, and expecting, and planning, and contriving and operating, for the accomplishment of this object. We do not look upon the affairs of this life as those alone in which humanity is interested. We have been taught differently by those who have had communication with the Lord, and
to whom he has revealed his will. We have been taught differently by the holy priesthood that we have in our midst; we have been taught differently by the Holy Spirit which we have received in God's appointed way, according to his law; which spirit has enlightened our minds and given unto us an evidence and a testimony similar to that which we heard Brother Smith speak of that he knew this work to be of God. How did he know it? Through obedience to the law of God, by the reception of the Holy Ghost and through the union and communion that exists between God and his children upon the earth. This is a principle of certainty and testimony, and an evidence that we all have the privilege of enjoying for ourselves, and of knowing that God lives; of knowing that this is the Church of Jesus Christ and the kingdom of God; and of knowing also that God lives and that he is our Father, and that we are his children; and of further knowing that, “when this earthly house of our tabernacle is dissolved,” we can feel like one of old, that “we have a building of God, a house not made with hands, eternal in the heavens,” waiting for us, and not for us only but for all
who love the appearing of our Lord and Savior Jesus Christ. Were it not for this hope, were it not for this spirit, were it not for this intelligence that has been communicated unto us by the light of revelation and by the manifestation of the Spirit of God, through the revelations of God to man in these the last days, by the opening of the heavens, by the administration of holy angels, and by the revelations of the will of God to man; were it not for this we should not have been here today, this congregation would not have been assembled here as they are; the Latter-day Saints would not have been in this territory; nor would they have been anywhere else; for it is because God has seen fit in the fullness of times, according to the testimony given by the holy prophets, who have prophesied since the world was, according to the designs and eternal purposes of God pertaining to the inhabitants of the earth—those who now live, those who have lived and those who will live; were it not for the purposes of God pertaining to these things, and the communications of his will to us, we could not be, as I before stated, in the position we now occupy. But God having designed to accomplish his work in the interests of the people of the world, in this day and age, in the interest of the myriads who have passed out of the world, in the interest of the living and the dead, he has commenced his work for the salvation, for the redemption and for the exaltation of the human family, and hence things are as we see them among us today.
When we talk about the theories of men, they are matters of very little importance; when we reflect upon their ideas or views, they are really unimportant, but when we
talk about the law of God, the plates of Jehovah and his designs pertaining to the world in which we live and its inhabitants, and to the inhabitants that have lived, and to all humanity, then we touch upon a subject that is grand, noble and sublime; one that enters into the recesses of the heart and that touches every fiber, and that causes our hopes and aspirations to reach within the veil, where Christ our forerunner has gone, and we feel convinced that there is an eternal fitness in all the laws, in all the truths, in all the ordinances, and in everything that God has revealed for the salvation and exaltation of the human family. We are here, and how did we come here? What was it that brought us here? Some hardly know; and then there are a great many who do understand this thing very well. We are here because we listened to the eternal truths of the gospel, and that gospel could not have been known unless it had been revealed. For no men nor any set of men, today, understand those principles which are calculated to exalt men in the celestial kingdom of God, nor could they comprehend them unless God had revealed them. And when we hear of the folly, the raving and ranting of ignorant men who know not God nor his laws, who would presume to dictate to Jehovah, who would teach something that they know nothing about; but being without revelation, are fitly represented in the Scriptures as “Knowing nothing but what they know naturally, as brute beasts, made to be taken and destroyed.” For instance, we have our cattle, our sheep and other animals which we raise and provide food for and feed and fatten them. What for? For the knife. How could we do it if they knew what we were doing it for? I do
not think they would get very fat. Still, one of the old prophets, in speaking of these men who are without revelation says, “They know nothing but what they know naturally as brute beasts.” We certainly do not wish such men for our instructors.
Many men at the present day will tell us that they will believe nothing but what they can see with their eyes, handle with their hands and comprehend with their judgments. And what are they prepared for? I might here ask, What does man in reality know of God and of his laws, or of the proper fitness of things what does he know about that vitality that he himself is in possession of, or that which any other animal is in possession of? He knows nothing pertaining to it, nor can he impart it. When we talk about the wisdom of man, how far does it go? We learn a few of the laws of nature. Who gave these laws? Who originated or organized them? Who placed these eternal laws in nature? Who made the solar system, for instance, to move with that accuracy and punctuality according to exact rules and laws who made any portion of that system, gave it its original force or sustains it in its motion? Who planted in matter its exact and various laws? Can any of the learned and the wise of this day and age make anything of that kind or anything approaching to it? Who gives life and vitality to man? Does man give it? We are told that “there is a spirit in man, and the inspiration of the Almighty giveth it understanding,” but without that what are we, although our organization may be complete in all its parts, yet without the spirit the body is lifeless, motionless and inanimate. What are we? At best but little specks in
motion moving about in the world? Puffed up, in many instances, with things we profess to know, when really we know nothing only as God communicates it, and can understand nothing only as he makes it manifest. Can all the philosophers of today make a grain of wheat and give vitality to it, much less a world? Or can they make a simple blade of grass? It is not a big thing to ask a wise man to do, especially those who desire to ignore God in his works, but can the wisest of our philosophers do it? No, nor can they discover the secrets of life, nor the impulses which act upon all nature in all the varied operations. Who governs the planetary system? The great God, the same who causes our earth as well as other systems to revolve upon their axes, and provides for them, and has measured and given them their times and seasons, and their laws. Who is it that causes the blood to flow through our veins? He that has given and does give intelligence to man. Can anybody point out any of those vital principles and show that they originated independently of God? No, they cannot. And so it is through all creation, no matter what you touch pertaining to nature. When man discovers a law of nature either in the mineral, the animal, the vegetable or any other kingdom, he will find that it is governed by strict eternal and unchangeable and undeviating laws. And when men discover that, what do they find out? Something which God has placed there, something that has always existed. We talk sometimes about the great discoveries we have made. We will refer to gas, for instance; some of us can remember very well when there was no such thing known among us as gas for lighting purposes. Who originated the ele-
ments of which it is composed? The great God; and that principle always existed. We speak about electricity and the uses to which it can be applied. Who originated that principle? “O, it was found out a few years ago and we found it very useful in communicating one with another; through its use we can send a message today from one part of the world to another, and can be in communication really with the world.” Well, we think we have done something very remarkable, in discovering something of that kind, and it really is a great discovery; but then that principle always existed, ever since the world was framed; the only thing that we can boast of is that we have discovered a certain principle which we did not know of before; and there are ten thousand other principles beyond, which we have not yet discovered; but when we do discover them we shall find them to be the same eternal laws of God. I am reminded sometimes of a little infant. You look at the body; it comes into the world; it has its common faculties. By and by it makes a discovery, it finds out that it has a hand, and it looks at it as much as to say, It is a very curious thing, and it is a remarkable discovery that I have made. Why, it always had a hand, but the baby did not always know it.
It has been remarked here by Bro. Penrose that all things are governed by law. This is so whether in the material world, or whether—I was going to say—in the immaterial world, but we do not know of such a thing; I will say therefore, the spiritual world, if you please. We are very singularly constituted, forming a combination of body and spirit. We learn a little about the bodies of men, but do we know about
the spirits? We know from history of some things which have taken place in the past, but what do we know about things pertaining to the future? Who can comprehend God or his ways? One of old in speaking upon this subject says, “It is high as heaven; what canst thou do? Deeper than hell; what canst thou understand?” There are some prominent features which God has revealed to us; and there are ten thousands of principles which he has not revealed. Those principles that he has revealed to us, like everything else pertaining to the works and the designs of God, bring a degree of certainty, assurance, intelligence and satisfaction that nothing earthly can impart. The Saints themselves, do not, in many instances, understand the “whys” and the “wherefores” pertaining to these matters. We are taught to obey certain laws; we are taught to repent of our sins, and to have hands laid upon our heads for the reception of the Holy Ghost. Here is a law that God has appointed, just the same as he has regulated these other systems of which I speak, and with which we are more or less familiar. We have electricity floating around us in every direction. In order to make it subserve our desires we have to use it according to certain laws. At present we have to string up wire properly connecting it and use a battery and a machine made for the purpose, in order to convey our thoughts to others at a distance; and without first paying due regard to these or other appliances that perhaps might be substituted, we could not communicate. When you comply with the law governing this matter, that is, when you erect the poles, string the wire, make your battery and have the machine and the circuit
complete, you may then convey your thoughts correctly over the wire by the means of electricity to others at a distance. You know they have been correctly sent because you can receive your answer back; and if necessary, have the message you sent repeated. Now the same principle is true in regard to the other things. And do the persons who operate the telegraph machine always understand all about the philosophy of it? No, but very few of them comparatively. Yet they learn to operate while somebody else does the thinking and prepares the machine and appliances for them for the purpose of introducing this mode of communicating. Now then, look at the principle that looks to many very simple associated with that way which God has ordained and appointed for man to become acquainted with him, and to be introduced to him and to his laws. How is it? Why the elder goes forth to preach, and what is he told to preach? Faith in the Lord Jesus Christ. Repentance and baptism for the remission of sins, and the laying on of hands for the reception of the Holy Ghost. Now these look to many as being very simple things, very simple; yet they are things which God has ordained, they are his laws, they were in former times, they are in this time. We cannot violate these and receive the blessings, and no other people can; I do not care who they are, they cannot do it. Let us go back to our experience. There are hundreds of you present who have received the spirit of the living God; how did you receive it? You say, an elder came along, and we heard him preach; he told me to believe in the Lord Jesus Christ and to repent of my sins, and that he was authorized to baptize me for the remission of
my sins, and he told me that if I did this that hands should then be laid upon my head and I should receive the Holy Ghost. This is the doctrine you heard. Then you had faith in God; you repented of your sins, your follies and wickedness, and you covenanted to fear God and keep his commandments, and to observe his laws. The elder then went forth and led you into the water, and he said, “Being commissioned of Jesus Christ I baptize you for the remission of your sins in the name of the Father and of the Son and of the Holy Ghost, Amen.” He then buried you in the water and raised and brought you out of it. After he did this, he laid his hands upon your head, and by the same authority he confirmed you a member of the Church of Jesus Christ of Latter-day Saints, and said, “Receive ye the Holy Ghost.”
Now that is a very peculiar operation when you come to think upon it. Why is it thus? A man goes forth who has authority given him of Jesus Christ, he baptized you for the remission of your sins in the name of the Father and of the Son and of the Holy Ghost. There is something very peculiar about it. It looks very simple; but if that man had no such authority, then he was an impostor; and if the man or men who ordained that elder conferring on him this priesthood, had not the authority to do so, then he or they were impostors; and if God had not given revelation instructing Joseph Smith in relation to these things, how they were to be done, then Joseph Smith himself was an impostor, as well as the apostles and all men professing authority. These are self-evident facts. We as a people do not profess to have received any authority from any other source,
from any man or set of men, or any church or any organization existing; and if God has not revealed it, then the whole thing is a falsehood and fiction, and there is nothing to it. Here is a picture [pointing to the ceiling] of the angel Moroni appearing unto Joseph Smith, revealing to him among other things the plates from which the Book of Mormon was translated. We have another here [pointing to John the Baptist conferring upon Joseph Smith and Oliver Cowdery the Aaronic priesthood], and still another, representing Peter, James and John conferring upon Joseph Smith the Melchizedek priesthood. Very well. Are these things true? There are thousands of Latter-day Saints who will tell you they know it. We will come to these things by and by. But if these things were not so, then our faith is in vain, then we are dark and benighted as others are, then the things we believe in are a phantom and can avail us nothing, either pertaining to this world or the world to come; then the building of these temples amounts to nothing, if these things are a fiction, and everything we have done and are engaged in amounts to nothing. But if they are true, then there is nothing of so great importance to the world of mankind and to us, as the revelation of these truths to man in these last days, and pertaining also to our association therewith.
Now, when an elder lays his hands upon a man and confirms upon him the Holy Ghost, he tells him to receive it by virtue of the authority conferred upon him. What authority? Why God restored the authority of the holy priesthood by those who held the keys of that priesthood and who administer in time and in eternity, who hold that priesthood upon the earth, and who now
hold it in the heavens. They came here to impart it to men, and did restore it to men. Very well, that being the case, man was again placed in communion with his God; not left any longer to guess and suppose and surmise and to think, but to know. For instance, I have myself been thousands of miles and hundreds of thousands to preach this Gospel; would I have gone if I had not known it to be true? No, I would not. There is nothing very pleasing in going forth to an unbelieving world to meet the errors and the prejudices of ages, and to oppose the false theories of men, to introduce the principles that are opposed and repudiated by the carnal mind, and by the corrupt everywhere; there is nothing very pleasant or inviting to be traduced and to have your name cast out as evil, no matter how honorable you may be, this has been the lot of the elders of this Church and is their lot today, by men who know not of what they speak, by men who are bigoted, superstitious and ignorant; men who comprehend not God nor his laws; but we know it, and I know the truths of which I speak, and bear testimony to it before you. If others do not know it, I cannot help it; I have obeyed the method appointed to receive these things, as you have had to do, to be initiated into the Church and kingdom, according to the laws which God has ordained. What I have done, then, all others in this Church have done; and the elders of Israel have been actuated by the same impulses, have obeyed the same doctrines and ordinances, and have administered the same ordinances to others. They are influenced by the same spirit, and they realized and knew for themselves of the things which they promulgated and taught. Is this con-
fined to elders alone? No. To the apostles and presidents? No. To the seventies or high priests or elders, bishops, priests, teachers or deacons? No. This is a thing which pertains to all; all who are Latter-day Saints, all who have complied with the requirements and who have thus placed themselves in the condition to receive this knowledge; and you men who are before and around me today are witnesses of the truth of that which I say, because you yourselves did receive the Holy Ghost, the Spirit of God which imparted to you a knowledge of the principles of the Gospel and placed you in communion with God your heavenly Father. And this Spirit has borne witness to our spirits as it has been said by one of old, “that we are the children of God: And if children, then heirs; heirs of God, and joint heirs with Christ.” We sometimes treat these things rather lightly, scarcely comprehending what we are doing; and I often think that our elders themselves hardly realize the significance of the situation they occupy when they say to him that believes, repents and is baptized, “Receive thou the Holy Ghost.” Is there a thing of more importance that we can think of anywhere than this which so many of us treat so lightly. The idea of a man, human and fallible, pronouncing the reception of the Holy Ghost upon his fellow man, and his fellow receiving that heavenly treasure, is one of the greatest manifestations of the faithfulness of God, in sanctioning the acts of his elders that it is possible for us to conceive of. He has said that through these ordinances he would confer the Holy Ghost; he has also fulfilled it, as the thousands who hear me today can bear record. Here is the thing that operated
upon you and which was the means of bringing you here to this place, from many of the nations of the earth.
Some people find fault with us about these things. I have said frequently to men that I cannot help my faith and I am sure you cannot help it; no man living can control my faith, for I have received a portion of the Spirit of the Lord and I know it; and if you have received a portion of that same Spirit you know it, and you cannot unknow it—it is impossible, you cannot unknow it, unless you sin against God and, as the apostle said, grieve the Spirit, by which you were sealed; then it withdraws from you, then you will not know much about it, no more than some do who take this course against us. The apostle said, “Grieve not the Spirit of God, by which you are sealed to the day of redemption;” do not grieve it, do not sin against God, do not violate his laws, do not corrupt yourselves; do not corrupt your bodies, for are they not, as one has said, “the temples of the living God?” Do not allow your spirits to be contaminated and led astray from correct principles, but cleave unto God in all humility, fidelity, faithfulness; observing his laws and keeping his commandments. Why, then, let me ask, are you here? You are here because the elders of Israel visited the place where you lived in this nation, or in nations afar off, preaching the principles of the everlasting Gospel which had been restored; and you believed their testimony, and obeyed the Gospel, and received a knowledge of its divinity, and because of this you came here; and hence the elders, the apostles, the presidents, and all the various peoples and members being touched by the spark of that fire that dwells in the bosom of God, being enlight-
ened by that Holy Spirit which is promised to those who obey his law, you left your homes, your friends, your associations, and came here to mingle with the Saints of the Most High, to unite with them and to assist in carrying out those purposes that God designs pertaining to the human family. Now in all this Joseph Smith and those associated with him—Oliver Cowdery, Martin Harris, Hyrum Smith, Sidney Rigdon and others—understood these principles; they commenced this work not of their own free will, and, yes, of their own free will, too; but they did not originate them. God originated them and they were instrumental in his hands in introducing them. These men having been ordained themselves, ordained others who went forth to proclaim that word of truth which they had received. And why did you come here? Because you received that testimony and believed it and obeyed it and received the Holy Ghost, and associated with those who believed the same principles. There was something that propelled you forward, you hardly knew why or how, but you were desirous to come to Zion. Why? Because you are living in the dispensation of the fulness of times, when God will gather together all things in one, and the keys of the gathering dispensation had been introduced; and because you had received of that spirit, and you never felt easy until you got here. Well, how was that? What operated upon you? The Spirit of God. Was it a something that was craving after wealth and position and power and aggrandizement, to have a great and honorable name? No, it was as you first were taught and as you afterwards comprehended, it was how to learn to save yourselves, to
save your progenitors, to save your posterity; it was that you might obtain a knowledge of the laws of life, fulfil the measure of your creation, and that while you felt as a man among men upon the earth, you might, by and by, through obedience to pure principles, stand among the Gods as a God, in the eternal worlds, and be exalted through the power of the Gospel. This is why you came here, and are coming here, and being here, we brought our bodies with us. We have to eat and drink, we need clothing. The curse has not been removed from the earth yet, therefore we have “to eat our bread by the sweat of our brow.” We have to do in regard to these matters as others do; and being here, what then? Why a number of people make what may be termed a community. We are living on land, and that land, in a territorial capacity is part and parcel of the United States, and as a territory of the United States, we necessarily form an integral part of the United States; being men, and having bodies as other men, independent of our general feelings, thoughts, actions and sentiments, we have to live and move, to eat, to drink, to occupy farms, houses, cities, and lands; and to perform all the varied duties of citizens, associated with the body politic. What next? We have our religious duties to perform, and that is to fear God and to observe his laws.
What else? We build temples. What for? To administer the ordinances of God. What ordinances? Those that God has revealed, and those that the world know nothing about; and if they had the temples already built for them today they would not know any more what to do with them than that pitcher does;
nor would we unless God had revealed it. Now we are going on quietly to attend to our duties, building our temples and administering in them. Here is Brother John L. Smith—how long Brother Smith have you been administering in the Temple at St. George? [Brother Smith: Four years, sir.] And for whom? For himself? Yes, a little, not much however, principally for others. For the welfare of whom? The living. Who else? Of the dead; that we may fulfil certain duties that God has called us to perform, to help in the accomplishment of his designs and purposes. And that as God has been pleased to restore to the earth the keys which Elijah held, who conferred his power upon others to turn the hearts of the fathers to the children, and the hearts of the children to the fathers, that the fathers who existed upon the earth in generations gone past, and we who are now in existence and our children that are following after us, might be cemented and united together by eternal bonds which God has pointed out. That there might be an alliance and cooperation between those in the heavens and those on the earth; that there might be a welding, uniting, cementing principle; in which the priesthood in the heavens and on the earth are united, to carry out the great designs of our heavenly Father in the salvation and redemption of the living and the dead, and that we might operate for them on the earth while they are operating for us in the heavens. For it is written, that “They without us cannot be made perfect,” neither can we become perfect without them. We, then, are operating in our part and they in theirs; we on the earth, they in the heavens; and with God they are operating, and with Jesus
Christ, who is the mediator of the new covenant, and with the ancient prophets and apostles of God, who lived before, who administered in time and in eternity, holding the everlasting priesthood, and who are all interested in the welfare of the world and the exaltation of man.
Well, now, what shall we do? Shall we go on with it? We will try to, the Lord being our helper. Some people say we are very wicked. Well, I do not think we are as good as we ought to be by a long way, but I do think we are very much better than they are. This is my opinion, with all our follies and all our weaknesses, and all our infirmities. And—well, I would not like to say what I know about them. God knows it. We will let that go. The Lord will judge men by their acts, and he will judge us and all others by our acts.
Now, we have a territorial form of government. I will come to that again. What shall we do? Observe the laws of men? I think that is a very easy thing to do. There is nothing very hard about that; if they will not interfere with us in religious matters, there is nothing very hard about keeping the laws of the land. Will we pay taxes? Yes. Will be loyal to the government? Yes. Will we sustain all good, honorable men that are rulers? Yes, and pray God to inspire them with wisdom, that they may be led in the right path. Will we fight with them and quarrel with them, and say hard words about them and misrepresent them as they do us? No, we will not. It would try me very much sometimes to have to tell the plain and unpalatable truth about them, of things which, without falsehood, I can say, I know for myself. Still, will they try to interfere with us? Yes. Who? All
kinds of foolish people, ignorant; narrow-minded, degraded, wallowing in iniquity and besmeared with corruption of every kind; and yet they talk to us about our impurities. They have reason to talk a little, but not much. We are not what we should be by a long way; we ought to be a great deal better than we are. I pray that God may enable us to be so.
Well, we do not interfere with them. Whose religion do we interfere with? Nobody's. I hope you do not, I know I do not; if they are satisfied with it, I am satisfied that they should have it. I believe in every man using the free exercise of his judgment and conscience, leaving the balance with God. I will tell people the truth; if they obey it, all right, if not, certainly I will not prosecute them or persecute them because of their views. But on the contrary, if anybody were to interfere in any way with the religious faith of anyone, I care not how foolish it might be, I would be among the first to stand forth in the defense of him whose rights were assailed; not because I believed in his religion at all; but because my sense of justice and equal rights would impel me to this action; for if I claim those rights myself I ought to respect them in others, holding as I do that it is the right of all men to believe in and worship as they please. And while there are thousands of highminded honorable men in this great nation who believe in and sustain the principles of freedom and equal rights, there are very many foolish, inconsiderate men who would recklessly tear down the temple of freedom erected by the fathers of this nation, and ruthlessly proscribe, prosecute and persecute all who cannot subscribe to their narrow erratic, unsupported ideas.
But will you not conform to their ideas? No, I will not, the Lord being my helper, and then the people will not God being their helper. The Lord has revealed unto us the truth, and we know it, and we will stand by it and maintain it from this time forth, God being our helper; and all who believe in that say aye [the congregation said aye]. That is the feeling of the Latter-day Saints I know. But will we interfere with anybody? No! No! We will not. With their politics? Not much. For while we are interested in the welfare of the nation, we care very little about the present political issues. We think that a great and magnanimous nation, however, could well afford to let us alone, and would feel like endorsing General Grant's axiom, “Let us have peace.” But then if people will interfere with us while we are pursuing the even tenor of our way, we will defend and protect ourselves from their assaults as best we may, and then we will commit them to God. We have not started this work, God commenced it, not us, and we are simply endeavoring to carry out his will and law. Will we do it? With the Lord's help we will. Will we fight against authority? No. Will we oppose the principles of this government? No. We will sustain them. But if people will act foolishly we cannot help it. If this nation can stand the results of the violation of constitutional principles, we can. If they tear down the bulwarks of freedom and with impunity trample under foot the rights of men we cannot help it. If it is our turn, today, to suffer wrong, it will be somebody else's tomorrow, national retrogressions are not often arrested. It behooves statesmen to pause in their career. The floodgates once opened who
shall stay the torrent? We of all men would save the ship of state and would say to these national patricides avaunt! But if they will act foolishly and continue to do so until they subvert the principles of liberty, and thus destroy one of the best governments ever instituted on earth, then if forsaken by all else, the elders of this Church will rally round the Constitution, lift up the standard of freedom, which is being trodden under foot and bedrabbled by demagogues, and proclaim liberty to the world; equal rights, liberty and equality; freedom of conscience and of worship to all men everywhere. That is not a prophecy of mine; it is a prophecy of Joseph Smith's, and I believe it very strongly. Will we oppose them? No. Let them go on in their own way and we will pray to God to turn the designs of wicked men, and if they will not repent and turn from their evil deeds, pray to him that they may be taken in their own trap, be caught in their own snare, and fall into the pit which they dig for us. Can you pray with a good conscience that this may befall them? Certainly. If men dig a pit for others they should not find fault if they fall into it themselves. And as sure as God lives they will do it, if they persevere in their iniquity, and as sure as we stand faithful to the principles of truth, God will stand by us, and the wrath of man will be made to praise him, and the remainder he will restrain; and they cannot help themselves. For both they and we are in the hands of God, and they can go no further than he permits them, neither can we. And we will try, as the friends of this nation and of humanity, to do right, and to sustain
all correct principles, in the maintenance of justice and equal rights to all; cultivating peace, respecting law, sustaining our institutions, and praying that right, justice and equity may prevail throughout the land; and that the hands of all honorable men may be strengthened to preserve inviolable the God-given institutions of this great nation. Let us also try to fulfil all of our duties as fathers, and our duties as mothers, our duties as children and our duties as citizens of the United States, our duties as Presidents, our duties as Apostles, our duties as High Priests, our duties as Seventies, our duties as Elders and our duties as Priests, Teachers and Deacons, and our duties as members of the Church of Jesus Christ of Latter-day Saints. Let us humble ourselves before the Lord, live in the light of the Spirit of God, that the Holy Spirit which we have received may be in us “as a light that shines brighter and brighter until the perfect day.” And if we are faithful, God will stand by Israel; he will preserve his elect; he will listen to our prayers: and we will go to work by his help to build up Zion and establish the Kingdom of God upon the earth; and we and our posterity will never cease doing it until the “kingdoms of this world shall become the kingdoms of our God and his Christ; and he shall rule forever and forever;” and then throughout the endless ages of eternity among the Gods in the eternal worlds we will join in singing, “Blessing, and glory, and honor, and power, and might, and majesty, and dominion, be ascribed to him that sitteth upon the throne, and unto the Lamb forever.” Even so. Amen. | <urn:uuid:cf658b4d-9744-497c-b26b-9c5941ad940c> | CC-MAIN-2022-33 | https://jod.mrm.org/21/340/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.982515 | 7,976 | 1.671875 | 2 |
Language is a very powerful thing. You can say what you mean and get the message across, or you could dance your message across. The language of dance, is a different type of language. Not many people think dancing is a language but it truly is. In The Little Mermaid: The Broadway Musical, there is a song called “One Step Closer” that Prince Eric sings to Ariel when they are dancing after they have had dinner. In the song, Eric sings:
“Just let your emotions tell your body what to do
See how much a single gesture can reveal!
And ev’ry little step
Ev’ry single step
Is one step closer
To saying what you feel”
I think this is a very important lyric in the song. It mentions how through dancing, you can reveal your emotions. For example, if someone were to be feeling angry, they might start stomping their feet to a rhythm. In the musical Annie, Annie and the rest of the orphans sing “It’s a Hard- Knock Life” and they stomp around because Miss. Hanigan, their caretaker, treats them horribly.
If someone is in love, they might be light on their feet and start twirling around and have their arms be flowing in the air. Fiddler On the Roof, is an amazing example of this. In the show three sisters sing the song “Matchmaker” which is about the girls finding the perfect groom to be.
If someone is sad, they might not dance at all, and I think that silence and standing or sitting still can say a lot as well. The person could have their head down, or just be staring off into space, with their knees tucked underneath their chin with their arms around their legs. An example of this, is shown in the musical The Phantom of the Opera. At the end The Phantom (Erik) sings to his monkey music box and has tears rolling down his face.
If someone is happy, then they might be jumping around, or skipping. Like in the new version of Little Women when Jo March and Laurie Laurence dance together on the porch. Their locking arms, skipping in a circle shows how happy they are to be in each other’s company.
“Dancing is a language that is felt instead of heard. It says much more than language ever could”(Little Mermaid: The Broadway Musical). Dancing is conversation without talking. You can express what ever emotion you are feeling through dance. | <urn:uuid:47ea40ff-978e-450a-8c0a-6a130078c439> | CC-MAIN-2022-33 | https://www.youthvoices.live/the-power-of-language-4/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.96318 | 517 | 3.078125 | 3 |
The Pfizer / BioNTech COVID-19 vaccine’s protection against severe cases of the disease holds steady after six months, according to new data released by the companies. But its ability to protect people from developing any symptoms of the disease dropped over time, the analysis showed.
The data could add to the debate around if and when people may need booster doses of the vaccines, which the Biden administration, Centers for Disease Control and Prevention, and other experts have been deliberating on for the past few months. The issue became more pressing when cases of COVID-19 in the United States started to surge as the Delta variant spread.
Overall, the vaccine was 91 percent effective against symptomatic COVID-19 over six months. It was the most protective in the stretch starting seven days after the second dose and running for two months: in that window, it was 96 percent effective. Its efficacy then dropped around 6 percent every two months — to 90 percent between months two and four after vaccination, and to around 84 percent between months four and six after vaccination.
There wasn’t a similar drop in efficacy against severe cases of COVID-19 — defined as cases where blood oxygen levels drop below 93 percent and heart and respiratory rate are elevated. The vaccine’s efficacy against those severe cases stayed high at 97 percent for the entire six-month stretch after people got their shots.
The data was published as a preprint by Pfizer and has not been reviewed by outside scientists. It was released on the day of the company’s earnings call, where it also released internal data showing that a third dose of the vaccine could boost levels of antibodies against the Delta variant of the virus.
The findings came from the study that started last summer to test the safety and efficacy of the vaccine. The first set of findings from that study were the results the Food and Drug Administration used to authorize the shot. The companies continued to follow the more than 42,000 participants in that study to check how the vaccine performed over time.
The analysis also found no new safety concerns in people who had been vaccinated for six months. The company will continue to follow participants for two years after they received the vaccines. | <urn:uuid:68cca06e-baba-40c5-9a1b-44c003c4e515> | CC-MAIN-2022-33 | https://www.theverge.com/2021/7/28/22598151/pfizer-covid-vaccine-efficacy-drop-booster | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571056.58/warc/CC-MAIN-20220809155137-20220809185137-00672.warc.gz | en | 0.975805 | 448 | 2.78125 | 3 |
How do you maintain focus and not lose track of the forest for the trees as you develop an app?
It's very easy to lose track of where code "belongs" once you're deep into development and end up with duplicate code in multiple places or routines that become muddy doing work that belongs elsewhere.
There are many tools and methodologies that can help, such as entity relationship diagrams, business models, communication diagrams and data flow diagrams. All very useful, especially for an app of any complexity. User interface designs, screen flow models, and UX design can also be useful. However, one of the most helpful tools I've found when designing complex apps and when deep in the actual development process is this game app design pattern.
A game app design pattern provides a visual chart of where each function "lives" in the code and how, at a high level, the functional groups are connected. Here is an example of a game app design pattern for a single player versus a computer player, or "AI". You can download a full PDF of this diagram at the end of the article.
This is a high-level model that hides a lot of detail. For example, the connections between the functional groups, with a few exceptions, are from one macro group to another and not to the sub functions within the groups. Again, this is mainly for readability. Keep in mind this diagram is meant to help keep the forest in view, not the individual trees.
And looking at the forest, most of these functional groups make sense and feel obvious, which is the point. The intent is to create and internalize an easy-to-understand mental map of the code for developers.
There are a number of "Controllers," in red, a single "Animation Controller," a "Game State" used by most of the app, and routines to control the player's moves – "Manage Allowable Moves," the AI's brain, "AI", and so forth. But let's start where the app starts, with "Main."
There's always a "Main," responsible for launching, suspending and exiting an app. No surprises there. The main routine may also be used to check for app permissions, create an initial database and perform tasks based on the device on which it's running. In this case, these functions have been moved to a series of "Utilities." This keeps the "Main" cleaner and also allows these utility functions to be used elsewhere in the app.
In this single player vs AI game, there are "Permissions", which tracks the user's permission to access certain resources (ie. Database). "Initializations" create the app's database and initially populate it. When the developer releases an updated version of the app, this routine will also make any necessary modifications to the database data and structure.
"App Navigation" is an example of a function that is used throughout the app. It is responsible for navigating between the app's screens and dictates the navigation transitions: slide, fade, etc."Device" allows every screen in the app to present its graphic objects based on the particulars of the device on which the app is running.
"Create", "Show", and "Hide & Destroy" handle the phases of a screen's appearance and use. This includes laying out the user interface, retrieving and displaying information, and managing memory.
The "UI Updaters" are routines that are called by a user's interaction with the screen that demand a change in state. These routines are also called by other routines external to the screen that change the UI state. An example of this would be the "AI" making a move that needs to communicate via text or graphics with the human player.
"Pass Thrus" may be language-dependent or development environment-dependent. Like the "UI Updaters" they are called from external routines to access other routines that would be otherwise unreachable or that create a conflict.
"User Interaction" leads to...
As the player and the AI make their moves, the "Animation Controller" is called to handle the movement and transformation of the game's objects, including the timing (how fast), location (where objects move to), and sequence (one animation may need to complete before the next starts).
Manage Allowable Moves
The functionality in this group manages two important aspects of game play. First, what objects are "Playable", meaning what objects can a player interact with given the current state of the game ("Game State"). Second, given the current state of the game, what moves is the current player "Allowed" to make. These routines are responsible for storing and updating this information in a way that controls each player's ability to interact with the game.
This is the AI player's "brain." As the diagram shows, the AI determines its best or required move and then executes its move by calling the "UI Updaters" and the "Pass Thrus" in the given game screen. This allows the AI to both communicate with the human player and animate its moves (the animation is handled via "Pass Thru" calls to the "Animation Controller").
And finally, the "Post-Move Execution" handles any follow-up actions required after the AI makes its move. In other words, the AI will evaluate its moves, determine which is best, make the move, and if the move requires another turn, the AI either makes another specific move or loops through the process of evaluation, execution, and post-execution again.
Game Flow Controller & Game State
Apps are event-driven, meaning the device's OS is constantly testing for events such as a user's touch or swipe, or checking for notifications, messages, GPS location and so forth. The equivalent process in this model is the "Game Flow Controller". This routine in theory could be called right from "Main," but in my experience that would be overkill.
When the player starts or resumes a game and the game screen is presented, this controller is called. Like a device's OS, this routine loops through itself using its partner routine, "Game State" to determine what needs to happen based on the current state of the game. In this sense it acts like a traffic cop, directing and controlling the flow of the game, from setting up a new game, resuming a game, switching players, to controlling the user interface options available to the player.
The "Game State" is a simple but crucial routine that queries the app's database any time it's called and and retrieves data about the current state of the game. Most of the app's routines need this information, especially the "Game Flow Controller" which uses this information to also control whether it continues to loop through itself or if it needs to wait for a player's interaction before continuing.
Game, Round, and Turn Controllers
These controllers contain the routines needed at various stages in the game and respond to calls from the "Game Flow Controller." If a new game needs to be started, paused, resumed, recovered, or ended, the "Game Controller" handles these conditions. The "Round Controller" and "Turn Controller" operate similarly.
As the controllers update the state of the game, "Game State" is called to refresh the current state of the game for "Game Flow Controller". As rounds or turns are updated "Manage Allowable Moves" is called to ensure players can only perform allowable actions and can only interact with playable objects.
In summary, having a "design pattern" or an "architecture" is simply a way to understand the structure of an app. This model helps keep the development of the app organized, the code structure clean, and maintenance, enhancements, and bug fixes easier to handle.
Different coding languages and different environments may dictate different architectures, but with any tool, you may choose to use what's useful for your particular application and ignore what doesn't work. Don't let the model become a straight jacket. That being said, for me this model has proven to be very useful over multiple projects. Hopefully you'll also find it a convenient and effective tool that helps you maintain focus and not lose track of the forest for the trees as you develop your game apps. | <urn:uuid:14e22cc3-c2da-4ccf-bd92-d96c65d8be04> | CC-MAIN-2022-33 | http://www.onebadant.com/index.php/oba-articles/288-gameapppattern | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571222.74/warc/CC-MAIN-20220810222056-20220811012056-00672.warc.gz | en | 0.944716 | 1,697 | 2.578125 | 3 |
I recently noticed that many Family Court litigants are clueless about filing and using the correct documents in their custody cases. There are different documents for diverse types of cases of course. But there are times when it is not just the type of case that matters, it is its purpose. There are petitions, complaints, responses, objections, oppositions, motions, show causes, cross-motions, cross-petition, and counterclaims. So, let’s discuss all family court documents in custody:
Type of Family Court Case
In Family Court, custody cases can go on forever. In fact, they typically do. If you are in court on custody once, you can almost bet on being back over the course of your child’s life until the age of majority. So, there is a difference, for example, in an initial case for Custody or Visitation and a Modification or Contempt case. The difference affects how the case will proceed, which rules apply and how they apply. So, an initial custody case might consist of the initial Complaint and maybe a Cross-Complaint as far as documents (pleadings). This is so because the parties are only trying to establish some sort of guidelines or parameters to co-parent. It is not uncommon that the parties are unaware of all the issues that may become an issue later.
Purpose of Family Court Documents in Custody
The other issue is what your objective is in the case. If you are seeking to shed light on the lies, deception, and false statements, then you might need to file a Response or Opposition. If your intentions are to present your own version of the circumstances, then you might want to file a Cross-Petition or Cross-Motion. But even further, if you have your own separate demands, then you should most certainly file a Cross-Motion or Cross-Petition in the custody or visitation case.
The document you file will still depend on the type of case, but your purpose for the document is important.
Procedure for Documents
Every single state has its own set of procedural rules when it comes to drafting, filing, and serving custody or visitation documents. They also have specific time frames and deadlines within which specific documents need to be filed. This is extremely important to know because it can affect how you choose to proceed. If you realize at some point in your case, that you should file a Cross-Petition what are your options?
Well, that depends on the point in which you realized it. Can you file a Cross-Petition at the time the case is scheduled for a hearing? If not, what can you do instead? These are all particularly important to know as you navigate your way through your case. You might not be able to, but you can ask for the court’s permission to file an Objection or Opposition. Or maybe you can get the court’s permission to extend the time for hearing/trial until you are able to have your Cross-Petition added to the court’s docket. The way you proceed is dictated by your court’s procedural rules as well as its administrative process.
How it All Comes into Play?
For those of you who do not know, my focus is always on the strategic aspect of custody cases. My unique approach takes a bird’s eye view of each case and produces a precise plan to help litigants reach their goals. This means that each of the elements I discussed above plays an important role. Timing, wording, positioning, etc. all these interplay in how a case should be presented for court success. So sometimes you might have missed a document filing deadline, but might be able to get on your side of the story another way. Therefore, it is critical to have these concepts in mind the moment you see yourself headed down this path.
It is extremely important that you are aware of your local court procedures, how to navigate your way around the court (and the website), and that you learn the different forms and their use. This knowledge can impact the overall outcome of your custody case. | <urn:uuid:8d786dd0-8396-4e4d-8f14-b27d10c583f6> | CC-MAIN-2022-33 | https://thedivorcesolutionist.com/category/child-custody/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571222.74/warc/CC-MAIN-20220810222056-20220811012056-00672.warc.gz | en | 0.951901 | 847 | 1.601563 | 2 |
There are plenty of scenarios where by a forensic animation performs a very important position during the conversation of difficult principles or situations from the courtroom. In some cases, they may be instrumental in supplying a pivotal piece of information that would or else be quite challenging to explain in terms by itself.
You can find certain moments every time a forensic animation is most relevant within the courtroom and wanting to use an animation for the “wow” factor isn’t the best point to accomplish. So, how Did you know if a forensic animation suits your scenario? Will you get the very best return on your own investment decision? How does one get the simplest transfer of information to the jurors? They are fantastic questions that any legal professional ought to check with before embarking on a forensic animation.
The subsequent are a listing of criteria that should assist you recognize if a forensic animation is best for you.
one. Hard to visualise?
Does the issue at hand encompass point of view, timing, relative distances or simply a approach/system?
The main reason you would probably want to offer a visible explanation of how something happened or how a thing performs is since It will be hard to demonstrate in phrases by yourself and it is necessary for your jury to comprehend and retain this facts.
Striving to explain to a jury how something could have appeared to a witness is a lot more difficult than exhibiting an animation and after that owning the witness state that “the animation is a superb representation of what I observed”. Timing and distances are sometimes complicated for people to imagine and may not surface as predicted. By way of example, every time a jury doujin is told that two cars have been linked to a head on collision and one driver was touring at 60 kilometers for each hour, they’ve got a preconceived notion regarding how quick the driving force was touring. Having said that, when 1 considers that another vehicle could have been touring at eighty kilometers for each hour, the resultant speed from the effect results in being obvious only when viewed by by means of an animation. Many times, people reconsider their preconceived notions to better align using your arguments.
Also, if the situation surrounds an industrial system, chemical reaction or even a company approach, a forensic animation may possibly help in educating the jury in a clear and easy fashion. This really is very true if the procedure is elaborate and never simply recognized by the lay man or woman.
two. Are you cozy describing The subject?
When attorneys get in above their heads seeking to clarify a topic that may be past their understanding a few matters take place. The jury will probably see which the attorney is battling a subject and they are awkward. Then, the jury could begin to concern the lawyer’s credibility. Even worse, the attorney might stumble on his/her have words and phrases and confuse the jury over a crucial issue that may be pivotal towards the understanding and end result from the trial.
In these situations, it’s best to possess a ready animation to go through and educate the jury. Generally, in a sophisticated issue, it might be smart to get the specialist witness to work with the animation bit by bit to improve the juror’s learning.
3. Will an animation increase the demo course of action?
At one time, this would in no way be a thought and also today, it is actually much less of an element. Nonetheless, A lot more judges are appreciative of instruments that assistance quicken the demo process. A forensic animation ought to be a thing that answers a lot more thoughts than it delivers up and keep on the points of problem. Typically forensic animations certainly are a compact, concise and an productive use of your time that is appreciated by judges and jurors alike.
4. Would you prefer to take a look at diverse scenarios?
Amongst the greatest great things about forensic animations isn’t really for that jury, but for the lawyer. That is the potential for functioning diverse eventualities and with the ability to visualize the possible end result of every. Just one can certainly “experiment” with various assumptions, evidence and variables and subsequently existing these for the jury.
Forensic animations offer a visual set of scenarios where by a case has its strengths and weaknesses. Analyzing the plausible situations when they have been summarized in a visual recreation signifies a powerful and less time consuming way to understand a single’s scenario. Parts of energy might be emphasized and regions of weak spot can be prevented. Depending on the kind of situation, getting the benefit of running different eventualities is likely to be a must have on your aspect.
5. Has another side well prepared a forensic animation?
This is often something which many Lawyers really feel they need to counter with the opposing animation. In some instances, it really is sensible to respond. Due to what lots of have coined the “CSI component”, numerous jurors have come to anticipate that prime tech animations will be Utilized in the courtroom. When the opposite facet has employed a forensic animation and you have not, it might have a psychological effect on how the jurors perceive your preparedness for the case. Conversely, if the other side hasn’t prepared an animation, it might be advantageous to at least one’s case to take action.
six. Fees & Timing
There are plenty of aspects to consider In regards to the cost of an animation considering that these change significantly depending upon the size and complexity of the animation. Additionally, there are the various rates amid forensic animators based on their capabilities and experience. On the other hand, a single need to weigh the cost of the animation relative the probable settlement expenses of the case. Get an experienced forensic animator to provide you an estimate up front for what the costs of a certain animation could possibly be. Generally, most forensic animators will overview the products and supply a quotation for gratis. This tends to greater assist you in analyzing the expense advantage of an animation.
Guarantee you have time with your circumstance to allow for enough disclosure to the other facet. Forensic animations acquire a considerable degree of effort sometimes and even if all the information is obtainable at once, they may get as many as quite a few months to accomplish.
One particular have to take into account the sort of animation remaining created and whether It will likely be admissible in courtroom. It makes no sense paying the time and expense and not being able to present a professional animation in court docket. There are lots of articles or blog posts written around the admissibility of forensic animations and demonstrative evidence generally. | <urn:uuid:b68ca496-480a-49fd-afc1-00253a17d8d1> | CC-MAIN-2022-33 | https://aspirenorthants.co.uk/2021/10/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571950.76/warc/CC-MAIN-20220813111851-20220813141851-00672.warc.gz | en | 0.955866 | 1,347 | 1.90625 | 2 |
Bill Ostrow's dream of building a library began when, as a member of the search committee to select a new rabbi for Mosaic Law Congregation, he interviewed Rabbi Reuven Taff. Candidate Taff noticed that a library was missing from Mosaic Law and Bill promised him that if he accepted the position, Bill would see to it that there would be library some day.
When the opportunity arose to make this dream a reality, Bill and his wife, Shola, could not think of a better way to leave a legacy to Mosaic Law and the Jewish community: one that would survive long after they were gone. Shola was an avid reader with thirst for knowledge and learning. She belonged to several Jewish book clubs and discussion/study groups.
Sadly, neither Bill nor Shola lived to see the library open, but their legacy is experienced daily through their daughter, Jolie Baron, our head librarian. They would be so proud of all that the KOH Library and Cultural Center has become. | <urn:uuid:4c7c5144-e177-4c11-ab01-44e2bc1b7868> | CC-MAIN-2022-33 | http://kohlcc.org/home/about-the-library/the-founders/17-shola-ostrow | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571222.74/warc/CC-MAIN-20220810222056-20220811012056-00672.warc.gz | en | 0.986233 | 205 | 1.828125 | 2 |
Dehydration solution or electrolytes is usually used to replenish the nutrients that are lost during diarrhoea or during stress and high temperature. The electrolyte supplement is used to improve the acid-base balance in the body. Diarrhoea and stress are the main cause of death in cattles which can affect the economic condition. It can cause slow growth and unhealthy body and it affects the genetic structure, health status and production. When there is symptoms of heat stress or dehydration there is a drop-in feed intake which lowers the nutrients requirement of the body and increase the consumption of energy within the body. Proper feeding can help the body to recover from heat stress and dehydration. If the symptom persists there is need of external electrolyte supplement which can help in replenishing the lost nutrients from the body. We use “Concelyte Pro” the best electrolyte supplement which helps in removing these problems and replenish the body with full nutrients. Its composition consists of Sodium chloride, potassium chloride, sodium bicarbonate, Magnesium, calcium etc. which makes it the best heat stress reliever supplement. Consuming this, it benefits the body in many ways.
- Maintains electrolyte balances by process of neutralization and thus provides strength.
- Act as an adjuvant and therapy during anti-biotic treatment.
- Rehydrates the body during summer.
- Improves immunity.
- Prevents dehydration.
- Energizes body.
For Cattles & Buffaloes
Or, as advised by veterinarian consultants. | <urn:uuid:a686542f-7ff8-4037-b1e1-5cb1555a1a18> | CC-MAIN-2022-33 | http://www.livestocknutrition.in/cattle-heat-stress-supplement.html | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.912104 | 331 | 1.96875 | 2 |
Data from: Genome-wide gene-associated microsatellite markers for the model invasive ascidian, Ciona intestinalis species complex
Lin, Yaping; Chen, Yiyong; Xiong, Wei; Zhan, Aibin (2015), Data from: Genome-wide gene-associated microsatellite markers for the model invasive ascidian, Ciona intestinalis species complex, Dryad, Dataset, https://doi.org/10.5061/dryad.dm98k
The vase tunicate, Ciona intestinalis species complex, has become a good model for ecological and evolutionary studies, especially those focusing on microevolution associated with rapidly changing environments. However, genome-wide genetic markers are still lacking. Here we characterized a large set of genome-wide gene-associated microsatellite markers for C. intestinalis spA (= C. robusta). Bioinformatic analysis identified 4654 microsatellites from expressed sequence tags (ESTs), 2126 of which successfully assigned to chromosomes were selected for further analysis. Based on the distribution evenness on chromosomes, function annotation and suitability for primer design, we chose 545 candidate microsatellites for further characterization. After amplification validation and variation assessment, 218 loci were polymorphic in at least one of the two populations collected from the coast of Arenys de Mar, Spain (N = 24 - 48) and Cape Town, South Africa (N = 24 - 33). The number of alleles, observed heterozygosity and expected heterozygosity ranged from two to 11, 0 to 0.833 and 0.021 to 0.818, and from two to 10, 0 to 0.879 and 0.031 to 0.845 for the Spanish and African populations, respectively. When all microsatellites were tested for cross-species utility, only 60 loci (25.8%) could be successfully amplified and all loci were polymorphic in C. intestinalis spB. A high level of genome-wide polymorphism is likely responsible for the low transferability. The large set of microsatellite markers characterized here is expected to provide a useful genome-wide resource for ecological and evolutionary studies using C. intestinalis as a model. | <urn:uuid:0eee4e6a-06aa-48ad-b640-17a3a464a2b9> | CC-MAIN-2022-33 | https://datadryad.org:443/stash/dataset/doi:10.5061/dryad.dm98k | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571950.76/warc/CC-MAIN-20220813111851-20220813141851-00672.warc.gz | en | 0.903481 | 467 | 1.625 | 2 |
U.S. Chesapeake Flotilla vs. Royal NavySailors provided the backbone of Baltimore's defense during the War of 1812. A strong detachment of U.S. Navy seamen defended trenches on the outskirts of the city while members of the U.S. Chesapeake Flotilla served Fort McHenry's largest cannons in the Water Battery. Here, eighteen men strained to load, aim and fire each of the 12,000 pound cannons as enemy bombs and rockets burst overhead.
|Series||This marker is part of the Maryland: Fort McHenry series|
|Marker Condition||No reports yet|
|Date Added||Tuesday, September 23rd, 2014 at 4:23pm PDT -07:00|
|UTM (WGS84 Datum)||18S E 363811 N 4347209|
|Decimal Degrees||39.26353333, -76.57860000|
|Degrees and Decimal Minutes||N 39° 15.812', W 76° 34.716'|
|Degrees, Minutes and Seconds||39° 15' 48.72" N, 76° 34' 42.96" W|
|Driving Directions||Google Maps|
|Area Code(s)||410, 301|
|Closest Postal Address||At or near 1451-1467 Constellation Plaza, Baltimore MD 21230, US|
|Alternative Maps||Google Maps, MapQuest, Bing Maps, Yahoo Maps, MSR Maps, OpenCycleMap, MyTopo Maps, OpenStreetMap|
Have you seen this marker? If so, check in and tell us about it. | <urn:uuid:72481455-67fc-4375-90f6-375b109ee2f0> | CC-MAIN-2022-33 | https://historicalmarkerproject.com/markers/HM121_sailors-fighting-sailors_Baltimore-MD.html | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.764628 | 364 | 2.09375 | 2 |
We are celebrating Shrove Tuesday with pancakes made from out own hulless oats. A coffee grinder full, and half an egg per person, seems about right, and then enough milk to make it the right consistency. Served with butter and honey it should power us up for the day.Growing cereals and and other small grain crops such as quinoa and amaranth is possible on a garden scale. I have blogged about growing quinoa and oats before. The main problem with the cereals is that birds like them too, and they may need to be netted or harvested while they are a bit green to save them from our wretched feathered friends. Drying them off in the polytunnel in a 'stook' works fine for this. The main drawback with quinoa is that the seeds are covered with a bitter coatng of saponins that must be removed before they are edible. This is a tedious task, and I am working on different ways of doing it. Amaranth likes a good summer.
Grains can all be grown in more or less the same way, on a garden scale. I sow them directly in the ground in rows about 20cm apart. I throw a piece of mono filament fish-netting over the bed, after sowing, to keep the birds off. As soon as the rows can be seen I take off the netting and hoe the bed. This kills the weeds before they get established and the space between the rows leaves room for my swivel hoe. Some cereals such as spelt and perennial wheat do better if sown in autumn, whereas oats, quinoa and buckwheat do fine sown in spring. So long as they are kept weeded they need very little attention until they are ready to harvest. The bird will alert you to this fact. They will be watching them constantly. Then you must act fast and get them under cover. Threshing and cleaning is a bit of a job but very satisfying.
We are running the first of a two part course on growing your own staple foods on the 18th of March. The course will include calculating your food needs, planting potatoes and sowing grains and pulses. You can book here, buy quinoa and amaranth seed here or buy cereal seeds here. Sooo....what is everyone giving up for lent? | <urn:uuid:8b3a5d32-1432-4c54-9f6b-91c33184f8bf> | CC-MAIN-2022-33 | http://brownenvelopeseeds.blogspot.com/2012/02/grow-your-own-pancakes.html | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571950.76/warc/CC-MAIN-20220813111851-20220813141851-00672.warc.gz | en | 0.969501 | 482 | 1.992188 | 2 |
Many people desire being successful and rich, but becoming an entrepreneur means producing a lot of sacrifices – in relationships, fun, and financial low self-esteem. Most people usually are equipped to produce these surrender. To succeed for the reason that an entrepreneur, you should be ready for years of effort and sacrifices. But there are numerous benefits to becoming an entrepreneur. Listed below are some of the major benefits of starting to be an entrepreneur.
Simply being resourceful, risk-taking, and self-motivated are https://scorebloomington.org/2021/10/16/virtual-data-room-pricing-comparison/ just a few of the traits required for an entrepreneur. Enterprisers are also risk-takers who see opportunity almost everywhere and have the drive to make the dreams a reality. Being a powerful entrepreneur does mean continuing the education and learning. While education requirements will change from one market to another, there are a few general requirements. If you are not really prepared to follow graduate college, a business schedule and a passion for the subject can assist you become a good entrepreneur.
The first step in becoming a business owner is to identify a problem or perhaps need that others contain. The business adage says that the service or product you provide must solve a common pain point. This will help you build your business around solving a problem that people confront. You can start the process by thinking like an incomer and identifying problems persons face. Then, you can create your business around solving individuals dilemmas. Whether you will absolutely a man or women, you can start a small business00. | <urn:uuid:3a1aaed3-27bf-43cc-93c3-c956d60470f8> | CC-MAIN-2022-33 | https://miweco.se/the-advantages-of-becoming-a-business-person/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.951649 | 329 | 2.265625 | 2 |
Q: There are a lot of worries about the Fiscal deficit for this financial year. Could you tell us the concerns around it and how the government plans to fund it?
A: Very loosely put, the fiscal deficit is the difference between the government’s expenditure and its receipts. The concern that surrounds it is how do you fill up the gap between your spendings and receipts? Or if you borrow today, how do you repay it tomorrow, and will you have enough to repay it?
And if we don’t borrow today, then how will we finance what we want to do? That is the same decision that any business or economic entity faces. Your borrowings are contingent on your belief that you can generate more income and pay off the debt later. Granted your activities are productive enough to cover the costs of borrowing. It’s the same logic that works for the government, but it can get a lot more complicated sometimes.
The fiscal deficit is higher owing to the huge shock to the economy last year that resulted in low receipts and businesses shutting down.. So, where does the government get its revenue from? Now, since the government does not do any productive activity (like run businesses or earn profits from them), it essentially taxes other productive work, its citizens, businesses, etc. That is how it raises its revenue. Now, when you have an economic shock, especially one as large as the COVID-19 pandemic, your productive activity slows down as businesses aren’t creating much since they are not profitable. So, their tax revenues, which are the proportion of what they produce go down.
So that’s the reason why you have a higher fiscal deficit. Now, the question about concern is really about how optimistic we are about our future and about our ability to meet the government’s increased debt burdens.
So the last part of the question you asked was how do you finance the fiscal deficit. One way is to disinvest. So you have wealth which you sell off and use the assets to finance expenditure.
The second way is that you go to people and borrow. So that’s the debt market. Typically, that’s the way the government fills the gap.
And the third way is by monetizing the fiscal deficit, which is essentially printing money. This is done by the RBI buying the government bonds and printing more money against that. So, it’s essentially just increasing the money supply.
Q: Could you tell us something about the expenditure for the agriculture sector. A lot of reports mention that there isn’t a lot being done for the farmers, even against the backdrop of the protests. Can we observe an emerging pattern of inequality here?
A: Yeah, I have an unpopular view about this. I think the only thing the government or the society can do for the farmers, is to ensure that we have fewer farmers. That is the only way out.
So I think that agriculture adds about 14-15% to our GDP and employs about 45-48% of the people. That is where you have inequality. At the upper end, you have people who are in productive sectors like services but on the lower hand, people are tied to agriculture.
Increase in productivity with so many farmers is bad for the farmers, it is good for the consumers. So the only thing the government can do is, therefore, focus on moving people away from farming into value-added activities. Typically it would involve people moving to cities and into manufacturing or services. Our problem has been that we don’t have a manufacturing sector, so we have been unable to implement this transition. And it is a very difficult transition as services typically require the kind of skills and human capital that people in rural India don’t have. So now what happens? This is a structural feature and the government has two choices: either people’s income increases itself so that they are no longer poor and reliant on you or if they remain poor, you will have to pay to support them. And that is the essence of this distinction between growth and inequality discussion.
If you don’t do anything in terms of investing in people, if the skills don’t improve, if they don’t engage with other jobs, there’s nothing you can do. None of them are leaving agriculture or moving away from social security schemes. So where do you bring the money from? So to me, this expenditure needs to be balanced. This choice needs to be made. And the only way to have to be able to manage this is to invest in growth.
Q: So does the government have to invest in education training or similar programs to encourage having fewer farmers in the agriculture industry to increase labour productivity?
A: See that is unfair. We all blame the government, but it is a difficult job to do. As I said, the government doesn’t engage in productive activities, but what it can do is enable the right kind of environment to generate productive activity. The bottom line is that businesses need to grow.
We need more of the right kinds of businesses and entrepreneurs, and more formality in our labour markets. The government’s job is to worry about why jobs are not being created. Now what they can do to resolve this is to encourage entrepreneurship and increased business activity so that people can start or grow businesses and hire more people.
Now, what is the challenge here? Consider how in a lot of banks that you deal with, look at what has happened with the call centres. They’ve all been replaced by chatbots. Call centres are not really skilled jobs. You just have to talk to people. But they were a huge boost to India in some sense, because they moved a lot of people out of lower-middle-class backgrounds into a sort of middle class, but now they’ll all go away. Just like how mobile phones ran out the STD booths. This is a reality that we are going to run into very soon. So what should the government do now? Well, at the micro-level, they should essentially invest people with enough skills and create an environment which encourages business activity.
So when we think about what the government can do in terms of job creation, I think over the long term, we need to be cognizant of the fact that by its own admission, this government is spending huge amounts of political capital on digitization but aren’t spending anything on creating it. The question is who will work in those areas? So if I look at the education of the labour force today in India, 28 to 30% or one-third of our labour force is illiterate. We don’t have the labour composition that can be a part of this economy that we are talking about. For example, mobile phone penetration in India is high, but only in absolute numbers. So it is a huge market for people. However, the government’s job is not to create huge markets, but to figure out what is happening to those people who don’t have mobile phones. How will they survive?
The digital divide in this country is huge. So, what technology 4.0 we are talking about? We don’t even have automation of the basic kind right now. Most businesses in this country don’t have computers. We really need to understand the reality in which we exist.
We have this challenge in the long-term that we need to start acknowledging and addressing now, and then you hope that there is enough creativity and innovativeness in your country’s population, which will take care of itself. And I believe there is. The government’s job is just to create and keep creating the right environment and then hope for the best.
There are things that they do in terms of job creation, for example, investing in infrastructure will create jobs, but they’ll create construction jobs. The whole world is moving towards, you know, having AI, ML and robots in construction and moving people away to more productive work. We are trying to create jobs where we have people moving from agriculture to construction. This is okay for now, but is this really what we want for the future? These are some hard questions that we need to answer.
Q: We also wanted to ask you about your expectations from the budget and whether or not they were met?
A: Honestly, I think this is a fair budget and I’m quite okay with it.
One of the things that I do like about the budget is asset monetization. There’s a lot of land that is lying around, which is not the government’s job to hold anyway. So, releasing productive assets and transferring them to other people in the economy who can use it better is a great idea. I would also like the Indian government to have a national social infrastructure pipeline at some point.
And I really would like them to have a plan, (like the one that they have for capital expenditure they’re making on infrastructure, for example; in which they give a plan for three, five or 10 years) for education and health. I think now is the time to make commitments. India needs to start thinking about how they’re going to tackle this problem of a low level of education and skilling and increasing enrollment ratios in secondary education.
There is all this discussion around technology 4.0, but how are we going to do it? Our kids don’t even finish school. So what are they going to do? They just want to use YouTube. They become a market for others. Agreed, the mobile phone penetration is high in India, but that just increases the size of the market for somebody else, because the technology is not in the hands of producers or entrepreneurs, that technology is in the hands of consumers. So yes, we’re consuming technology a lot, but what are we doing with it? Or we are basically giving a huge market to Google and Facebook and YouTube.
And yes, we can replace TikTok with Tik Kik and PUBG with FAU-G. But that is not what we need to do. If you want to harness this technology, you need to turn these to as many people as possible, especially to producers and entrepreneurs.
We really need to have a plan for education and health, just like we do for other forms of investment because human capital is a form of investment, not expenditure. We really need to get our act together there.
Q: There’s a lot of information available about the budget. What would you recommend as a good, informative source for somebody who just wants to understand it?
A: I would suggest that you just look at the budget documents, they are annotated along with footnotes explaining everything. You can just go to the website (www.indiabudget.gov.in).The best way to learn for yourself is to spend time on it and make your own judgments, that is what I would advise.
Nishant Chadha is a Fellow and Head of Projects at the India Development Foundation, and a visiting associate professor of Economics at Ashoka University. | <urn:uuid:61032a4b-7062-4056-9766-386962bfe093> | CC-MAIN-2022-33 | https://openaxis.in/tag/union-budget/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571222.74/warc/CC-MAIN-20220810222056-20220811012056-00672.warc.gz | en | 0.971053 | 2,300 | 2.515625 | 3 |
Starting a New Project: Tools of a Technical Writer
Facile pen, subject knowledge, and ability to transform technical subtleties into clarities for the end-users — these are must-have talents for a technical writer. Indeed, there’s more to it — we have already written about the skills of a good tech writer. Today we’ll focus on how technical writers start a new documentation project, what they do for starters, how they gather information, and which tools they use.
Any new product is taking shape from the conception and planning stage, then progressing to the product development stage and finally reaching the product delivery stage. In the same way, when technical writers start a project, they go through the following three steps: collect, record, and publish. In this article, we would like to elaborate on the research mastery when creating technical documentation for a product.
Expected Audience: Aim Wisely
A technical writer’s primary job is to document new procedures or product features. At this stage, a technical writer should identify the potential document users and various documentation requirements of the product or feature.
In order to write for the intended audience, tech writers should put themselves in the place of target readers, see the problems they may face, and show them how to efficiently solve the issues with the product.
Technical writers should avoid getting stuck in introductory information they had to learn themselves and instead concentrate on things specific to the company’s tool, which might be immediately useful to users. Conversely, when writing documentation for the average user, it is easy for the technical writer to get too technical or too detailed. Part of the art of technical documentation is knowing the right amount of detail to convey depending on the user. A good tech writer uses featured snippets to solve the issue. Their central aim is to directly answer the user’s query in a clear and concise manner with a piece of text extracted from an article on that subject.
A tech writer must determine what the readers are looking for when they begin to read the document and what they’ll get out of it.
That’s when data analysis tools come in handy, such as Google Analytics, MOZ, or Zotero.
Architecture: Build Your Document
Bearing in mind who the users are, the tech writer can then conceptualize and plan out the document. Good information architecture is a key supplement to the main product architecture. Well-structured content can be used wherever required in any context. However, technical writers may not have the macro level product vision to handle this stage. Still, let’s enlarge upon that subject to understand the purpose.
To visualize the design of a system, a standard modeling language (SML) or unified modeling language (UML) is used. It helps developers specify, visualize, and construct. The core essence of data modeling — plotting and illustrating the relationship between various entities. The documentation done in the process helps the technical writer greatly conduct technical communication. Naturally, tools used in this phase are more design/modeling tools than technical writing software tools.
These are called data modeling tools, such as Draw.io, Lucidchart, MySQL Workbench, and the like.
Elicitation: Consult SMEs
After a tech writer has the concept, he/she should collect information for new documentation. The first thing to do is ask questions-and that means extracting information from one or more subject matter experts (SME) through an interview. Interviewing SMEs is not that simple; it takes preparation and technique. It’s a soft skill that can pay big dividends well beyond the immediate technical communication project.
STC Fellow Rich Maggiani noted that “Interviewing is research as a social act.”
Every technical writer knows that when preparing to interview an SME, you must do your homework, i.e., doing the background research. Search out existing technical, promotional, and informational documents to provide an overview of the product or service. Start with the company intranet, network directories, and even bookshelves that might contain hard copy information, and expand your search to the internet to get publicly available information.
All notes and data gained should be recorded somewhere. That’s when you use such tools as MS Word, NotePad, Google Docs. It is better to summarize all the relevant information in a flowchart.
After all the preparation phases, the writing begins, along with reviewing, editing, and publishing. All these are better to perform in a help authoring tool. ClickHelp fits here perfectly. It’s a browser-based documentation tool to create online user manuals, knowledge bases, help files, and publish them in a portal. With so many features at your fingertips, ClickHelp can make your work process better.
Other tools that might be useful for working with content are:
- Clip2net, ShareX, Lightshot for taking screenshots;
- Defect tracking systems like Jira, Mantis, Redmine — to track labor contribution for a project and tasks to perform;
- Camtasia for videos;
- Grammarly for spell checking;
The toolkit of a technical writer is diverse and manifold. Producing effective technical communication content requires that you’re ready to seek out the experts, ask the relevant questions, and shape the answers into content that your audience wishes to consume. Interviewing SMEs is a technique for extracting essential information that comes with practice.
An excellent technical style is a great way to avoid a situation where the reader begins to wonder how competent the author is on the subject at hand. And remember: if you think loud and clear, your writing is crisp.
Good luck with your technical writing!
Author, host and deliver documentation across platforms and devices
Originally published at https://clickhelp.com. | <urn:uuid:f3050a75-19b0-467e-b3c3-7c66532a65ee> | CC-MAIN-2022-33 | https://medium.com/level-up-web/starting-a-new-project-tools-of-a-technical-writer-9c91a6c3d243?source=post_internal_links---------5---------------------------- | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.904572 | 1,218 | 2.359375 | 2 |
Article – Troubleshooting Zoom Issues – Zoom camera not working
Microsoft Teams for combining team chat and video conferencing. Bbefore hope these best practice tips on Zoom will help you put your best foot forward! In our experience, Meet also doesn’t degrade calls as gracefully as Zoom when meeitng internet connection is slow. No labels. Best apps The 5 best Notion alternatives in The 5 best Notion alternatives in Read the Zapier blog for tips on productivity, automation, and growing your business. You can draw freehand, and the program smooths things out—a crappy circle becomes a perfect one, for example.
– How to test zoom video and audio before meeting – none:
Jan 15, · Check the box next to Hide non-video participants. Turn off the camera/mic before a Zoom meeting. Check the box next to Turn off my video when joining meetings. Click the Audio option. Sep 26, · Professor Robert McMillen shows you how to test audio video and speakers before your next Zoom meeting. Professor Robert McMillen shows you how to test audio video and speakers before your next. Oct 04, · Step 1: Log in to your Zoom account. Step 2: Hover your cursor over the “HOST A MEETING” link at the top-right corner of the screen, and select one of the following options: With Video On. With Video Off. Screen Share Only. Step 3: The website will redirect you to the Zoom app and start a meeting.
How to test zoom video and audio before meeting – none: –
Other participants cannot hear you · If the participant is not joined, they will see an icon that says Join With Audio in the lower-left of their. Video and Audio · Unless your appearance or background is very inappropriate or distracting, turn ON your video. · Test your video and audio before your meeting. Participants are encouraged to test Zoom before All participants must have video and sound turned by the Court to improve your video conference. | <urn:uuid:78178e6e-f5eb-482d-a5f0-cb125970dc9a> | CC-MAIN-2022-33 | https://bigdataghana.com/2022/07/10/how-to-test-zoom-video-and-audio-before-meeting-2/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571950.76/warc/CC-MAIN-20220813111851-20220813141851-00672.warc.gz | en | 0.87986 | 416 | 1.507813 | 2 |
As we work to grow our firm further, it sometimes happens that we have used all the features QuickBooks software has to offer, but few things still remain unaccomplished which cannot be done by the application alone. This can be annoying and frustrating if you are on a busy schedule and lots of data must be entered into the system.
QuickBooks Desktop hosting offers functionalities to make accounting easier. But, as with most applications, it doesn’t have everything a user may need. However, there are many things a user can do with the help of QuickBooks add-ons (which can be from a third-party provider or Intuit itself).
These QuickBooks add-ons can help SMBs with almost everything from managing cash flow to automating aspects of inventory management, lowering costs, and saving time.
QuickBooks Without Add-Ons
Before the release of SDK (Software Development Kits), Intuit Interchange Format (IIF) files were used to import lists into QuickBooks. While the IIF method is still being used today but is not recommended by Intuit for other than basic functions. Below are some limitations of the IIF method:
- Two-way sharing of data is not possible with this method
- If files contain transactions, import files are difficult to create
- No precautions against duplicate imports of transactions
- The integration is not a smooth process; it needs separate file preparation, single-user mode
- After importing of files, there is no error checking or log file
- Imports may create an accidental odd list of entries in QuickBooks, like a new service item
- No precautions against unintended overwriting of existing entries
Many QuickBooks add-ons are available in the Intuit marketplace which can help you overcome these limitations. Below are some of the benefits of QuickBooks add-ons:
1. Payment Plans
Nowadays clients prefer to have payment plans instead of paying the whole amount in one go. QuickBooks add-ons allow you to automate this feature by offering customized and flexible payment plans for clients. It also lets you regulate terms, fees, and frequency. Once you include a payment plan on your QuickBooks, it automatically updates the invoice balance in QuickBooks.
2. Easier Expense Management
With QuickBooks add-ons, such as Zoho Expense, expense management becomes a lot faster and simpler. Instead of processing and collecting paper receipts, you now have the option to work on digital records. Users can simply take a picture of the receipts, from which the app would create the required digital data and take it forward for approval.
Purchase made by credit cards can also be automatically synchronized. All the expense data would get updated to the pre-set accounts instantaneously in QuickBooks. The spent amount gets credited to the users’ bank account one day after the statement is cleared.
3. Practice Management
QuickBooks add-ons allow automated accounting client on-boarding, workflow deployment, and recurring invoices. There are various add-ons available, for example, LivePlan, that would streamline the process of producing engaging and well-written content to help you secure new clients, thus saving your time.
When integrated with QuickBooks, these add-ons make it easy to send invoices and collect the amount upfront as these add-ons provide a business insights dashboard where it analyses the data drawn from your QuickBooks and present the results in easy-to-understand graphs and charts. So, you can see exactly where your firm is standing and how it stacks up against your competitors.
4. Automated Scheduling Appointments
Another benefit offered by QuickBooks add-ons is that they let you manage client scheduling, invoicing, and payments in one place. One such example of these add-ons is Stampli.
Clients can check the real-time availability, book appointments quickly with no need to contact you, re-schedule with a single click, and make online payments. You will get automatic reminders, approvals, and follow-up messages. You can easily sync all this information with your QuickBooks account.
5. Inventory Management
Although QuickBooks may put a lot of business-related data and information at your fingertips from a browser, inventory features aren’t its forte. There are many QuickBooks add-ons like MiSys that can integrate with the software to help firms with inventory management, manufacturing support tools, sales order processing, all of which are easily accessible from a laptop and smartphone browser.
Some advanced features such as the ability to track items by serial number, support for inventory in different geographical locations, and cost history for particular items are also available with these QuickBooks add-ons.
6. Cash Flow Forecasting
With QuickBooks add-ons, you can keep your company’s finances in order. Instead of being caught in the endless game of keeping on top of your finances, you can stay ahead by filling up your budgets with bills and invoices pulled from the QuickBooks software.
Various add-ons are available which can integrate with the software seamlessly to keep your finances on track. This integration eliminates the need for manual tasks such as data entry, resulting in increased accuracy, reduced time consumption, and an always updated forecast for the users. These add-ons are easy to set-up and understand.
7. Go Paperless with QuickBooks Add-Ons
QuickBooks add-ons can help your firm go paperless by performing a simple task of storing files and documents, which can be easily attached with QuickBooks entry. All you need to do is scan and attach the document to the invoices, record, bill, and other entries and files.
As all your documents are stored in one place, it makes your accounting audit-ready and easy for auditors (both internal and external) to examine the records of the firm.
8. Time Tracking and Employee Management
QuickBooks-addons can facilitate employee management and make time tracking of employees handy. From creating and delegating work schedules to track time of employees, these add-ons (which are GPS-enabled) make it a breeze for clocking time, regardless of the employee location.
QuickBooks add-ons have the ability to track time even in the offline mode and give you updates when network connectivity is available. Once the timesheet data is approved, it is then passed to QuickBooks which is further made available for processing payroll.
9. Set Up Your Facebook Storefront
If you are looking to turn Facebook into a sales channel, QuickBooks add-on is the best option available. With just a few clicks, these add-ons can work with the software to set up a storefront on your Facebook business page.
OneWay Commerce is one such app. With the free version of the app, you can support up to nine products.
Which QuickBooks add-ons are you using? Which ones would you recommend? Do write to us in the comments section.
Chat With A Solutions Consultant | <urn:uuid:4c6a0855-46c0-4062-9af8-8409996c1cd0> | CC-MAIN-2022-33 | https://www.acecloudhosting.com/blog/why-quickbooks-add-ons/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571222.74/warc/CC-MAIN-20220810222056-20220811012056-00672.warc.gz | en | 0.936357 | 1,440 | 1.554688 | 2 |
Lyon, 9 July 2020 – SPIE Industrie & Tertiaire, a French subsidiary of the SPIE group, the independent European leader in multi-technical services in the fields of energy and communications, is currently involved in developing the new veterinary vaccine production unit for Boehringer Ingelheim in Jonage, in the Rhone region of France. The subsidiary was awarded two lots and is involved in four other major lots, including the HVAC, which is at the heart of the client’s processes due to the very exacting requirements in terms of biological containment.
Scheduled to be put into operation in 2022, this 15,000 m² high-tech research and production unit will consolidate Boehringer Ingelheim’s foothold in the Lyon life sciences ecosystem. In the long term, the site will produce 400 million doses of veterinary vaccines each year to fight foot-and-mouth disease and bluetongue disease.
In order to make this major investment, the Technip Energies teams from TechnipFMC, one of the world’s leading companies in engineering and construction of turnkey industrial projects, and the Boehringer Ingelheim teams chose the SPIE’s Industrie & Tertiaire divisions to provide the HVAC services, low-current industrial electricity and instrumentation for two process areas (viral culture and purification). The experience of SPIE Industrie & Tertiaire in the pharmaceutical industry and its expertise in BIM were part of the decision-making criteria.
BIM as a solution for the complexity of the work
The challenge for Technip Energies is to coordinate the numerous parties involved, who all need to comply with a particularly complex specification: “We need 20 to 25 different specialisms to work together at the same time. The job of managing and monitoring all these services, particularly during the study and design phases, is therefore especially important”, explains Franck Bayon, Project Manager at Technip Energies.
Since 2018, the teams at SPIE Industrie & Tertiaire have been working closely with those from Technip Energies as part of a collaborative model hosted on the BIM 360 platform. Starting with the design phase, all the parties involved need to take into account the future work, the end uses and the dedicated operation and maintenance.
A commitment to efficiency that allows SPIE to reduce the lead times and financial and environmental costs involved in implementing the technical equipment.
A fully collaborative platform
Hosted in the cloud, the 3D models are accessible to all the companies involved with the help of BIM 360. “Thanks to its collaborative management, all the service providers have the same level of information and can work directly on the model, carry out implementation studies and use them to draw up 2D plans,” adds Franck Bayon.
During the synthesis stage, Technip Energies chose BIM Track so as to manage any potential conflicts. As SPIE has comprehensive experience in using this platform, it will be able to optimise volumes and perfectly manage the space and any collisions.
At the high point of activity, the project will involve up 70 SPIE Industrie & Tertiaire staff members. The use of collaborative modelling does not stop at the study phase, the model will also be accessible on the site: using tablets, the technicians and supervisors will have access to all the plans during both the implementation and acceptance phases.
“Implementing this project for Boehringer Ingelheim will enable us to strengthen our position as an integrator of smart and agile solutions within the pharmaceutical industry. Thanks to our process knowledge, expertise in installing clean rooms and the responsiveness of our teams, we are a preferred partner for companies in the pharmaceutical industry to support them throughout the lifecycle of their projects: from conception to qualification”, concludes Xavier Daubignard, Business Director in the Industrie Est division of SPIE Industrie & Tertiaire.
“The partnership between Revit and BIM 360 brings a digital dimension to our business areas”, explains Frédéric Moraleda, BIM Manager at SPIE Industrie & Tertiaire. “The model and the data it provides are accessible to everyone from any device (tablet, PC, smartphone). Leveraging this data requires knowledge of how to collect, arrange and use it. This requires commitment from everyone involved. With digital technology, a certain amount of time is needed for people to adapt but mastering this and committing to using it give us greater productivity and traceability in our projects.”
SPIEPascal Omnès Group Communications Director Phone : + 33 (0)1 34 41 81 11 E-mail : email@example.com
SPIE FranceSandra Beau Communications Department Phone : +33 (0)1 34 41 88 61 E-mail : firstname.lastname@example.org
SPIE Industrie & Tertiaire - division IndustrieStéphanie Avenard Communications Manager Phone : +33 (0)6 34 66 50 06 E-mail : email@example.com
SPIE Industrie & Tertiaire - division TertiaireAurélie Antajan Communications Manager Phone : +33 (0)6 71 56 96 42 E-mail : firstname.lastname@example.org
Agence ShanLola Gozlan Senior Consultant Phone : +33 (0)1 44 50 58 72 E-mail : email@example.com | <urn:uuid:17d05dae-06b9-4ce8-858f-a7b1bace9f27> | CC-MAIN-2022-33 | https://www.spie.com/en/news/spie-helping-create-new-veterinary-vaccine-production-unit-boehringer-ingelheim-jonage | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882570793.14/warc/CC-MAIN-20220808092125-20220808122125-00672.warc.gz | en | 0.87423 | 1,184 | 1.539063 | 2 |
There are now two options available for recertification as an Asphalt Roadway Technician.
Exam Only Option
Individuals who pass the written exam with a score of 80% or higher will be re-certified to perform Asphalt Roadway Technician duties on SCDOT projects for a period of three years. No re-test option is available for individuals who do not pass the written exam. If an individual does not pass the written exam, that individual must attend a full Asphalt Roadway Technician course in order to attempt certification again.
No materials may be brought into the exam other than pencils and a calculator. Cell phones must either be left outside the testing facility or surrendered to the proctor during the exam. A clean copy of the course manual will be provided to each attendee at the exam. For preparation purposes, the sections of the manual are available electronically below:
Section 1 - Responsibilities
Section 2 - Materials
Section 3 - Pavement Evaluation
Section 4 - Preparation for Paving
Section 5 - Effect of Mix Design and Plant Production
Section 6 - Placement
Section 7 - Compaction
Section 8 - Control Strips and Target Density
Section 9 - Segregation
Section 10 - Longitudinal Joints
Section 11 - SMA and OGFC
Section 12 - Preventative Maintenance Thin Lift Surface
Section 13 - Problems
Section 14 - Nuclear Gauge
Section 15 - SCDOT Standard Specification SLIDES
Section 16 - SCDOT QA Specification SLIDES
Other SCDOT Resources(*Note)
Note: Other materials in the manual for this course are not posted here because of periodic updates by SCDOT. Those materials include selected sections of the SCDOT Supplemental Specifications, SCDOT Test Procedures, and SCDOT Forms, and SCDOT QPLs. The most updated versions of all of those materials may be found on the SCDOT website (www.scdot.org).
Full Course Option
Individuals who complete the two-and-a-half (2½) day course and pass the written exam with a score of 80% or higher will be re-certified to perform Asphalt Roadway Technician duties on SCDOT projects for a period of five years. If an individual does not pass the written exam but scores at least 60% or higher, one re-test attempt is allowed for an additional fee. In that individual does not pass the written exam during the re-test attempt, the individual must attend another full Asphalt Roadway Technician course in order to attempt certification again.
The course contains a general overview of material including all specification and procedural changes that may have occurred. The participants are also required to perform mathematical problems that occur while working as a roadway technician. The instructors for the course are made up of knowledgeable asphalt industry consultants, equipment manufacturers, academia, contractors and SCDOT representatives. The exam is open notes and open book.
Entry Requirements/What to Expect:
Frequency of Re-certification:
The certification period is three years with the exam only option and five years when taking the full course. It is the responsibility of the individual to keep track of his/her certification expiration date. The individual is also responsible for registering for the re-certification exam or course, attending the re-certification exam or course, and passing the written exam with a score of 80% or higher.
Re-certification Date Policy (as of June 2005):
The SCDOT Technician Certification Board hereby requests that the certification expiration dates for re-certifications obtained within one year prior to the technician's original date of expiration be issued based on the original expiration date. For example, if a technician's certification expires April 2006, and that technician attends a re-certification course and passes the exam in April 2005, his/her certification will be extended five years from the original April 2006 date to April 2011. However, if that technician chooses to attend a re-certification course in March 2005 and passes the exam, the re-certification will be valid from March 2005 to March 2010 (because the technician passed the exam outside of the one-year window). If that technician does not obtain the re-certification before April 2006, then his/her certification expires on that date. | <urn:uuid:226939ae-0a02-4e38-ac91-12ee5d4c76d8> | CC-MAIN-2022-33 | https://www.tctc.edu/programs/corporate-and-community-education/scdot-programs/asphalt-roadway-technician-recertification/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882570793.14/warc/CC-MAIN-20220808092125-20220808122125-00672.warc.gz | en | 0.915621 | 888 | 1.5625 | 2 |
According to the Paleo Diet, we humans would be better off eating like we did back in the caveman days. We should eat meat (lots of meat), vegetables, and fruit; work out intensely (think running after wooly mammoths); and avoid any food that requires agriculture and civilization to produce (e.g. bread, cheese, Twinkies).
Our bodies, the Paleo thinking goes, are evolutionarily geared toward the hunter-gatherer lifestyle: we've only been pyramid-building, wheat-farming, food magazine-reading types for a tiny fraction of our species' history on earth, and our guts just haven't caught up to the modern diet. But according to one scientist, if we're going to base what we eat on how our stomachs evolved, paleo dieters are going to have to go a few million years farther back than the last Ice Age.
Rob Dunn, a biologist at North Carolina State University, wrote a great article on Scientific American's website today pointing out that our real gastric ancestors--monkeys and great apes--mostly eat vegetables, fruits, and nuts. The whole article is interesting, but basically says that we humans are equipped with a digestive tract that evolved to deal with a leafy diet, but has since adapted to eating starchier grains. Our guts can handle pretty much anything we can throw at them (allergies aside), and there certainly isn't any reason to suppose that we're better off eating mostly meat.
You can read the whole thing here (and be sure to forward it to any evolutionarily self-righteous Paleo-ers in your life).
[via Scientific American] | <urn:uuid:17cd9c2d-e4ea-43b8-a269-cc973a0bbc00> | CC-MAIN-2022-33 | https://www.bonappetit.com/trends/article/a-biologist-explains-why-the-paleo-diet-doesn-t-make-any-sense | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571056.58/warc/CC-MAIN-20220809155137-20220809185137-00672.warc.gz | en | 0.955152 | 337 | 2.296875 | 2 |
The purpose of this Special Teams Kickoff Coverage Drills is to teach and practice discipline in staying in position on Punt- and Kickoff-Coverage.
Put 2 players as kickoff coverage players on one sideline on yardlines 10 yards apart i.e. one on the 20 yardline and one on the 10 yardline.
Put a returner on the opposite sideline in the middle of these two. In our example on the 15 yardline.
On command the two coverage players sprint forward to the second hashmark.
Once they reach the 1st hashmark the returner starts running towards them.
When they reach the 2nd hashmark the returner is free to run anywhere he wants, his “sidelines” are the Goalline and the 40 yardline.
The coverage players have to keep him “between” them, narrowing the distance as they get closer to the returner.
- It is important, that the kickoff coverage players keep their distance constant while sprinting to the 2nd hashmark and that they arrive there at the same time if possible. If possible pair them up like they are also on kickoff coverage in a game.
- It is also very important, that the kickoff coverage players keep their hips and shoulder parallel to the returner and the returner must not get outside either of them.
- yardlines and hashmarks (or cones marking the corresponding spots). | <urn:uuid:ff22a2cc-3dc2-4f58-b4d6-62a87a983541> | CC-MAIN-2022-33 | https://www.footballdrills.com/football-team-drills/special-teams-drills/kickoff-coverage-drill/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.963028 | 306 | 2.0625 | 2 |
As was the case with the other Jiles novels I have read, Stormy Weather is a novel of strong women in hard times.
In this case, our heroine is Jeanine Stoddard, who had the bad luck to become a teenager just as the Great Depression arrived. Soon her family have become migrants, traveling from town to town as their father tries to find work.
They lose jobs, lose housing, lose belongings, make do with less and then still less, and then things start to get really bad, until Stormy Weather reaches a point where so many heart-breaking tragedies have been visted upon the Stoddards that I actually put the book down for a while to rest.
And then I picked it back up, and I am so glad I did.
Jeanine and her sisters don't just endure hardships, they triumph over them. She looks adversity in the mouth, gives it a swift punch in the chops, and somehow finds a way through it.
It's interesting to read a book about the Great Depression during the pandemic years of 2020-2021. And it's particularly interesting when it's an extremely well-written book, such as Stormy Weather. We, in our modern times, know only a little about the Great Depression. It wasn't so long ago, but it is now long enough in the past that most of us don't hear about the Great Depression from our grandparents or some other relatives who lived through it firsthand. Rather, people like me learn about the Great Depression from authors like Agee, or Steinbeck, or Dos Passos.
Perhaps Jiles is not yet ready to be classed among these, but Stormy Weather is beautiful and vivid in its own plain-spoken, blunt, direct manner:
So they began to make their lives there, throughout the fall and winter of 1937. They tried to piece their lives together the way people draw maps of remembered places; they get things wrong and out of proportion, they erase and redraw again. From the radio they heard of people dying in the dust storms just to the north of them, in Oklahoma and the Panhandle. That Gloria Vanderbilt was reduced to dressmaking for a living. Of the faraway rich with more money than there ever was in the world while men starved and had no work and women starved and worked both, of strikes at the textile mills in Rhode Island and all the people going to California to pick peas or whatever there was to pick. But the Hamilton clock seemed to tell only of their own long hours of labor against the dust and the drought. They were in the midst of the Dirty Thirties, and that decade's modish obsession with important people in far places, with gangsters and movie stars and oil barons and swing bands. It was easy to feel themselves invisible and empty of significance, to forget that behind every human life is an immense chain of happenstance that includes the gravest concerns; murder and theft and betrayal, great love; lives spent in burning spiritual devotion and others in miserly denial; that despite the supposed conformity of country places there might be an oil field worker who kept a trunk of fossil fish or a man with a desparate stutter who dreamed of being a radio announcer, a dwarf with a rivet gun or an old main on a rooftop with a telescope, spending her finest hours observing the harmonics of the planetary dance.
I'm sure it is easy, if you set out to write a book about the Great Depression, to want to write about "important people in far places," and to forget that the Depression was really about people who were "invisible and empty of significance."
Jiles is fully aware that the way you tell the stories of great events, such as the Civil War (Enemy Women) or the opening of the western frontier (News of the World) or the Great Depression (Stormy Weather), is to tell the stories of the ordinary people who inhabited these places and times. As she reveals in an afterword, the ordinary people in Stormy Weather, like those in Enemy Women and News of the World, were in fact her own ancestors, and the strength and honesty of her writing comes directly from the strength and honesty of these people, doing what they had to in the situations in which they found themselves.
And, somehow, though hard work, patience, effort, and a fair bit of that thing we call luck, such people find joy, as they always do:
This turned the conversation toward marriage in general. They waited out the dust storm that was hammering against the steel sides of the drive shed by giving their opinions on marriage during a time of Depression and drought and dust storms. And a very short man said that no matter what happened in the world people got married. It didn't have anything to do with what the weather was like or if you had any money or not, people just went and got married. Another man said that a war was coming and here this boy was in the service, that was something you had to keep in mind. He could get sent to some aerodrome in a foreign country. But the short man said it didn't matter about wars, either. It was the damnedest thing. He didn't know what would matter, anywise.
And, for me, this is what made Stormy Weather a near-perfect book for me to read during the dark days of the winter of 2020. | <urn:uuid:7c164f6e-e38f-4e02-88ab-ffae3d4292f5> | CC-MAIN-2022-33 | https://bryanpendleton.blogspot.com/2021/01/stormy-weather-very-short-review.html | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571950.76/warc/CC-MAIN-20220813111851-20220813141851-00672.warc.gz | en | 0.981086 | 1,108 | 2.125 | 2 |
Self-care Tips for aHUS Patients
For people with atypical hemolytic uremic syndrome (aHUS), self-care is important to help cope with the multiple health problems resulting from the disease, including hemolytic anemia, thrombocytopenia (low platelet count), kidney failure, nausea, shortness of breath, fatigue, heart disease, and seizures. If you have aHUS, here are some suggestions that can help.
Mind your diet
aHUS can be triggered by various environmental factors — including diet – in people who are genetically predisposed. Certain foods can also be linked to disease flare-ups.
Diet recommendations to help prevent or minimize such flare-ups include avoiding contaminated food, lowering your salt intake, identifying allergy-causing foods and their substitutes, and consulting a dietitian.
aHUS and its symptoms can cause considerable stress, especially if not attended to diligently. Self-care tips for managing stress include understanding your symptoms, cultivating a good diet and overall healthy lifestyle, trying to stay optimistic, and networking with other patients and caregivers.
A tool called mindfulness can help you cope with the stress that often accompanies the challenges of living with aHUS. Mindfulness is the practice of being constantly aware of your thoughts, feelings, sensations, and environment. Rather than rehashing the past or imagining the future, mindfulness means embracing what is sensed at the moment. That can help you deal with life’s ills more calmly and sensibly.
Recognize signs of depression
aHUS affects the kidneys and many patients end up needing dialysis. A 2016 global poll of aHUS patients indicated that 27% of those who had undergone dialysis experienced anxiety and depression, so some people with aHUS may benefit from psychological care.
Signs of depression to watch for include low physical activity, increased irritability and reckless behavior, low work productivity, loss of appetite and sleep, increased dependence on smoking and alcohol, reduced therapy compliance, and suicidal thoughts.
Join a support group
aHUS is a very rare disorder that affects about 20,000 people in the world. The rarity of the disease can make access to information difficult and time-consuming. This is where advocacy and support groups can help. Tips for finding such groups, and what to expect from them include registering for aHUS support services, checking out resources provided by pharmaceutical companies, enrolling in the aHUS Registry, and joining patient associations on social media.
Take steps to cope
It’s important for you and your caregivers to proactively monitor symptoms and take precautions and other measures to help cope with aHUS. That includes keeping track of treatments and blood test results, staying clear of environmental triggers, having an emergency room letter handy, and networking with other patients.
Use the spoon theory
A metaphor called the spoon theory can help you describe to family and friends what life is like with a chronic disorder. According to the theory, you start each day with 12 spoons, and have to give up one spoon for each task you perform: brushing your teeth, dressing, visiting the doctor, making dinner, etc. When you’ve gone through all your spoons, that’s it. Your day is done. By contrast, healthy people usually have all the energy necessary — a seemingly infinite spoon supply — to do whatever they need to do.
Take a trip
If you’re up to it, getting away may do wonders for your overall health. However, travel does take extra planning and preparation. That includes making sure you have enough medicine, undergoing a blood test to check your kidney health, securing a wheelchair or other special accommodation, setting up dialysis treatment, and gathering information the dialysis center will need.
Plan for the future
Because aHUS may affect your lifespan, planning for the future can give you peace of mind. This can, in turn, positively affect your overall health. There are legal and financial considerations, and end-of-life care and organ donation decisions that you might need to make. Discuss your future with your care team, and perhaps a counselor.
Last updated: Aug. 24, 2020
aHUS News is strictly a news and information website about the disease. It does not provide medical advice, diagnosis, or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. | <urn:uuid:3a138e98-31be-40c5-bc11-ef9d5a5fdbe2> | CC-MAIN-2022-33 | https://ahusnews.com/health-insights/self-care-tips-for-ahus-patients/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.943998 | 966 | 2.6875 | 3 |
Law n.º 13.429/2017, which was sanctioned on March 31, 2017, regulates the services provided through outsourced manpower (“terceirização”), as well as changes the legislation regarding temporary employment.
We indicate below the main points contained in the sanctioned law, mostly in regards to the practical changes in these hiring modalities:
About the Temporary Employment Contract:
- Possibility of using the temporary employment contract in order to meet the so-called “complementary demand of services” (understood as the demand resulting from: unforeseeable factors; when foreseeable, factors that are intermittent, periodic or seasonal in nature; or, even in order to replace employees on strike, when the strike is considered illegal or abusive);
- extension of the maximum duration of the temporary employment contract for up to 180 days, consecutive or not, which may be further extended up to 90 additional days, consecutive or not;
- in the event of termination of the period, the temporary worker may only provide services to the same contractor after 90 days from the end of the previous contract;
- minimum share capital requirement of BRL100,000.00 for registration of the temporary employment agency;
- requirements for the validity of the contract between the temporary employment agency and the contractor: (i) qualification of the parties; (ii) justification for temporary work; (iii) term of service; (iv) value and, (v) provisions about health, hygiene and safety of the workers;
- for temporary employees hired for up to 30 days, it is possible to establish a system of direct payment of the installment fees to the Severance Indemnity Fund (FGTS), proportional vacations and proportional Christmas Bonus (13th salary);
- subsidiary liability of the contractor for non-compliance with labor rights relating to the period in which the work occurs.
About the Outsourcing of Services (“Terceirização”):
- the impossibility of forming an employment relationship between the workers, or partners of the companies that provide services, whatever their line of business, with the contracting company;
- minimum capital share requirement (ranging from BRL10,000.00 to BRL250,000.00, according to the number of employees) for the company to provide services;
- the possibility of outsourcing all activities of the contracting company (both the so-called “supporting activities”, as well as the “leading activities”);
- the responsibility of the contracting company to guarantee the safety, hygiene and health conditions of the workers, when the services are rendered on its premises, or place previously agreed to in contract;
- the contracting company may extend to the services-providing company’s employees the same facilities of medical, emergency and meal services for its employees on the premises, or in a place previously agreed to in contract;
- subsidiary liability for labor and benefits obligations related to the period in which the services are rendered;
- requirement for the validity of the contract between the services-taking and the services-providing companies ((i) qualification of the parties; (ii) the justification for the outsourced work; (iii) term of delivery; (iv) value and, (v) provisions about health, hygiene and safety of the workers).
In summary, according to the tenor of the already denominated “Outsourcing Law” (or “Lei da Terceirização”), the possibility of a company to use outsourced manpower without any restrictions was opened up, i.e., it is possible to outsource all the activities performed, including those related to the core business, which was not permitted by the Labor Courts before this Law.
In relation to temporary work, though, the changes were less drastic, but they are still considerably relevant.
It is worth emphasizing that the mentioned Law was sanctioned with partial veto by the Brazilian Presidency. According to the Bill sent to the presidential sanction, initially there was the possibility of the maximum term of the temporary work established by the law to be extended through a collective bargaining agreement, but this permission was vetoed by the President.
The referred vetoes, however, will be voted on by the Chamber of Deputies, which can maintain, or not, these restrictions established by the President. Besides this, it is important to note that there is another Bill currently being drafted in the Federal Senate (PL 4.330/04), that was already approved by the Chamber of Deputies, and also concerns the outsourcing of labor. If approved, this second Bill will allow the Executive Branch to select the legal provisions to be vetoed on either Bill.
* * *
Our Labor & Employment team is available to resolve any doubts and to clarify the Law in question, as well as relevant matters related to it. We are also on hand to evaluate and seek measures to minimize the practical impacts that the Law may cause.
Observations in this update about Brazilian law are by Tauil & Chequer Advogados. They are not intended to provide legal advice to any entity; any entity considering the possibility of a transaction must seek advice tailored to its particular circumstances. | <urn:uuid:e41f26c8-ae76-4816-818c-de7c1888678e> | CC-MAIN-2022-33 | https://www.mayerbrown.com/en/perspectives-events/publications/2017/04/brazil-summary-of-new-law-that-regulates-the-outso | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882570793.14/warc/CC-MAIN-20220808092125-20220808122125-00672.warc.gz | en | 0.958726 | 1,066 | 1.507813 | 2 |
THE SEARCH FOR SOMETHING GOOD ABOUT WWII
This is a story about how a young 18 year old teenager, Betty Jo Bartram met Alvin Waltz, the love of her life and her life long companion. It was a hot August day in 1943, when a special troop train was traveling east (on the N&W Rail Road) from Indian Town Gap Pa. to Camp Picket Va. We would all go down near the RR tracks and wave at the soldiers when the troop trains passed through. I remember them being so long. They would be taking the soldiers to training camps and to the East & West coast for debarkation to the European & Pacific Theaters. It was WWII and we were fighting the Japanese and the Germans at the same time. The logistics would have been enormous moving so many troops and equipment.
On this particular day, Betty, her sister Garnet, cousins Margaret and Juanita Bartram and good friend Thelma Lynch were down by the rail road waving to the troops. This young soldier Alvin Waltz threw from the train a stick of Wrigley’s Chewing Gum with his address. Betty picked up his address and gum. Letters began to flow between them and love blossomed. She kept all his love letters and the gum. Betty jokingly told the girls, she would, “someday waltz him home.”
Alvin was from a farming community in Southern Ill. Betty was living on Sunnyside (Tug River) 2 miles south of Fort Gay, WV near the N&W Rail Road Tracks. Betty like so many sweethearts, wives, sisters and even mothers went to work in factories. They had all been retooled as defense plants to make war materials, tanks, guns, air plains etc. to fight with. Betty went to work for Dominion Electric in Mansfield, OH. She was making smoke bomb casings. The ladies were referred to by some as “Rosie the Riveters”. Many young people do not realize that there were no automobiles made in the years 1943, 44 or 45 due to the war.
Betty’s Father, Harlan Bartram was concerned about his daughter and this soldier that no one had ever seen. He ask his niece, Carnas (Bartram) Branham to write to the Post Master in Alvin’s home town (Eldorado Ill.) and inquire as to Alvin’s character. She did, and the Postmaster responded, giving Alvin and his family high marks. (Things sure have changed).
Before being shipped overseas, Alvin got a furlough and came to Mansfield to visit Betty, where they met for the first time, while she was working at Dominion Electric. Later, Betty and her Sister- in-Law Lena Mae took a trip to Ill. to visit Alvin’s parents and extended family.
Alvin was then shipped to England. One of his initial duties was being a driver for generals. He even drove for the Supreme Commander, General Dwight D. Eisenhower. Alvin was in HQ. Btry. 54th Armored Battalion, Third Armored Division. Alvin was in a lot of combat and survived many battles. He made the Normandy Landing. He drove across France in a ammunition truck named “Patsy” and was in the Battle of the Bulge. During his service he suffered a ruptured appendix and had yellow fever causing him to lose his hair. He had 4 brothers that were within just a few miles of each other, but never crossed paths. They all 5 came home safely. The war ended in Europe on May 8, and in Japan on September, 2 1945. Alvin was discharged on October 3, 1945. Alvin had served 2 years prior to Pearl Harbor, from 1939 to 1941. He had been home only 1 month before being called back into service.
Betty and Alvin were married October 12, 1945 only 9 days after his discharge, by the Rev. J. C. Hager, in Louisa, KY. She had waltzed him to the altar as she had predicted. They lived on Sunnyside and for a brief time in Ill. before moving to Louisa. He worked for Lee Hinkle, in his furniture store. They then moved to Mansfield, OH and he worked at Westinghouse before being laid off. He then worked for Mansfield Plumbing Products until his retirement in 1976.
Betty and Alvin had two Children. Sherry (Earl) “Butch” Smith and Frank (Deborah Dotson) “Debbie” Waltz. The Waltz family bought and lived on an 82 acre farm reliving similar experience they had grown up in. This was in the Lucas-Bellville, OH area. Betty enjoyed quilting, sewing and gardening. Alvin enjoyed woodworking, gardening, fishing and camping. Alvin born April 5, 1913 was 101 years old when he passed away on February 3, 2015. Alvin was from a family of 11 children. Betty born November 26, 1924 passed away 5 months later on July 7, at age 90. She was from a family of 6 children. Betty and Alvin were married for 69 years and lived in the Colonial Manor together the last 5 years of their lives.
As described above, WWII changed so many lives. Some for the better and some not so good. I recently wrote a story about Betty’s 1st cousin Jerry Bartram that was killed August 9, 1944 in Saint-Lo, France in WWII. That story, unlike Betty’s, revealed the ravages of war and the affect on so many lives.
–John Jarrett Peters, President WCGHS | <urn:uuid:4dba0bd1-b946-41e7-ab3e-209daee5b1bd> | CC-MAIN-2022-33 | https://www.thelevisalazer.com/2017/06/15/the-search-for-something-good-about-wwii/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571222.74/warc/CC-MAIN-20220810222056-20220811012056-00672.warc.gz | en | 0.989583 | 1,185 | 1.679688 | 2 |
There are plenty of good reasons to examine how writing is taught in schools; however, this week, an article looked at how it probably shouldn’t be taught.
Also, a teenager writes about the value of writing outside the classroom, MAD magazine is celebrating a birthday, Google n-gram improves, and a look at the origins of the word “sketchy.”
More on the writing revolution: A few weeks ago, The Atlantic began a series of articles and essays about why American students can’t write. The root article explored a high school in New York that turned itself around by focusing on writing in all classes. That article’s author wrote a follow-up piece urging other schools to follow the example. Too often, she said, schools rely on creative writing classes as the only necessary writing instruction: “The assumption, it seems, is that coherent sentences spill from children as easily as tears or laughter, as long as teachers are nurturing and provide a safe space.” Instead, schools should do what New Dorp High School is doing by teaching kids to articulate thoughts through writing about any subject, according to the author.
A Teenager’s Take on The Importance of Writing: Reminding us that writing can aid learning in school or in life, the Learning Network blog at The New York Times featured a post from a teenager in a foster home, and how writing has helped him cope with loss. Also a good lesson on dedication—”three pages every night before I go to bed.” | <urn:uuid:148669a4-4677-4cee-af4c-b89d1b08f1ba> | CC-MAIN-2022-33 | https://www.prdaily.com/how-not-to-teach-writing-in-schools/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.9673 | 317 | 2.78125 | 3 |
Glitches Mar Voting, Frustrate Voters in Georgia, Other States
The 2018 U.S. midterm elections wound to a close Tuesday amid voter frustration in some parts of the country as worries about cyberattacks gave way to concerns about voting irregularities in a handful of states.
From Florida to Georgia to Texas, election monitors reported a gamut of glitches, from broken voting machines and a shortage of paper ballots to unexpectedly shuttered polling stations and agonizingly long lines.
Officials were quick to note, though, that problems were isolated and rapidly addressed by election officials. If so, it was little consolation to those voters who in some cases spent hours lined up to cast a ballot – and sometimes never got to do so.
In Georgia, Ontaria Woods said she waited more than three hours at a Gwinette County polling place and saw two dozen people who had come to vote leave because of the lines.
"We've been trying to tell them to wait, but people have children,'" Woods said. "People are getting hungry. People are tired."
Nowhere was the frustration more palpable in Georgia, where Democrat Stacey Adams was running to be the country’s first female black governor against Republican Brian Kemp, the secretary of state whose oversight of elections was a central campaign issue.
Voters reported showing up only to find that their names were not on active voter registration rolls. Others said they’d been denied provisional ballots, Sara Henderson, executive director Common Cause of Georgia, told VOA.
After numerous reports of long lines, malfunctioning equipment and other issues, Common Cause got two local judges to extend voting hours at several precincts.
But Henderson said the results in close contests may not be known for several days or longer. That is because voters who cast provisional ballots would have to return to their election boards within three days to have their ballots validated.
"I think we’re in for a few days of trying to figure all this out," Henderson said.
Well before Tuesday’s vote, Georgia’s electoral system had drawn the scrutiny of voting rights advocates. Last month, Common Cause petitioned a court to block a state law requiring voter registration forms to exactly match data on file with state agencies.
The law had potentially barred more than 53,000 Georgians from registering to vote.
Many of those affected by the ruling were later allowed to register after a court issued an injunction temporarily suspending the match rules.
Elsewhere, reports of broken ballot scanners surfaced at several polling places in New York City, the Associated Press reported.
Turnout was so heavy at one packed precinct on Manhattan's Upper West Side that the line to scan ballots stretched around a junior high school gym. Voters arriving at two separate polling stations discovered that most scanners had broken down, forcing some people to drop their ballots in "emergency ballot boxes" or vote with an affidavit ballot.
"There are broken scanners everywhere in Brooklyn," Stefan Ringel, spokesman for Brooklyn Borough President Eric Adams, said.
In Phoenix, a polling site was foreclosed on overnight. The owners of the property locked the doors, taking election officials by surprise.
Voters had been sent to another precinct nearby, but Maricopa County Recorder Adrian Fontes said the location in Chandler was up and running shortly after 7 a.m. Tuesday.
For about an hour after polls opened Tuesday morning, a Sarasota County, Florida, precinct had to tell voters to come back later because their ballots were not available.
Computer problems snarled voting for hours in Indiana, where a judge ordered 12 polling places in one northwestern county to stay open late after voting didn't start on time.
In Texas, home of a narrowly contested U.S. Senate race, delays were reported in Houston after apparent issues with registration check-in machines.
The U.S. Border Patrol also canceled a "crowd control exercise" that was scheduled for Tuesday in El Paso after criticism from civil liberties groups that it was too close to a polling center and could scare voters away.
Federal officials said there were no signs of any foreign cyberattacks on critical election systems, although social media trolls targeted some voters with misinformation.
Several hours before polls closed, Homeland Security Secretary Kirstjen Nielsen cautioned that the Russians "have a full court press through many means."
Still, officials insisted that two years of preparations are paying off as intrusion sensors had found no evidence of hacked systems.
There were "no tie-backs to any foreign actors that we’ve seen," said Chris Krebs, undersecretary for the Department of Homeland Security’s protection directorate.
Social media companies acted swiftly to take down what appeared to be deliberate misinformation, Krebs said. Several incidents were referred to law enforcement for investigation.
Nearly 100 million Americans were expected to take to the polls in an election that was widely seen as a referendum on the presidency of Donald Trump. A record 36 million Americans cast their ballots during early voting.
National Security Correspondent Jeff Seldin contributed to this report. Some material for this report came from The Associated Press. | <urn:uuid:04e536bc-0acd-4d82-9661-9b5005390102> | CC-MAIN-2022-33 | https://americasvoice.news/glitches-mar-voting-frustrate-voters-in-georgia-other-states/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.974775 | 1,043 | 1.929688 | 2 |
Exciting places in Sweden
8 unique places in Sweden worth exploring
Did you know that there are "talking" stones in Sweden and a narrow gorge just 1-2 meters wide that would be a fun challenge to cross? These are just a few places you can visit by car at a pace that suits you. Rediscover road trips and explore interesting places.
Bexell's Talking Stones
Allow enough time to enjoy every word engraved on the stones in the forest. On the stones you will find quotes from fiction, more than 180 aphorisms and the names of famous state and public figures. Alfred Bexell, a landowner and member of parliament, implemented his idea with the help of two stonemasons in the 19th century. He did so most likely to share his interest in exploring history and philosophy with future generations. These engravings were discovered by chance in the early 1930s. It is said that not all of the "talking" stones have yet been found. Therefore, when you visit Sweden, Varberg, it is definitely worth going to the forest to admire these stones and, who knows, maybe you will find another "talking" stone that has not been found so far.
Borras mountain range
Have you walked under a rock? An exciting place that is definitely worth discovering is located in Varöbacka, Halland County. It is a mountain range in Borras which is 10 m deep and 1-2 m wide. Put on comfortable shoes and go through a nearly 100 m long mountain range, at the end of which there is a stone trapped at a height of about 1.5 m. Going under the rock is definitely worth capturing with a camera or phone. Admire views of the surrounding area from the plateau at the exit of the mountain range.
Dala horse and wooden bear
Did you know who is one of Sweden's four largest predators? A bear. And did you know that Sweden has the largest bear statue in the world, 13 m high and 80 tons heavy? The symbol of the small town Sveg, a wooden bear, is made of wooden boards.
In addition to the largest bear statue in the world, you can also see the largest statue of a dala horse in Sweden, 13 m high and 12.8 m long. While Dala horses are usually made of wood and decorated with brightly colored details, the statue on the Dalarna border in Avesta is made of concrete. If you happen to visit the Dalarna Museum, you will find it in the permanent exhibition by Tomas Holst made in 2000 in the early shape of the world's smallest dala horse.
Orsa predator park
In Europe's largest predator park in Orsa, you can observe predators in their natural environment. In addition to bears, wolves and lynx, you can also see a Persian leopard, a snow leopard and an Amur tiger in the park. Exciting discovery can also be seen in the Polar World in the park, the Leopard Center and the Tiger House. Predator Park is open all year round.
2-3 hours is not enough to visit the most famous and largest zoo in the Nordic countries in Norrköping municipality, you should consider the whole day, because there is excitement and joy of discovery for visitors of all ages.
In the safari park you can ride a gondola at the top of the trees and watch the lions and giraffes from above. Enjoy a dolphin show in the dolphinarium, watch predators up close in the Tiger World. Also, the smallest visitors to the zoo can have fun in the world of the bear Bamse.
In Sweden you will find both pristine sandy beaches and crowded city beaches. It takes time to get to Böda beach on the east coast of the island of Öland, but the kilometers of white sand beach is worth it. In the southern part of the beach there are cafes, showers, camping sites and the opportunity to play various ball games. Tylosand Beach in Halland County, which is popular with locals and tourists alike, is the best time to enjoy from July to August, when the water is warm enough. Within walking distance of the beach are cafes, restaurants, hotels. | <urn:uuid:57f940a4-4a96-47de-8deb-213f967d6465> | CC-MAIN-2022-33 | https://www.dfds.com/en/passenger-ferries/destinations/sweden/interesting-places-to-visit | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.958404 | 879 | 1.84375 | 2 |
Any fans of Bubble Guppies out here? We sure do in this house! Ms C loves bubble guppies especially Molly. For those who don’t know Bubble Guppies, it is shown at 9.30am on Nick Jr. It is an interactive show that teaches kids about a wide range of topics – from dinosaurs to dentists, rock & roll to recycling, and colours to cowboys. Through these topics, kids learn about science, maths, literacy, and much more in this preschool musical comedy set in a vibrant, aquarium-inspired underwater classroom.
We were sent these Fisher Price Bubble Guppies for review:
- Rock and Roll Stage
- Goby Rolling Figure
- Oona Rolling Figure
- 8″ Molly Plush
Setting up the Rock and Roll Stage is straightforward and requires just 5 easy steps. Simply push and click the pieces together and paste the stickers. It requires 3x AA batteries which are not included and you will need a small Philips screwdriver to open the battery compartment. I love that the stickers are quite thick and glossy. It is not the cheap paper kind that would rip easily.
You launch the guppies by placing them on the top of the dressing room mirror. They pass through the star doors and rolls down the ramp. When they hit the light-up stage, the music will come on. You can also press the button for it to play a song from the TV show. This set comes with Molly rolling figure and 3 play pieces which are fixed.
At the end of the stage, you can add more ramps by buying individual guppies. These are the two characters with their ramps provided. Each rolling figure has a metal ball in the base to help them slide down the ramp. They are well made and should withstand a lot of bashing. All these toys are suitable for 18 months and above. By adding more guppies, the children could be encouraged to be a lot more imaginative. The 8″ Molly Plush is very well made and cuddly. Ms C is cuddling her in bed tonight!
This is a short video I made to show you how it works.
Disclosure: We received the samples for the purposes of writing this review, however, all thoughts and opinions remain our own. | <urn:uuid:a975f163-16c6-4820-8e43-d0d826bebcb7> | CC-MAIN-2022-33 | https://etspeaksfromhome.co.uk/2013/07/fisher-price-bubble-guppies-coming-to.html | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571222.74/warc/CC-MAIN-20220810222056-20220811012056-00672.warc.gz | en | 0.960109 | 468 | 1.625 | 2 |
According to Edelman’s 2013 Trust Barometer, there’s a crisis in leadership: less than 1/5th of the general public believes business and government leaders will tell the truth when confronted with a difficult issue. In spite of billions spent on leadership development, many haven’t been equipped with the personal, daily moral awareness necessary to navigate complex business issues
To address this gap, Mikael Meir has designed a series of Ethics Workshops for the corporate world. Combining his experience as a teacher of Ethics in Finance at Schulich School of Business (Toronto, Canada), along with a profound personal understanding of the architecture of unethical behavior, Meir’s workshops are engaging, interactive, experiential and filled with real-life stories
The content is customized to include examples of ethical issues that arise in your industry.
- Ethical rules and frameworks that can be applied to individuals’ functional roles
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Formats Available: Keynote Address, Half Day Workshop, Full Day Workshop, Small-Group and Panel Discussion, Webinars, Tele-seminars
To engage Mikael for your next event, please get in touch by phone at (416) 465-5667, or email him. | <urn:uuid:b24f389d-2de8-4e28-a81f-87c79df4a8a6> | CC-MAIN-2022-33 | https://mikaelmeir.com/speaking/ethics-programs/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571056.58/warc/CC-MAIN-20220809155137-20220809185137-00672.warc.gz | en | 0.927172 | 330 | 2.015625 | 2 |
Biologiska effekter av fysisk aktivitet - FYSS
This can be a Molecular Weight (g/mol): 569.16 MDL Number: MFCD00150754 InChI Key: NTBQNWBHIXNPRU-MSQVLRTGSA-L Synonym: atp disodium salt hydrate, atp Molecular Weight (g/mol): 569.16 MDL Number: MFCD00150754 InChI Key: NTBQNWBHIXNPRU-MSQVLRTGSA-L Synonym: atp disodium salt hydrate, atp Nyckelord: Adenosine Triphosphate/pharmacology, Humans, Kinetics, Lycopersicon esculentum/drug effects/*enzymology, Molecular Weight, Protein Structure, av CE Andersson · 2004 — Catabolism is the set of reactions where nutrient molecules are converted into smaller products while energy and reductive power are produced in the form of ATP. av N Nourizad · 2004 — The excess of dNTP(s) and the ATP produced are removed by the nucleotide degrading The enzyme has a molecular weight of 315 kDa and consists of six Choose from a range of DNA, RNA and protein molecular weight markers. Use the DNA molecular weight markers for both conventional and pulsed field gel A novel method was developed in this study based on the expression of P2X2 receptor channel in secreting cells. The presence of ATP sensitive channel on the Mol. formula: C15H12O. formula. Hazard classification & labelling Help material including extremely high molecular weight hydrocarbons obtained as a solid Thymidine Kinases are coupling a phosphate group from ATP to the dimers to tetramers with a molecular weight of approximately 100 kDa4.
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Nucleic Acid Molecular Weight Conversions Exact M.W. of ssRNA (e.g., RNA Transcript): M.W. = (An x 329.2) + (Un x 306.2) + (Cn x 305.2) + (Gn x 345.2) + 159ª Black lines in the MW lanes are magic marker on the film to indicate the positions of the prestained molecular weight standards on the blot. For full image please see paper. Western blot - Anti-ATP5A antibody [15H4C4] - Mitochondrial Marker (ab14748) Computing molecular weight (molecular mass) To calculate molecular weight of a chemical compound enter it's formula, specify its isotope mass number after each element in square brackets. Examples of molecular weight computations: CO2, SO2.
Resveratrol is These proteins include the mitochondrial ATP-sensitive K+ channel (Costa et al. 2005; Jaburek et al.
IJMS Free Full-Text Fructose and Uric Acid: Major Mediators
The mitochondrial ATP synthase is a multimeric enzyme complex with an overall molecular weight of about 600,000 Da. The ATP synthase is a molecular motor composed of two separable parts: F1 and Fo. Se hela listan på bodybuilding.com ATP synthase is one of the wonders of the molecular world.
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Structure of an ATP Molecule. If you’re well-versed with organic chemistry, then you’ll probably agree that the structure of an ATP molecule is no biggie. Molecular Weight Formula; 507.1834: C10H16N5O13P3: ATP is also known as adenosine triphosphate. Model Sets That Can Build ATP. methyl (hydroxy-phosphonooxy-phosphoryl) hydrogen phosphate , 56-65-5 , ATP , adenosine-5\'-triphosphate , adenosine-triphosphate , adenylpyrophosphate , Laevadosin , 1975-01-23 In this work, we report on an ATP-responsive low-molecular-weight polyethylenimine (LMW-PEI)-based supramolecular assembly. It formed via host–guest interaction between PEI (MW = 1.8 kDa)-α-cyclodextrin (α-CD) conjugates and PEI1.8k-phenylboronic acid (PBA) conjugates.
Definitions of molecular mass, molecular weight, molar mass and molar weight
Mitochondrial membrane ATP synthase (F(1)F(0) Black lines in the MW lanes are magic marker on the film to indicate the positions of the prestained molecular weight standards on the blot. For full image please see paper.
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That's really cool. So what does this mean? Featuring tennis live scores, results, stats, rankings, ATP player and tournament information, news, video highlights & more from men's professional tennis on the ATP Tour. Glucose has a molecular weight of 180 Da, and contains the same amount of energy as 31 ATP molecules; Fatty acids vary in size, but a gram of fat contains about twice as much energy as a gram of glucose (or glycogen) The difference in energy density is huge, you would need enormous amounts of ATP to replace glucose/glycogen as energy storage 2010-05-12 · The question is: adenosine triphosphate (ATP) is an important substance in all living cells. A sample with a mass of 0.8138 grams was analyzed and found to contain 0.1927 grams of carbons, 0.02590 grams of hydrogen, and 0.1124 grams of nitrogen, and 0.1491 grams of phosphorus. The remainder was oxygen. Its formula weight was determined to be 507.
Mitochondrial membrane ATP synthase (F(1)F(0) ATP synthase or Complex V) produces ATP from ADP in the presence of a proton gradient across the membrane which is generated by electron transport complexes of the respiratory chain. Predicted molecular weight: 120 kDa. Target. All lanes : Anti-ATP citrate lyase antibody (ab157098) at 0.4 µg/ml Lane 1 : Jurkat whole cell lysate at 50 µg
We assume you are converting between moles AtP and gram. You can view more details on each measurement unit: molecular weight of AtP or grams The SI base unit for amount of substance is the mole. 1 mole is equal to 1 moles AtP, or 240.973761 grams.
Living cells maintain the ratio of ATP to ADP at a point ten orders of magnitude from equilibrium, with ATP concentrations fivefold higher than the concentration of ADP. ›› AtP molecular weight. Molar mass of AtP = 240.973761 g/mol. Convert grams AtP to moles or moles AtP to grams. Molecular weight calculation: 210.0 + 30.973761 ›› Percent composition by element Adenosine 5′-triphosphate disodium salt hydrate (ATP); Grade I, >= 99%, microbial source; P2 purinocepter agonist; P2 purinergic agonist; increases activity of Ca2+-activated K+ channels; substrate for ATP-dependent enzyme systemsAdenosine 5′-triphosphat Molecular Weight: 529.47 g/mol: Computed by PubChem 2.1 (PubChem release 2019.06.18) Hydrogen Bond Donor Count: 5: Computed by Cactvs 18.104.22.168 (PubChem release 2019.06.18) Hydrogen Bond Acceptor Count: 17: Computed by Cactvs 22.214.171.124 (PubChem release 2019.06.18) Rotatable Bond Count: 8: Computed by Cactvs 126.96.36.199 (PubChem release 2019.06.18 Search results for atp at Sigma-Aldrich. Species Human (51761) , Species Mouse (50769) , Species Zebrafish (100330943) , Species cow (508723) , Species cow (617199) , Species Horse (100059537) , Species Horse (100059750) , Species domestic cat (101085594) , Species dog (100687016) , Species chicken (418936) , Species sheep (101115632) , Species domestic guinea pig (100729844) , Species naked Adenosine 5′-Triphosphate (ATP) is nucleotide used as a substrate for many ATP-dependent enzyme systems, including protein kinases, protein phosphatases and DNA ligation. No detectable RNase, DNase, phosphatase or protease contaminating activities. ≥99% purity, as determined by HPLC; Optimal activity and stability for up to 24 months ATP synthase is a protein that catalyzes the formation of the energy storage molecule adenosine triphosphate (ATP) using adenosine diphosphate (ADP) and inorganic phosphate (P i).
PDF | The adaptation of mitochondrial ATP production rate (MAPR) to training and detraining was evaluated in nine healthy men. Muscle samples wt) were thawed and homogenized in a Potter Elvehjem mol/l) and bovine. The enzyme is a tetramer (relative molecular weight approximately 440000) of In nervous tissue, ATP citrate-lyase may be involved in the biosynthesis of
ATP-dependent NADH kinase (ATP:NADH 2´-phosphotransferase, EC 188.8.131.52) has been identified. The enzyme has a predicted molecular weight of 49 kDa.
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LIGHT HARVESTING COMPLEXES IN HIGHER PLANTS
THE JOURNAL OF BIOLOGICAL CHEMISTRY 0 1994 by The American Society for Biochemistry and Molecular Biology, Inc. Vol. 269, No. 5, Issue of February 4, pp. 3539-3547, 1994 Printed in USA. Identification, Purification, and Characterization of a High Molecular Weight, ATP-dependent Activator (PA700) of the 20 S Proteasome” (Received for publication, July 26, 1993, and in revised form, October … Adenosine triphosphate, or ATP, acts as a source of fuel within your cells. Formed from a series of chemical reactions, carbohydrates, proteins and fats can all be converted into ATP following digestion. Each cell within your body utilizes ATP to fuel the chemical reactions required for … At another site, they assemble as ATP, and at the third site, the rotation readies the fully formed ATP to pop off the synthase molecule, for use throughout the cell.
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(1 u is equal to 1/12 the mass of one atom of carbon-12) Molar mass (molar weight) is the mass of one mole of a substance and is expressed in g/mol. Human immunoglobulins are composed of 82-96 % protein and 4-18 % carbohydrate. Average serum concentration of human IgGs (mg/ml): IgG1: 8; IgG2: 4 all right so if we were going to go on the ambitious task of telling up how much ATP was produced in one cycle of cellular respiration or just to be super clear here I mean how much each EP was produced per the oxidation or breakdown of one molecule of glucose in cellular respiration we might start off by just getting ourself organized and reminding ourselves that there are two kind of main Figure 11.9 ATP synthase is a complex, molecular machine that uses a proton (H +) gradient to form ATP from ADP and inorganic phosphate (P i). (Credit: modification of work by Klaus Hoffmeier) Chemiosmosis ( Figure 11.7 ) is used to generate 90% of the ATP made during aerobic glucose catabolism. Se hela listan på fr.wikipedia.org ATP exists in cells as just one member of a pool of adenine nucleotides which consists of not only ATP, but also ADP and AMP (along with Pi). These constituents are readily interconvertible. We actually break down an amount of ATP each day equal to about our body weight. With the help of enzymes and hydrolysis, a phosphate group (P i) can be transferred from a molecule of ATP onto Calmo, turning Calmo into a new, less stable molecule "Nutto". | <urn:uuid:ded14bf5-a071-4e34-9f0e-2f6424e1f66c> | CC-MAIN-2022-33 | https://affarerztbs.web.app/11307/2527.html | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571950.76/warc/CC-MAIN-20220813111851-20220813141851-00672.warc.gz | en | 0.828909 | 2,876 | 1.929688 | 2 |
SAINT VINCENT AND THE GRENADINES – August 21st 2019 – Two Vincentians have been successful in attaining Chevening Scholarships to pursue a one year Master’s degree in the United Kingdom for the academic year 2019/2020. The successful applicants are Miss Jenell Gibson and Mr. Jeshua Bardoo. Miss Gibson will be pursuing a Master of Laws at the University College, London while Mr. Bardoo will be pursing an LLM Human Rights Law at Brunel University. This year, Saint Vincent and the Grenadines was one of four countries within the Eastern Caribbean and Barbados to secure spaces for the coveted award. Ten scholarships were awarded to nationals within the Eastern Caribbean and Barbados. Two scholarships were awarded to Antiguans, three scholarships were awarded to Barbadians and three scholarships were awarded to Saint Lucians. The Chevening scholarships are awarded to future leaders, influencers and decision makers from all over the world to develop professionally and academically, network extensively, experience UK culture and build lasting positive relationships with the UK. Chevening is the UK government’s international Awards programme aimed at developing global leaders and is funded by the Foreign and Commonwealth Office and partner organisations. The application period for the 2020/2021 scholarships is now open and eligible Vincentians are encouraged to apply. | <urn:uuid:4ac6c2f0-1d62-4b71-9569-639c10a4c08d> | CC-MAIN-2022-33 | https://annsvg.com/index.php/2019/08/21/vincentians-awarded-chevening-scholarships/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571950.76/warc/CC-MAIN-20220813111851-20220813141851-00672.warc.gz | en | 0.952628 | 274 | 1.5625 | 2 |
Multiple Of Motif Traditional Sandals Selop For The Agustusan – Indonesia is a country that has a great deal of culture and customs that may be considered intriguing and unique to understand. There are many civilizations from each area in Indonesia so there are things we have to know in this country that is beloved. It is inseparable from activities carried out by each community in their respective regions or the name of customs in dress. Sandal became one of the tools footwear that’s widely worn by people both young kids to adults sandals from each of these areas would have a price if sold on the market. Interestingly, all these sandals have a unique layout, attractive and comfortable to wear. Please see the info below about the Multiple Of Motif Traditional Sandals Selop For The Agustusan at Indonesia.
About Video Of Multiple Of Motif Traditional Sandals Selop For The Agustusan
Difference Of Listing of Traditional Sandal in Indonesia
Difference Of Cost of Woven Sandals & Traditional Sandals Selop
This sandal is created of materials taken straight from nature, as an instance, the substance used to make woven necklace is taken from many leaves such as pandan leaves, and mendong leaves, and water hyacinth leaves, and broomsticks. Whereas the base uses rubber and lots of different materials to fortify. These sandals have many different shapes and motifs so people the cost for these sandals, like sandals is about IDR 40,000 – IDR 50,000 economical, just and comfortable to wear.
Difference Of Cost of Traditional Slippers & Traditional Sandals Selop
These sandals we see worn in wedding ceremonies, circumcisions or events that use clothes. These sandals are shut so they can protect the feet from items, furthermore add to the aesthetic and artistic belief of this 1 sandal. These sandals’ price is cheap starting from IDR 50,000 – IDR 70,000.
Comparison Of Price of the Bestong Tarumpah Sandal & Traditional Sandals Selop
The next cost of standard sandals is Tarumpah Bestong, which can be an expensive sandal. A lot of individuals wear these sandals because the major ingredient for making them stems from animal skins like many others and Snakes. These vases have the shape of vases in ancient times the difference is the surface at the peak of the sandals that are glistening. As they are made especially for men, these sandals are often worn for boys. The purchase cost of those sandals can achieve IDR 300,000 / Series of Sandals.
Difference Of Cost of Tarumpah Sandals & Traditional Sandals Selop
In contrast to the Bestong Tarumpah we talked about previously, that one is generally reserved for girls. The price of all Tarumpah sandals can also be marginally less expensive than Tarumpah Bestong, the price of one set of these sandals is approximately IDR 45,000 – IDR 100,000 (based on the substance and quality). Their creation is falling because they are losing out to rivals who are making vases with broader innovations, Even though these sandals are trendy. There are still many people who are and enjoy these sandals because they’re comfortable to use the cultural heritage of Indonesia.
Comparison Of The Purchase Price Of The Geulis Kelom Sandal & Traditional Sandals Selop
This 1 design is a design that’s popular with divers themes, its shape is thought to have high art with the existence of several themes such as batik, granules, flowers and so forth. Not surprisingly, these sandals have lovers. Of course the cost of these sandals is high because it does have amazing artwork.
Difference Of Of Particular Traditional Sandal Models & Traditional Sandals Selop in Indonesia
Comparison Of Clogs Sandals & Traditional Sandals Selop
This sandal version is quite well known in Indonesia, you’ll locate these vases in various regions in Indonesia. The source of those clogs vases came in East Java. In the past, these clogs include a title. Clogs are made from a easy material that’s timber with great quality so it is durable to wear daily, this 1 footwear is popular since it has a special shape and differs from vases generally. The edges are only given to encourage legs.
Difference Of Kellom Geulis Sandals & Traditional Sandals Selop
These vases are very common in other nations such as Singapore and Malaysia, sandals with various interesting, distinctive and cool motifs are exceptional sandals originating from Indonesia. The form and theme make lots of people like this one. Typically, these Kellom sandals have a great deal of accessories that decorate the surface of their sandals so it seems attractive and more lavish to look at. You may find these vases West Java, in Cirebon City. For the superior version can attain 100 dollars these sandals are offered in a price for the regular edition.
Comparison Of Tarupah Sandals & Traditional Sandals Selop
The next special sandal comes in East Java, the title of the sandal is Tarupah. The normal sandals of this country of Indonesia possess a shape, even though they are wearing more stuff, but it does not make this look dull. There are materials from leather which are utilised to decorate vases to make it seem more elegant and unique. Because many continue to be interested in purchasing them, Plenty of crafters are faithful to produce those sandals. These sandals are suitable to be obtained to certain occasions, along with being durable and strong, the substance used for making sandals that are Tarupah is also of high quality.
Comparison Of Bestong Tarumpah slippers & Traditional Sandals Selop
If formerly it was just called Tarupah, then the subsequent unique sandals are called Tarupah Bestong. Tarupah Bestong is a version sandal that has a form such as a shoe. These sandals are extremely rare since they are offered at prices that are high. Does not come from substances that are random or cheap, but high-quality materials. The Bestong tarupah sandals’ cheapest cost is around 100 dollars.
Comparison Of Conventional Slippers & Traditional Sandals Selop
Next unique antiques from Indonesia that are frequently employed by the people of Indonesia are slippers which use quality materials from rubber and leather. Because the top is roughly 70% covered these sandals are far more appealing and look lavish. Suitable to be taken to events or to relax. These sandals are sold at prices, so the cost is expensive, but some sandals wear themes.
The intriguing thing about these sandals is that the raw materials come from crops. That is why, these vases have an expensive price because aside from being unique, there are certain arts which you cannot locate in vases.
That is all the information about the Multiple Of Motif Traditional Sandals Selop For The Agustusan in Indonesia. Thanks. | <urn:uuid:63cfcabc-e120-418b-bc72-5818da0541c9> | CC-MAIN-2022-33 | https://en.fashionnewso.com/traditional-sandals/multiple-of-motif-traditional-sandals-selop-for-the-agustusan/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882570793.14/warc/CC-MAIN-20220808092125-20220808122125-00672.warc.gz | en | 0.942237 | 1,473 | 1.914063 | 2 |
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On 28th April 2022, as part of activities in our Our Future is Green project (“OFG”), a visit was organised to Renovalia’s offices in Villarrobledo for 5th grade students at Nuestra Señora del Carmen school, led by its Principal, Mr José Jimenez.
All OFG activities are aimed at educating in environmental protection and raising awareness on climate change.
Renovalia executives Manuel Martínez and Pedro Losa, members of the volunteer network organised specifically for OFG, gave pupils training talks on the Environment and different sources of Renewable Energy, with the lively participation of all attendees, who asked questions on the topics discussed. They also had the chance to visit the Control Centre for all Renovalia’s facilities around the world, where they saw how each site is managed by the Operation & Maintenance (O&M) teams.
The pupils later visited the facilities at our “Casa del Angel” photovoltaic farm, 16 km from the offices, where they were able to see firsthand how solar energy is obtained. | <urn:uuid:5d3051a4-fce2-4c98-9bad-539d21410910> | CC-MAIN-2022-33 | https://www.renovaliaenergygroup.com/csr/newsletter-jun_2022-en/ofg-ntra-senora-carmen-school-newsletter-jun-2022-en/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882570793.14/warc/CC-MAIN-20220808092125-20220808122125-00672.warc.gz | en | 0.970837 | 229 | 1.882813 | 2 |
Half of All Grants Go to 1% of Applicants: RVA Man Wants to Change That
Non-profit groups often rely on grants to pay for their activities, but applying is time-consuming and challenging. Now, a Richmond man has developed software that could make the process easier and help organizations with money find new and worthy sources of funding.
Philip Deng has spent over a decade working for non-profit organizations, and that’s meant writing a fair number of grant proposals. Parts of those pitches must be tailored, but other sections not so much.
“There’s an art to crafting the language in a way that the funder is going to really resonate with," he explains, "but getting to that point is often really tedious.”
So he’s found ways to speed the process – translating his tricks of the non-profit trade into software called Grantable.
“You can re-use writing between different proposals. Grantable software is a platform that keeps all of your material in a library," Deng says. "Basically you can just get to the piece of information you need in seconds, and then pop that over into your proposal you’re working on.”
It may also help funding organizations to sort through pitches more efficiently. Right now, many take applications by invitation only. If they were to accept proposals from everyone, they fear being overwhelmed.
“They end up giving to the same groups that they already know, year in and year out, so they’re sort of stuck. They can’t open the gates, because they’ll be overwhelmed, but they want to open the gates, because they know there are people out there that they really want to fund.”
Right now, he says, one percent of non-profits get more than half of the grant money available. He’ll be testing his software this summer. | <urn:uuid:ebc4caba-ee81-48bf-9307-a9c05eec4c77> | CC-MAIN-2022-33 | https://www.wvtf.org/news/2021-07-02/half-of-all-grants-go-to-1-of-applicants-rva-man-wants-to-change-that | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.972718 | 397 | 1.664063 | 2 |
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- He thought of waiting, but to stop the powerful system of the Pompeian was inconceivable, and he was instantly wafted into a chair.Chapter 24 (43% in)
- With his wife, since it was inconceivable to explain that he was going to seek Paul's spirit in the wilderness, he frugally employed the lie prepared over a year ago and scarcely used at all.Chapter 25 (22% in)
- Brothers, that's what they must be, loving brothers, and then strikes would be as inconceivable as hatred in the home!"Chapter 27 (40% in)
There are no more uses of "inconceivable" in Babbitt.
Typical Usage (best examples) | <urn:uuid:d4c1373e-7a06-45a2-a5a8-32d0d90fd27e> | CC-MAIN-2022-33 | https://www.verbalworkout.com/u/u109/u617664.htm | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.972637 | 163 | 2.25 | 2 |
You are considering returning to graduate school or have already applied to a graduate school program. First and foremost, congratulations on your decision to further your education; many graduate school programs provide prospective candidates with the specialization needed to succeed in their careers.
Student loan default is an economic problem in the United States. 44.2 million Americans already owe $1.5 trillion in overall student loan debt, according to a recent survey. For graduates from the class of 2017, the total volume of student loan debt was about $40,000, a 6 percent rise from the previous year. The amount of debt will take decades to pay back and poses a financial strain that causes many young adults, such as getting married, owning a home, or adopting children, to put off big life decisions.
Every year, the U.S. Department of Education receives more than $120 billion in financial assistance. But in order to tap into the funds available, it is important that graduate learners be well versed in the different forms of grants, loans, and work-study services by which this money is disbursed.
The central mission of Federal Student Aid is to guarantee that all qualifying Americans benefit from federal financial assistance—grants, loans, and work-study programs—for college after high school. Federal Student Aid services are the nation’s primary provider of student financial assistance: during the 2010-11 academic year alone, Federal Student Aid delivered about $144 billion in new aid to almost 15 million post-secondary students and their families. In addition to Washington, D.C. headquarters, a workforce of 1,200 is located in 10 cities.
Universities and colleges offer versatile or self-paced study formats for students. In 2018, more than 35% of U.S. college students enrolled in certain distance classes, and only 17% enrolled in online courses solely. The same virtual curriculum, advanced preparation, and support services can be offered by online programs as conventional courses, and students will have access mostly to the same financial assistance. | <urn:uuid:66eb3e8a-23ce-464f-bc15-27be3a003a45> | CC-MAIN-2022-33 | https://www.collegehippo.com/blog/tag/federal-loans/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.968286 | 411 | 2.296875 | 2 |
The goal of the MiniLatex project is to put a defined subset of LaTeX in the browser. This means being able to “live edit” LaTeX in a web app and to immediately see the result rendered as web page — well, if not immediately, at least very, very quickly! Another goal is to never, ever have to rewrite text. Documents written for the web in MiniLatex should be exportable at the click of a button to a file on the author’s computer that can be typeset using
pdlatex or some other standard LaTeX tool.
Both of these goals are attainable. Here is a proof of concept:
This blog will report on progress on the development of MiniLatex and provide a forum for comments and discussion. Some articles will be technical, even quite technical, while others are intended for the general reader who may use MiniLatex as a writing tool. We are still in the research and development phase, so your feedback is both welcome and essential.
Here are some articles of interest.
And here are examples of documents written in MiniLatex
The examples above were written using the web app www.knode.io. It hosts a MiniLatex rendering engine written in Elm.
On the Horizon
- MiniLatex, as a defined subset of LaTeX, is an entity independent of whatever engine is used to transform MiniLatex source text into HTML. At the moment, there is just one engine, implemented in Elm. I plan to write a Haskell engine at some point.
- Once Elm 0.19 is released, MiniLatex will run much, much faster.
- When MathJax 3.0 is released, it will be integrated into Elm. This will result in an estimated 10-fold increase in processing speed for the MathJax part of the processing pipeline.
Good company in a journey makes the way seem shorter. — Izaak Walton | <urn:uuid:20980de5-50ee-4ac8-859f-5abcd53f2c08> | CC-MAIN-2022-33 | https://minilatex.com/2018/02/10/the-journey-begins/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571222.74/warc/CC-MAIN-20220810222056-20220811012056-00672.warc.gz | en | 0.924273 | 404 | 2.15625 | 2 |
Conclusions: Prevalence of hyponatremia is significant in palliative care patients. A prospective study looking at the causes and clinical outcomes associated with hyponatremia in palliative care patients is needed.
Sandsdalen, Tuva; Rystedt, Ingrid; Grøndahl, Vigdis Abrahamsen; Hov, Reidun; Høye, Sevald; Wilde-Larsson, Bodil
Instruments specific to palliative care tend to measure care quality from relative perspectives or have insufficient theoretical foundation. The instrument Quality from the Patient's Perspective (QPP) is based on a model for care quality derived from patients' perceptions of care, although it has not been psychometrically evaluated for use in palliative care. The aim of this study was to adapt the QPP for use in palliative care contexts, and to describe patients' perceptions of the care quality in terms of the subjective importance of the care aspects and the perceptions of the care received. A cross-sectional study was conducted between November 2013 and December 2014 which included 191 patients (73% response rate) in late palliative phase at hospice inpatient units, hospice day-care units, wards in nursing homes that specialized in palliative care and homecare districts, all in Norway. An explorative factor analysis using principal component analysis, including data from 184 patients, was performed for psychometric evaluation. Internal consistency was assessed by Cronbach's alpha and paired t-tests were used to describe patients' perceptions of their care. The QPP instrument was adapted for palliative care in four steps: (1) selecting items from the QPP, (2) modifying items and (3) constructing new items to the palliative care setting, and (4) a pilot evaluation. QPP instrument specific to palliative care (QPP-PC) consists of 51 items and 12 factors with an eigenvalue ≥1.0, and showed a stable factor solution that explained 68.25% of the total variance. The reliability coefficients were acceptable for most factors (0.79-0.96). Patients scored most aspects of care related to both subjective importance and actual care received as high. Areas for improvement were symptom relief, participation, continuity, and planning and cooperation. The QPP-PC is based on a theoretical model of quality of care, and has its roots in patients' perspectives. The instrument was
Wiese, C H R; Vagts, D A; Kampa, U; Pfeiffer, G; Grom, I-U; Gerth, M A; Graf, B M; Zausig, Y A
At the end of life acute exacerbations of medical symptoms (e.g. dyspnea) in palliative care patients often result in emergency medical services being alerted. The goals of this study were to discuss cooperation between emergency medical and palliative care structures to optimize the quality of care in emergencies involving palliative care patients. For data collection an open discussion of the main topics by experts in palliative and emergency medical care was employed. Main outcome measures and recommendations included responses regarding current practices related to expert opinions and international literature sources. As the essential points of consensus the following recommendations for optimization of care were named: (1) integration of palliative care in the emergency medicine curricula for pre-hospital emergency physicians and paramedics, (2) development of outpatient palliative care, (3) integration of palliative care teams into emergency medical structures, (4) cooperation between palliative and emergency medical care, (5) integration of crisis intervention into outpatient palliative emergency medical care, (6) provision of emergency plans and emergency medical boxes, (7) provision of palliative crisis cards and do not attempt resuscitation (DNAR) orders, (8) psychosocial aspects concerning palliative emergencies and (9) definition of palliative patients and their special situation by the physician responsible for prior treatment. Prehospital emergency physicians are confronted with emergencies in palliative care patients every day. In the treatment of these emergencies there are potentially serious conflicts due to the different therapeutic concepts of palliative medical care and emergency medical services. This study demonstrates that there is a need for regulated criteria for the therapy of palliative patients and patients at the end of life in emergency situations. Overall, more clinical investigations concerning end-of-life care and unresponsive
Strömgren, Annette S; Goldschmidt, Dorthe; Groenvold, Mogens
the symptomatology of participating patients and examines differences in symptomatology between patients in three palliative care functions: inpatient, outpatient, and palliative home care. RESULTS: Of 267 eligible patients who were referred to a department of palliative medicine, initial self......-based study of symptomatology in consecutive cancer patients in palliative care, achieving rather complete data from the participants. The symptomatology in these patients was very pronounced. The questionnaires were able to detect clinically important differences between places of service....
Pinto, Priya; Brown, Tartania; Khilkin, Michael; Chuang, Elizabeth
To compare the clinical outcomes of patients who did and did not receive palliative care consultation among those who experienced out-of-hospital cardiac arrest and underwent therapeutic hypothermia. We identified patients at a single academic medical center who had undergone therapeutic hypothermia after out-of-hospital cardiac arrest between 2009 and 2013. We performed a retrospective chart review for demographic data, hospital and critical care length of stay, and clinical outcomes of care. We reviewed the charts of 62 patients, of which 35 (56%) received a palliative care consultation and 27 (44%) did not. Palliative care consultation occurred an average of 8.3 days after admission. Patients receiving palliative care consultation were more likely to have a do-not-resuscitate (DNR) order placed (odds ratio: 2.3, P care or not (16.7 vs 17.1 days, P = .90). Intensive care length of stay was also similar (11.3 vs 12.6 days, P = .55). Palliative care consultation was underutilized and utilized late in this cohort. Palliative consultation was associated with DNR orders but did not affect measures of utilization such as hospital and intensive care length of stay.
Simoens, Steven; Kutten, Betty; Keirse, Emmanuel; Berghe, Paul Vanden; Beguin, Claire; Desmedt, Marianne; Deveugele, Myriam; Léonard, Christian; Paulus, Dominique; Menten, Johan
In addition to the effectiveness of hospital care models for terminal patients, policy makers and health care payers are concerned about their costs. This study aims to measure the hospital costs of treating terminal patients in Belgium from the health care payer perspective. Also, this study compares the costs of palliative and usual care in different types of hospital wards. A multicenter, retrospective cohort study compared costs of palliative care with usual care in acute hospital wards and with care in palliative care units. The study enrolled terminal patients from a representative sample of hospitals. Health care costs included fixed hospital costs and charges relating to medical fees, pharmacy and other charges. Data sources consisted of hospital accountancy data and invoice data. Six hospitals participated in the study, generating a total of 146 patients. The findings showed that palliative care in a palliative care unit was more expensive than palliative care in an acute ward due to higher staffing levels in palliative care units. Palliative care in an acute ward is cheaper than usual care in an acute ward. This study suggests that palliative care models in acute wards need to be supported because such care models appear to be less expensive than usual care and because such care models are likely to better reflect the needs of terminal patients. This finding emphasizes the importance of the timely recognition of the need for palliative care in terminal patients treated in acute wards.
Neergaard, Mette Asbjørn; Jensen, Anders Bonde; Olesen, Frede
BACKGROUND. Palliative care for cancer patients is an important part of a GP's work. Although every GP is frequently involved in care for terminally ill cancer patients, only little is known about how these palliative efforts are perceived by the patients and their families, a knowledge...... that is vital to further improve palliative care in the primary sector.AIM. The aim of the study was to analyse the quality of palliative home care with focus on the GP's role based on evaluations by relatives of recently deceased cancer patients and professionals from both the primary and secondary health care...... approach.RESULTS. The analyses revealed several key areas, e.g.: 1) How to take, give and maintain professional responsibility for palliative home care. 2) A need for transparent communication both among primary care professionals and among professionals across the primary/secondary interface. 3...
Vierhout, M; Daniels, M; Mazzotta, P; Vlahos, J; Mason, W P; Bernstein, M
Palliative care, a specialty aimed at providing optimal care to patients with life-limiting and chronic conditions, has several benefits. Although palliative care is appropriate for neurosurgical conditions, including brain cancer, few studies have examined the views of brain cancer patients about palliative care. We aimed to explore the thoughts of brain cancer patients about palliative care, their opinions about early palliative care, and their preferred care setting. Semi-structured interviews and the qualitative research methodologies of grounded theory were used to explore perceptions of palliative care on the part of 39 brain cancer outpatients. Seven overarching actions emerged: ■Patients would prefer to receive palliative care in the home.■Increased time with caregivers and family are the main appeals of home care.■Patients express dissatisfaction with brief and superficial interactions with health care providers.■Patients believe that palliative care can contribute to their emotional well-being.■Patients are open to palliative care if they believe that it will not diminish optimism.■There is a preconceived idea that palliative care is directly linked to active dying, and that supposed link generates fear in some patients.■Patients prefer to be educated about palliative care as an option early in their illness, even if they are fearful of it. Overall, when educated about the true meaning of palliative care, most patients express interest in accessing palliative care services. Although the level of fear concerning palliative care varies in patients, most recognize the associated benefits.
Full Text Available Patients with heart failure have a significant symptom burden and other palliative care needs often over a longer period than patients with cancer. It is acknowledged that this need may be unmet but by how much has not been quantified in primary care data at the population level.This was the first use of Clinical Practice Research Datalink, the world's largest primary care database to explore recognition of the need for palliative care. Heart failure and cancer patients who had died in 2009 aged 18 or over and had at least one year of primary care records were identified. A palliative approach to care among patients with heart failure was compared to that among patients with cancer using entry onto a palliative care register as a marker for a palliative approach to care.Among patients with heart failure, 7% (234/3 122 were entered on the palliative care register compared to 48% (3 669/7 608 of cancer patients. Of heart failure patients on the palliative care register, 29% (69/234 were entered onto the register within a week of their death.This confirms that the stark inequity in recognition of palliative care needs for people with heart failure in a large primary care dataset. We recommend a move away from prognosis based criteria for palliative care towards a patient centred approach, with assessment of and attention to palliative needs including advance care planning throughout the disease trajectory.
Boersma, Isabel; Miyasaki, Janis; Kutner, Jean
Palliative care is an approach to the care of patients and families facing progressive and chronic illnesses that focuses on the relief of suffering due to physical symptoms, psychosocial issues, and spiritual distress. As neurologists care for patients with chronic, progressive, life-limiting, and disabling conditions, it is important that they understand and learn to apply the principles of palliative medicine. In this article, we aim to provide a practical starting point in palliative medicine for neurologists by answering the following questions: (1) What is palliative care and what is hospice care? (2) What are the palliative care needs of neurology patients? (3) Do neurology patients have unique palliative care needs? and (4) How can palliative care be integrated into neurology practice? We cover several fundamental palliative care skills relevant to neurologists, including communication of bad news, symptom assessment and management, advance care planning, caregiver assessment, and appropriate referral to hospice and other palliative care services. We conclude by suggesting areas for future educational efforts and research. PMID:24991027
Background: Sleep disorders are frequent in patients with advanced cancer receiving palliative-care, especially in elderly patients (1). Sleep disorders during palliative-care may be related with anxiety, opioids related central-sleep apnoea or corticoids therapy between others (2). Our aim was to quantify the effectiveness of hypnotic medication in the sleep quality in advanced cancer receiving palliative-care elderly patients. Material and methods: A descriptive cross-sectional study was...
Fuly, Patrícia dos Santos Claro; Pires, Livia Márcia Vidal; Souza, Claudia Quinto Santos de; Oliveira, Beatriz Guitton Renaud Baptista de; Padilha, Katia Grillo
Abstract OBJECTIVE To verify the nursing workload required by cancer patients undergoing palliative care and possible associations between the demographic and clinical characteristics of the patients and the nursing workload. METHOD This is a quantitative, cross-sectional, prospective study developed in the Connective Bone Tissue (TOC) clinics of Unit II of the Brazilian National Cancer Institute José Alencar Gomes da Silva with patients undergoing palliative care. RESULTS Analysis of 197 ...
... for Patients and Families What Is Palliative Care? Definition Palliative care (pronounced pal-lee-uh-tiv) is specialized medical care for people with serious illness. This type of care is focused on providing relief from the symptoms and stress of a serious illness. The goal is to ...
Olsman, Erik; Leget, Carlo; Onwuteaka-Philipsen, Bregje; Willems, Dick
Healthcare professionals' perspectives on palliative care patients' hope influence communication. However, these perspectives have hardly been examined. To describe healthcare professionals' perspectives on palliative care patients' hope found in the literature. The interpretative synthesis
Olsman, E.; Leget, C.; Onwuteaka-Philipsen, B.D.; Willems, D.
Background: Healthcare professionals? perspectives on palliative care patients? hope influence communication. However, these perspectives have hardly been examined. Aim: To describe healthcare professionals? perspectives on palliative care patients? hope found in the literature. Design: The
Irany Carvalho da Silva
Full Text Available Palliative care is aimed at people with diseases without perspective of cure or terminally, aiming to provide a better quality of life. This study aims to investigating the discourse of nurses about their understanding of palliative care to elderly patient with cancer and identify strategies used by nurses to promote palliative care to the elderly cancer patient. It is an exploratory research of a qualitative nature, carried out with thirteen nurses from a philanthropic institution in the city of João Pessoa, through a questionnaire. The empirical material was subjected to thematic content analysis, resulting in three categories: design of nurses to assist the elderly in Palliative Care: promoting comfort and minimizing the suffering, the importance of palliative care in humanized care to the elderly with cancer and strategies for the Promotion of Care of the Elderly with Cancer. Participants highlighted the palliative care as essential in the humanization of care, ensuring the dignity and quality of life among the elderly with cancer without possibilities of cure, adding such assistance, the family. Keywords: Palliative Care; Nurse; Elderly; Cancer.
Wiskar, Katie J; Celi, Leo Anthony; McDermid, Robert C; Walley, Keith R; Russell, James A; Boyd, John H; Rush, Barret
Palliative care is recommended for advanced heart failure (HF) by several major societies, though prior studies indicate that it is underutilized. To investigate patterns of palliative care referral for patients admitted with HF exacerbations, as well as to examine patient and hospital factors associated with different rates of palliative care referral. Retrospective nationwide cohort analysis utilizing the National Inpatient Sample from 2006 to 2012. Patients referred to palliative care were compared to those who were not. Patients ≥18 years of age with a primary diagnosis of HF requiring mechanical ventilation (MV) were included. A cohort of non-HF patients with metastatic cancer was created for temporal comparison. Between 2006 and 2012, 74 824 patients underwent MV for HF. A referral to palliative care was made in 2903 (3.9%) patients. The rate of referral for palliative care in HF increased from 0.8% in 2006 to 6.4% in 2012 ( P care referral in patients with cancer increased from 2.9% in 2006 to 11.9% in 2012 ( P care ( P care. The use of palliative care for patients with advanced HF increased during the study period; however, palliative care remains underutilized in this setting. Patient factors such as race and SES affect access to palliative care.
A randomised, multicentre clinical trial of specialised palliative care plus standard treatment versus standard treatment alone for cancer patients with palliative care needs: the Danish palliative care trial (DanPaCT) protocol
Johnsen, Anna Thit; Damkier, Anette; Vejlgaard, Tove Bahn
Advanced cancer patients experience considerable symptoms, problems, and needs. Early referral of these patients to specialised palliative care (SPC) could improve their symptoms and problems.The Danish Palliative Care Trial (DanPaCT) investigates whether patients with metastatic cancer, who report...... palliative needs in a screening, will benefit from being referred to 'early SPC'....
Martinez-Litago, E; Martínez-Velasco, M C; Muniesa-Zaragozano, M P
Patients with advanced chronic diseases receive fragmented care, which entails high resource consumption and a poor quality of life. Uncertainty in the prognosis and scarce investigation into the importance of symptomatic control in this patient group hinders a proper therapeutic approach. Palliative care teams optimise the use of resources through comprehensive patient care, the optimization of the patient's environment, communication, the preparation of early care plans and the creation of coordinated healthcare circuits, which improve the quality of the patient's care in advanced stages of the disease. In the end-of-life phase, the therapeutic approach is focused on symptomatic control, selecting treatments according to the cause, comorbidities and the patient's wishes. To control refractory symptoms, palliative sedation is considered an indispensable option. Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.
Full Text Available Abstract Chronic obstructive pulmonary disease (COPD is a major cause of disability, morbidity and mortality in old age. Patients with advanced stage COPD are most likely to be admitted three to four times per year with acute exacerbations of COPD (AECOPD which are costly to manage. The adverse events of AECOPD are associated with poor quality of life, severe physical disability, loneliness, and depression and anxiety symptoms. Currently there is a lack of palliative care provision for patients with advanced stage COPD compared with cancer patients despite having poor prognosis, intolerable dyspnoea, lower levels of self efficacy, greater disability, poor quality of life and higher levels of anxiety and depression. These symptoms affect patients' quality of life and can be a source of concern for family and carers as most patients are likely to be housebound and may be in need of continuous support and care. Evidence of palliative care provision for cancer patients indicate that it improves quality of life and reduces health care costs. The reasons why COPD patients do not receive palliative care are complex. This partly may relate to prognostic accuracy of patients' survival which poses a challenge for healthcare professionals, including general practitioners for patients with advanced stage COPD, as they are less likely to engage in end-of-life care planning in contrast with terminal disease like cancer. Furthermore there is a lack of resources which constraints for the wider availability of the palliative care programmes in the health care system. Potential barriers may include unwillingness of patients to discuss advance care planning and end-of-life care with their general practitioners, lack of time, increased workload, and fear of uncertainty of the information to provide about the prognosis of the disease and also lack of appropriate tools to guide general practitioners when to refer patients for palliative care. COPD is a chronic
This paper reports a study to assess the palliative care needs of the adult population served by a healthcare provider organization in Northern Ireland from the perspectives of patients, informal carers and healthcare providers. Assessing palliative care need is a key factor for health service planning. Traditionally, palliative care has been associated with end-of-life care and cancer. More recently, the concept has been extended to include care for both cancer and non-cancer populations. Various approaches have been advocated for assessing need, including the exploration of professional provider and user perspectives of need. Semi-structured qualitative interviews were undertaken with a purposive sample of patients and lay carers receiving palliative care services (n = 24). Focus groups were also conducted with multi-professional palliative care providers (n = 52 participants) and face to face interviews were undertaken with key managerial stakeholders in the area (n = 7). The focus groups and interviews concentrated on assessment of palliative care need. All the interviews were transcribed verbatim and analysed using Burnard's framework. Professional providers experienced difficulty in defining the term palliative care. Difficulties in communication and information exchange, and fragmented co-ordination between services were identified. The main areas of need identified by all participants were social and psychological support; financial concerns; and the need for choice and information. All participants considered that there was inequity between palliative care service provision for patients with cancer and non-cancer diseases. All patients, regardless of diagnosis, should be able to access palliative care appropriate to their individual needs. For this to happen in practice, an integrated approach to palliative care is essential. The study methodology confirms the value of developing a comprehensive approach to assessing palliative care need.
Swetz, Keith M; Kamal, Arif H
Palliative care prioritizes symptom management and quality of life throughout the course of serious illness. Regardless of whether care is inpatient or outpatient, primary or subspecialty, a solid understanding of the basics of effective communication, symptom management, and end-of-life care is crucial. This article reviews these essentials and provides an overview of current evidence to support patient-centered palliative care.
Hayes, Jessica Elizabeth; Hart, Bethne; Phillips, Jane
Depression is an important condition to consider if we are to optimise the care outcomes for patients with palliative care needs. Depression has a high incidence in palliative patients, with up to 15% diagnosed with major depression and 37% expressing some form of depressive symptoms ( O'Connor et al, 2010 ). The challenge is to ensure that palliative care patients with depression are identified in a timely manner and that their depression is effectively managed. To examine how Australian specialist inpatient palliative care nurses perceive, assess and respond to depression in a patient case study. This descriptive pilot study is a replication of a United States study by Little et al (2005) , exploring contemporary Australian specialist palliative care nurses' screening, assessment and management of depression in people with a progressive life-limiting illness. A survey titled 'Specialist palliative care nurses managing patients with complex care needs' questioned the nursing assessment, knowledge and clinical care priorities related to a case vignette of a patient demonstrating signs of depression. A total of 33 nurses completed this survey. Less than half (39.4%) of the participants identified depression as a major issue arising from the case vignette. Depression screening tools were not widely known. Functionality assessments measuring activities of daily living were the most recognised and widely used tools by participants. This small sample pilot study demonstrated that specialist palliative care nurses are still not confident in their screening and responding to a patient with depression. The available evidenced based depression screening tools were unfamiliar to these nurses and not widely used which can result in depression remaining undetected and undermanaged. The connections between physical health and mental health need stronger recognition and response within nursing care of palliative patients.
Full Text Available Background: Chronic diseases such as cancer would lead to various health needs in patients and their families. To meet needs, developing new educational nursing courses is necessary. Therefore this study was conducted to empower nurses through designing and conducting short-term educational courses for training palliative care nurses. Materials and Methods: This study was a community-based action research which was conducted at Isfahan hospitals that provide services for cancer patients during 2015 at four stages (planning, acting, reflection, and evaluation. Participants (33 samples included nurses, head nurses, managers of nursing services, nursing professors and professors of oncology department. Data were gathered through individual and group interviews and analyzed using content analysis. Results: Data analysis resulted in 3 categories of "professional development of nursing in palliative care" which included subcategories of: knowledge-based performance and positive change in attitude, "obstacles to provide palliative care" with subcategories of: insufficient professional responsibility, insufficient ability in managing some of patients' symptoms and inappropriate interaction between nurses and physicians and "strategies for improving provision of palliative care" with subcategories of: improving the interactions between physicians and nurses, continuous trainings for palliative care and the necessity of developing palliative care in the country. Conclusions: To facilitate the process of providing palliative care to cancer patients, necessary actions and measures must be conducted including improvement of interaction between the members of health team, organizing continuing educational courses on palliative care and development of providing palliative care all over the country by managers of health centers.
To describe palliative care as part of comprehensive oncology nursing care. A review of the palliative care, oncology, and nursing literature over the past 10 years. Palliative care is mandated as part of comprehensive cancer care. A cancer diagnosis often results in distress in the physical, psychosocial, spiritual, and emotional domains of care. Oncology nurses are essential in providing palliative care from diagnosis to death to patients with cancer. They address the myriad aspects of cancer. With palliative care skills and knowledge, oncology nurses can provide quality cancer care. There are many opportunities in which oncology nurses can promote palliative care. Oncology nurses must obtain knowledge and skills in primary palliative care to provide comprehensive cancer care. Copyright © 2015 Elsevier Inc. All rights reserved.
... care is usually provided by palliative care specialists, health care practitioners who have received special training and/or certification in palliative care. They provide holistic care to the patient and family or caregiver ...
Weissman, David E; Morrison, R Sean; Meier, Diane E
Data collection and analysis are vital for strategic planning, quality improvement, and demonstration of palliative care program impact to hospital administrators, private funders and policymakers. Since 2000, the Center to Advance Palliative Care (CAPC) has provided technical assistance to hospitals, health systems and hospices working to start, sustain, and grow nonhospice palliative care programs. CAPC convened a consensus panel in 2008 to develop recommendations for specific clinical and customer metrics that programs should track. The panel agreed on four key domains of clinical metrics and two domains of customer metrics. Clinical metrics include: daily assessment of physical/psychological/spiritual symptoms by a symptom assessment tool; establishment of patient-centered goals of care; support to patient/family caregivers; and management of transitions across care sites. For customer metrics, consensus was reached on two domains that should be tracked to assess satisfaction: patient/family satisfaction, and referring clinician satisfaction. In an effort to ensure access to reliably high-quality palliative care data throughout the nation, hospital palliative care programs are encouraged to collect and report outcomes for each of the metric domains described here.
Real, Shirley; Cobbe, Sinead; Slattery, Sinead
Edema in palliative care patients is a common symptom, however, the research base for all aspects of its care is extremely poor. To evaluate a specialist palliative care edema service in order to report on the patient population referred, the types of edema encountered, and the causes of edema. Prior to study, three different edema types were described for evaluation: lymphedema, nonlymphatic edema, and a combination of the two. Retrospective chart evaluation was completed from August 2013 through January 2014. Patients with edema assessed by the specialist palliative care physiotherapy edema service. Sixty-three cases were included, comprising 10.5% of all new palliative care referrals during the study period. Ninety-two percent (n = 58) had a diagnosis of cancer and 57% (n = 36) were female. Age ranged from 45-97 years. The most common edema type was a mixed edema (46%, n = 29), followed by lymphedema (27%, n = 18) and nonlymphatic edema (16%, n = 10). Lymphorrhea occurred in 9.5% of cases. The most common reasons for edema, based on clinical opinion, were blocked lymphatics (33%) and dependency from immobility (27%). The most common site for edema was in the lower limbs (89%, n = 56). The time lapse from the last treatment to death ranged from 1-225 days. Having a mixed edema type or lymphorrhea was a relatively poor prognostic sign. This is the first study to describe in detail the occurrence of edema in palliative care patients. Edema may be present for many months prior to death making the search for effective treatments imperative.
Badger, Nathan J; Frizelle, Dorothy; Adams, Debi; Johnson, Miriam J
UK guidelines recommend palliative care access for people with Parkinson's disease; however, this remains sporadic, and it is unknown whether specialist palliative care helps patients and carers cope with this distressing condition. This study aimed to explore whether, and how, access to specialist palliative care services affected patients' and carers' coping with Parkinson's disease. Semistructured interviews were conducted, audio-recorded and verbatim transcribed. Data were analysed using interpretative phenomenological analysis. Participants were patients with advanced idiopathic Parkinson's disease (n=3), and carers of people with Parkinson's disease (n=5, however, one diagnosis was reviewed) receiving care from an integrated specialist palliative care and Parkinson's disease service in North East England. Access to specialist palliative care helped participants cope with some aspects of advanced Parkinson's disease. Three superordinate themes were developed:' managing uncertainty', 'impacts on the self' and 'specialist palliative care maintaining a positive outlook'. Specialist palliative care helped patients and carers cope with advanced Parkinson's disease. Specialist palliative care is a complex intervention that acknowledges the complex and holistic nature of Parkinson's disease, enabling health in some domains despite continued presence of pathology. These exploratory findings support the utility of this approach for people living with Parkinson's disease. © 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.
Osagiede, Osayande; Colibaseanu, Dorin T; Spaulding, Aaron C; Frank, Ryan D; Merchea, Amit; Kelley, Scott R; Uitti, Ryan J; Ailawadhi, Sikander
Palliative care has been increasingly recognized as an important part of cancer care but remains underutilized in patients with solid cancers. There is a current gap in knowledge regarding why palliative care is underutilized nationwide. To identify the factors associated with palliative care use among deceased patients with solid cancer tumors. Using the 2016 National Cancer Data Base, we identified deceased patients (2004-2013) with breast, colon, lung, melanoma, and prostate cancer. Data were described as percentages. Associations between palliative care use and patient, facility, and geographic characteristics were evaluated through multivariate logistic regression. A total of 1 840 111 patients were analyzed; 9.6% received palliative care. Palliative care use was higher in the following patient groups: survival >24 months (17% vs 2%), male (54% vs 46%), higher Charlson-Deyo comorbidity score (16% vs 8%), treatment at designated cancer programs (74% vs 71%), lung cancer (76% vs 28%), higher grade cancer (53% vs 24%), and stage IV cancer (59% vs 13%). Patients who lived in communities with a greater percentage of high school degrees had higher odds of receiving palliative care; Central and Pacific regions of the United States had lower odds of palliative care use than the East Coast. Patients with colon, melanoma, or prostate cancer had lower odds of palliative care than patients with breast cancer, whereas those with lung cancer had higher odds. Palliative care use in solid cancer tumors is variable, with a preference for patients with lung cancer, younger age, known insurance status, and higher educational level.
Full Text Available RG Duenk,1 C Verhagen,1 PNR Dekhuijzen,2 KCP Vissers,1 Y Engels,1,* Y Heijdra2,* 1Department of Anesthesiology, Pain and Palliative Medicine, 2Department of Lung Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands *These authors contributed equally to this work Introduction: Early palliative care is not a common practice for patients with COPD. Important barriers are the identification of patients for palliative care and the organization of such care in this patient group. Objective: Pulmonologists have a central role in providing good quality palliative care for patients with COPD. To guide future research and develop services, their view on palliative care for these patients was explored. Methods: A survey study was performed by the members of the Netherlands Association of Physicians for Lung Diseases and Tuberculosis. Results: The 256 respondents (31.8% covered 85.9% of the hospital organizations in the Netherlands. Most pulmonologists (92.2% indicated to distinguish a palliative phase in the COPD trajectory, but there was no consensus about the different criteria used for its identification. Aspects of palliative care in COPD considered important were advance care planning conversation (82%, communication between pulmonologist and general practitioner (77%, and identification of the palliative phase (75.8%, while the latter was considered the most important aspect for improvement (67.6%. Pulmonologists indicated to prefer organizing palliative care for hospitalized patients with COPD themselves (55.5%, while 30.9% indicated to prefer cooperation with a specialized palliative care team (SPCT. In the ambulatory setting, a multidisciplinary cooperation between pulmonologist, general practitioner, and a respiratory nurse specialist was preferred (71.1%. Conclusion: To encourage pulmonologists to timely initiate palliative care in COPD, we recommend to conduct further research into more specific identification
Collins, Anna; McLachlan, Sue-Anne; Philip, Jennifer
Communication about palliative care is a complex task frequently delayed until otherwise unavoidable. There is a need for discussion of palliative care to be viewed as a distinct communication task that is guided by empirical data. However, little is known of patient views and responses to these encounters. To explore patient views surrounding communication about palliative care and their responses to its discussion. Cross-sectional, prospective, exploratory qualitative design, involving narrative-style interviews and underpinned by an interpretative phenomenological framework. Purposively sampled, English-speaking, adult patients with advanced cancer ( n = 30) recruited from cancer services at a tertiary metropolitan hospital in Melbourne, Australia. Three major themes evolved. (1) Death as unspeakable: death was expressed using only implicit, ambiguous or technical terms and perceived to be outside the parameters of medical interactions. (2) Palliative care as a euphemism for death: the term 'palliative care' was perceived to be used by health professionals as a tool to talk about dying and understood by patients as a euphemism for death. (3) Palliative care as unspeakable: 'palliative care' was personified by patients to mean not just death, but my death, in turn, also becoming unspeakable. This study provides important new patient insights and responses to the discussion of palliative care. Results demonstrate that the task of discussing palliative care remains complex, difficult and limited by our language. Greater consistency, sensitivity and sophistication are required when talking about palliative care to patients who may benefit from this care.
Full Text Available SUMMARY Objective: To describe the clinical and sociodemographic profile of cancer patients admitted to the Emergency Center for High Complexity Oncologic Assistance, observing the coverage of palliative and home care. Method: Cross sectional study including adult cancer patients admitted to the emergency service (September-December/2011 with a minimum length of hospital stay of two hours. Student’s t-test and Pearson chi-square test were used to compare the means. Results: 191 patients were enrolled, 47.6% elderly, 64.4% women, 75.4% from the city of Recife and greater area. The symptom prevalent at admission was pain (46.6%. 4.2% of patients were linked to palliative care and 2.1% to home care. The most prevalent cancers: cervix (18.3%, breast (13.6% and prostate (10.5%; 70.7% were in advanced stages (IV, 47.1%; 39.4% without any cancer therapy. Conclusion: Patients sought the emergency service on account of pain, probably due to the incipient coverage of palliative and home care. These actions should be included to oncologic therapy as soon as possible to minimize the suffering of the patient/family and integrate the skills of oncologists and emergency professionals.
PURPOSE OF REVIEW: Patients with heart failure seem particularly suited to palliative care having needs that fall within the prototypical palliative care domains. Despite this there is still much debate as to who should respond to these needs and when. RECENT FINDINGS: Since the early 1990s many studies have been published outlining the unmet needs of patients with heart failure. However, there have been limitations to these studies and they have not guided professionals as to how to respond. More recently comparative studies using cancer as the reference have explored similarities and highlighted differences in need between heart failure and cancer patients. These studies are useful for informing future service development. SUMMARY: Patients with heart failure have variable needs and variable disease trajectories. A targeted response to these needs is required. Palliative triggers or transitions should be recognized by professionals caring for patients with heart failure. It is unlikely that either specialist palliative care or medical specialists working in isolation will be sufficiently experienced to respond to these needs. Research is required to determine the effectiveness of different collaborative approaches; heart failure specialist care aligned with palliative care consultancy or heart failure-oriented palliative care services.
... FAQ Handout for Patients and Families What Is Pediatric Palliative Care? Pediatric Palliative care (pronounced pal-lee-uh-tiv) is ... life for both the child and the family. Pediatric palliative care is provided by a team of ...
Grønvold, Mogens; Adsersen, Mathilde; Hansen, Maiken Bang
Aims: The aim of the Danish Palliative Care Database (DPD) is to monitor, evaluate, and improve the clinical quality of specialized palliative care (SPC) (ie, the activity of hospital-based palliative care teams/departments and hospices) in Denmark. Study population: The study population is all...... patients were registered in DPD during the 5 years 2010–2014. Of those registered, 96% had cancer. Conclusion: DPD is a national clinical quality database for SPC having clinically relevant variables and high data and patient completeness....
Yun, Young Ho; Kang, Eun Kyo; Lee, Jihye; Choo, Jiyeon; Ryu, Hyewon; Yun, Hye-Min; Kang, Jung Hun; Kim, Tae You; Sim, Jin-Ah; Kim, Yaeji
In this study, we aimed to develop and validate an instrument that could be used by patients with cancer to evaluate their quality of palliative care. Development of the questionnaire followed the four-phase process: item generation and reduction, construction, pilot testing, and field testing. Based on the literature, we constructed a list of items for the quality of palliative care from 104 quality care issues divided into 14 subscales. We constructed scales of 43 items that only the cancer patients were asked to answer. Using relevance and feasibility criteria and pilot testing, we developed a 44-item questionnaire. To assess the sensitivity and validity of the questionnaire, we recruited 220 patients over 18 years of age from three Korean hospitals. Factor analysis of the data and fit statistics process resulted in the 4-factor, 32-item Quality Care Questionnaire-Palliative Care (QCQ-PC), which covers appropriate communication with health care professionals (ten items), discussing value of life and goals of care (nine items), support and counseling for needs of holistic care (seven items), and accessibility and sustainability of care (six items). All subscales and total scores showed a high internal consistency (Cronbach alpha range, 0.89 to 0.97). Multi-trait scaling analysis showed good convergent (0.568-0.995) and discriminant (0.472-0.869) validity. The correlation between the total and subscale scores of QCQ-PC and those of EORTC QLQ-C15-PAL, MQOL, SAT-SF, and DCS was obtained. This study demonstrates that the QCQ-PC can be adopted to assess the quality of care in patients with cancer.
Heckel, M; Stiel, S; Frauendorf, T; Hanke, R M; Ostgathe, C
Specialised outpatient palliative care teams (in Germany called SAPV) aim to ensure best possible end-of-life care for outpatients with complex needs. Information on the influence of living areas (rural vs. urban) on patient and care related aspects is rare. This study aims to explore differences between palliative care patients in urban and rural dwellings concerning their nursing and service characteristics. A retrospective data analysis of documentary data for 502 patients supplied by SAPV team from December 2009 to June 2012 was conducted. Patients and care characteristics were investigated by frequency analysis and were compared for both groups of urban and rural dwelling patients (T test, Chi², Fisher's exact test p care, disease and service related aspects of palliative home care could be detected. An exception is that the rate of re-admittance to hospital is higher for rural dwelling patients (Fisher's exact test p=0.022). Although predominantly presumed, the single service analysis shows - except for the re-admittance rate to hospital - no considerable differences between palliative care patients regarding their living area. Our findings indicate that patients cared for in rural and urban settings have similar needs and impose similar requirements on palliative care teams. © Georg Thieme Verlag KG Stuttgart · New York.
Mehnert, A; Schröder, A S; Puhlmann, K; Müllerleile, U; Koch, U
Most patients, family members, health care professional as well as volunteers would agree that dignified care and being allowed to die with dignity are superior and unquestionable goals of palliative care. Although the majority of people have a more or less vague concept of dignity and despite its significance for palliative care, only a few empirical approaches to describe the sense of dignity from patients' and health care professionals' perspectives have been undertaken. However, individual descriptions of the dignity concept and definitions can serve as an impetus to improve the current palliative care practice by the development and evaluation of psychotherapeutic interventions for patients near the end of life and the allocation of resources. This article considers an internationally developed empirical-based model of dignity in severe and terminal ill patients by Chochinov et al. Furthermore, it illustrates the understanding of dignity as well as self-perceived exertions of influence on a patient's dignity from the perspective of health care professionals and volunteers. Psychotherapeutic interventions and strategies are introduced that can help conserve the sense of dignity of patients during palliative care.
Trovo de Araújo, Monica Martins; da Silva, Maria Júlia Paes
The objective of this study is to verify the relevance and utilization of communication strategies in palliative care. This is a multicenter qualitative study using a questionnaire, performed from August of 2008 to July of 2009 with 303 health care professionals who worked with patients receiving palliative care. Data were subjected to descriptive statistical analysis. Most participants (57.7%) were unable to state at least one verbal communication strategy, and only 15.2% were able to describe five signs or non-verbal communication strategies. The verbal strategies most commonly mentioned were those related to answering questions about the disease/treatment. Among the non-verbal strategies used, the most common were affective touch, looking, smiling, physical proximity, and careful listening. Though professionals have assigned a high degree of importance to communication in palliative care, they showed poor knowledge regarding communication strategies. Final considerations include the necessity of training professionals to communicate effectively in palliative care.
Kwang, Ang Yee; Kandiah, Mirnalini
This study aimed to evaluate the nutritional status of patients with cancer in palliative care and to examine the interrelationship between objective and subjective nutritional assessment measures. Patients' nutritional status in a palliative care unit of a Malaysian government hospital and a hospice facility were assessed using anthropometric measurements, weight loss at 1/6 months, and the scored patient-generated subjective global assessment (PG-SGA). Moderate-to-severe malnutrition was observed in a range from 31% to 69% using both measurements. Common nutritional impact symptoms were pain, xerostomia, and anorexia. Patient-generated subjective global assessment scores were significantly correlated with anthropometric measurements (P nutritional status assessment of patients with cancer in palliative care.
In Kenya, cancers as a disease group rank third as a cause of death after infectious and cardiovascular diseases. It is estimated that the annual incidence of cancer is about 37,000 new cases with an annual mortality of 28,000 cases (Kenya National Cancer Control Strategy 2010). The incidence of non-communicable diseases accounts for more than 50% of total hospital admissions and over 55% of hospital deaths (Kenya National Strategy for the Prevention and Control of Non Communicable Diseases 2015-2020). The prevalence of HIV is 6.8 (KIAS 2014). Most of these patients will benefit from palliative care services, hence the need to integrate palliative care services in the public healthcare system. The process of integrating palliative care in public hospitals involved advocacy both at the national level and at the institutional level, training of healthcare professionals, and setting up services within the hospitals that we worked with. Technical support was provided to each individual institution as needed. Eleven provincial hospitals across the country have now integrated palliative care services (Palliative Care Units) and are now centres of excellence. Over 220 healthcare providers have been trained, and approximately, over 30,000 patients have benefited from these services. Oral morphine is now available in the hospital palliative care units. As a success of the pilot project, Kenya Hospices and Palliative Care Association (KEHPCA) is now working with the Ministry of Health Kenya to integrate palliative care services in 30 other county hospitals across the country, thus ensuring more availability and access to more patients. Other developing countries can learn from Kenya's successful experience.
Busolo, David; Woodgate, Roberta
The objective of this review is to synthesize the best available evidence on palliative care experiences of adult cancer patients from ethnocultural groups.More specifically, this systematic review seeks to answer the following questions:1. What are the palliative care experiences of adult cancer patients from diverse ethnocultural groups?2. What meanings do adult patients with cancer from diverse ethnocultural groups assign to their experiences with palliative care? Globally, over 20.4 million people need palliative care services annually. The majority of these people (19 million) are adults, with 34% of them being patients diagnosed with cancer. With the current increase in the aging population, especially in developed countries, the number of adults requiring palliative care is expected to rise. Furthermore, how palliative care is offered and received continues to be shaped by culture and ethnicity. Likewise, culture and ethnicity influence how palliative care patients experience diseases like cancer, and seek and utilize palliative care services. Also, healthcare providers sometimes find it challenging to address the palliative care needs of patients from different ethnocultural groups. Sometimes these challenges are believed to be due to cultural incompetence of the care provider. When palliative care patients and their providers differ in their perception of care needs and how to address them, negative palliative care experiences are likely to ensue. Therefore, as the demand for palliative care increases, and ethnocultural factors continue to affect palliation, it is important to gain a better understanding of palliative care experiences of patients from different ethnocultural groups.The terms culture and ethnicity have been defined and used differently in literature which sometimes lead to confusion. Ethnicity has been defined as distinctive shared origins or social backgrounds and traditions of a group of people that are maintained between generations and
Borgsteede, S.D.; Deliens, L.; Francke, A.L.; Stalman, W.A.B.; Willems, D.L.; Eijk, T.T.M. van; Wal, G. van der
Object of the study: Epidemiological research into palliative care faces the problem of defining an adequate research population. Subjects in studies are alternately defined as patients receiving 'palliative care' , 'palliative treatment' or 'end of life care'. So far, it is not known how
Prizer, Lindsay P; Gay, Jennifer L; Perkins, Molly M; Wilson, Mark G; Emerson, Kerstin G; Glass, Anne P; Miyasaki, Janis M
A palliative approach is recommended in the care of Parkinson's disease patients; however, many patients only receive this care in the form of hospice at the end of life. Physician attitudes about palliative care have been shown to influence referrals for patients with chronic disease, and negative physician perceptions may affect early palliative referrals for Parkinson's disease patients. To use Social Exchange Theory to examine the association between neurologist-perceived costs and benefits of palliative care referral for Parkinson's disease patients and their reported referral practices. A cross-sectional survey study of neurologists. A total of 62 neurologists recruited from the National Parkinson Foundation, the Medical Association of Georgia, and the American Academy of Neurology's clinician database. Participants reported significantly stronger endorsement of the rewards ( M = 3.34, SD = 0.37) of palliative care referrals than the costs ( M = 2.13, SD = 0.30; t(61) = -16.10, p < 0.0001). A Poisson regression found that perceived costs, perceived rewards, physician type, and the number of complementary clinicians in practice were significant predictors of palliative care referral. Physicians may be more likely to refer patients to non-terminal palliative care if (1) they work in interdisciplinary settings and/or (2) previous personal or patient experience with palliative care was positive. They may be less likely to refer if (1) they fear a loss of autonomy in patient care, (2) they are unaware of available programs, and/or (3) they believe they address palliative needs. Initiatives to educate neurologists on the benefits and availability of non-terminal palliative services could improve patient access to this care.
Vater, Laura B; Rebesco, Gina; Schenker, Yael; Torke, Alexia M; Gramelspacher, Gregory
Professional guidelines recommend that palliative care begin early in advanced cancer management, yet integration of palliative and cancer care remains suboptimal. Cancer centers may miss opportunities to provide palliative care information online. In this study, we described the palliative care content on cancer center websites. We conducted a systematic content analysis of 62 National Cancer Institute- (NCI) designated cancer center websites. We assessed the content of center homepages and analyzed search results using the terms palliative care, supportive care, and hospice. For palliative and supportive care webpages, we assessed services offered and language used to describe care. Two researchers analyzed all websites using a standardized coding manual. Kappa values ranged from 0.78 to 1. NCI-designated cancer center homepages presented information about cancer-directed therapy (61%) more frequently than palliative care (5%). Ten percent of cancer centers had no webpage with palliative care information for patients. Among centers with information for patients, the majority (96%) defined palliative or supportive care, but 30% did not discuss delivery of palliative care alongside curative treatment, and 14% did not mention provision of care early in the disease process. Cancer center homepages rarely mention palliative care services. While the majority of centers have webpages with palliative care content, they sometimes omit information about early use of care. Improving accessibility of palliative care information and increasing emphasis on early provision of services may improve integration of palliative and cancer care.
Yu, Mo; Guerriere, Denise N; Coyte, Peter C
In Canada, health system restructuring has led to a greater focus on home-based palliative care as an alternative to institutionalised palliative care. However, little is known about the effect of this change on end-of-life care costs and the extent to which the financial burden of care has shifted from the acute care public sector to families. The purpose of this study was to assess the societal costs of end-of-life care associated with two places of death (hospital and home) using a prospective cohort design in a home-based palliative care programme. Societal cost includes all costs incurred during the course of palliative care irrespective of payer (e.g. health system, out-of-pocket, informal care-giving costs, etc.). Primary caregivers of terminal cancer patients were recruited from the Temmy Latner Centre for Palliative Care in Toronto, Canada. Demographic, service utilisation, care-giving time, health and functional status, and death data were collected by telephone interviews with primary caregivers over the course of patients' palliative trajectory. Logistic regression was conducted to model an individual's propensity for home death. Total societal costs of end-of-life care and component costs were compared between home and hospital death using propensity score stratification. Costs were presented in 2012 Canadian dollars ($1.00 CDN = $1.00 USD). The estimated total societal cost of end-of-life care was $34,197.73 per patient over the entire palliative trajectory (4 months on average). Results showed no significant difference (P > 0.05) in total societal costs between home and hospital death patients. Higher hospitalisation costs for hospital death patients were replaced by higher unpaid caregiver time and outpatient service costs for home death patients. Thus, from a societal cost perspective, alternative sites of death, while not associated with a significant change in total societal cost of end-of-life care, resulted in changes in the distribution of
Full Text Available ... The story demonstrates how palliative care can positively influence a patient's and family's experience with illness. Category ... Cancer: Palliative Care - Duration: 3:29. American Cancer Society 4,364 views 3:29 Perinatal Palliative Care - ...
Latorraca, Carolina de Oliveira Cruz; Martimbianco, Ana Luiza Cabrera; Pachito, Daniela Vianna; Pacheco, Rafael Leite; Riera, Rachel
Nineteen million adults worldwide are in need of palliative care. Of those who have access to it, 80% fail to receive an efficient management of symptoms. To assess the effectiveness and safety of mindfulness meditation for palliative care patients. We searched CENTRAL, MEDLINE, Embase, LILACS, PEDro, CINAHL, PsycINFO, Opengrey, ClinicalTrials.gov and WHO-ICTRP. No restriction of language, status or date of publication was applied. We considered randomised clinical trials (RCTs) comparing any mindfulness meditation scheme vs any comparator for palliative care. Cochrane Risk of Bias (Rob) Table was used for assessing methodological quality of RCTs. Screening, data extraction and methodological assessments were performed by two reviewers. Mean differences (MD) (confidence intervals of 95% (CI 95%)) were considered for estimating effect size. Quality of evidence was appraised by GRADE. Four RCTs, 234 participants, were included. All studies presented high risk of bias in at least one RoB table criteria. We assessed 4 comparisons, but only 2 studies showed statistically significant difference for at least one outcome. 1. Mindfulness meditation (eight weeks, one session/week, daily individual practice) vs control: statistically significant difference in favour of control for quality of life - physical aspects. 2. Mindfulness meditation (single 5-minute session) vs control: benefit in favour of mindfulness for stress outcome in both time-points. None of the included studies analysed safety and harms outcomes. Although two studies have showed statistically significant difference, only one showed effectiveness of mindfulness meditation in improving perceived stress. This study focused on one single session of mindfulness of 5 minutes for adult cancer patients in palliative care, but it was considered as possessing high risk of bias. Other schemes of mindfulness meditation did not show benefit in any outcome evaluated (low and very low quality evidence). © 2017 John Wiley
Pask, Sophie; Pinto, Cathryn; Bristowe, Katherine; van Vliet, Liesbeth; Nicholson, Caroline; Evans, Catherine J; George, Rob; Bailey, Katharine; Davies, Joanna M; Guo, Ping; Daveson, Barbara A; Higginson, Irene J; Murtagh, Fliss Em
Palliative care patients are often described as complex but evidence on complexity is limited. We need to understand complexity, including at individual patient-level, to define specialist palliative care, characterise palliative care populations and meaningfully compare interventions/outcomes. To explore palliative care stakeholders' views on what makes a patient more or less complex and insights on capturing complexity at patient-level. In-depth qualitative interviews, analysed using Framework analysis. Semi-structured interviews across six UK centres with patients, family, professionals, managers and senior leads, purposively sampled by experience, background, location and setting (hospital, hospice and community). 65 participants provided an understanding of complexity, which extended far beyond the commonly used physical, psychological, social and spiritual domains. Complexity included how patients interact with family/professionals, how services' respond to needs and societal perspectives on care. 'Pre-existing', 'cumulative' and 'invisible' complexity are further important dimensions to delivering effective palliative and end-of-life care. The dynamic nature of illness and needs over time was also profoundly influential. Adapting Bronfenbrenner's Ecological Systems Theory, we categorised findings into the microsystem (person, needs and characteristics), chronosystem (dynamic influences of time), mesosystem (interactions with family/health professionals), exosystem (palliative care services/systems) and macrosystem (societal influences). Stakeholders found it acceptable to capture complexity at the patient-level, with perceived benefits for improving palliative care resource allocation. Our conceptual framework encompasses additional elements beyond physical, psychological, social and spiritual domains and advances systematic understanding of complexity within the context of palliative care. This framework helps capture patient-level complexity and target
work of all involved in palliative care and understanding this will ... palliative care. The quality of life for patients and the manner of ... In palliative care, the creation of a safe space for families to talk is important. Communication ... family finds balance only with, and in your ... those relationships that are signifi- cant for the ...
Yedidia, Michael J
Palliative care was studied for its potential to yield lessons for transforming doctor-patient relationships to promote patient-centered care. Examination of patient and provider experiences of the transition from curative to palliative care promises valuable insights about establishing and maintaining trust as the goals of care shift and about addressing a broad spectrum of patient needs. The study was guided by a conceptual framework grounded in existing models to address five dimensions of doctor-patient relationships: range of needs addressed, source of authority, maintenance of trust, emotional involvement, and expression of authenticity. Data collection included observation of the care of 40 patients in the inpatient hospice unit and at home, interviews with patients and family members, and in-depth interviews with 22 physicians and two nurses providing end-of-life care. Standard qualitative procedures were used to analyze the data, incorporating techniques for maximizing the validity of the results and broadening their relevance to other contexts. Findings provide evidence for challenging prominent assumptions about possibilities for doctor-patient relationships: questioning the merits of the prohibition on emotional involvement, dependence on protocols for handling difficult communication issues, unqualified reliance on consumer empowerment to assure that care is responsive to patients' needs, and adoption of narrowly defined boundaries between medical and social service systems in caring for patients. Medical education can play a role in preparing doctors to assume new roles by openly addressing management of emotions in routine clinical work, incorporating personal awareness training, facilitating reflection on interactions with patients through use of standardized patients and videotapes, and expanding capacity to effectively address a broad range of needs through teamwork training.
Claessen, S.J.; Francke, A.L.; Deliens, L.
Aim: The aim of this study was to explore how GPs in the Netherlands recognize patients’ needs for palliative care. Methods: We conducted qualitative semi-structured interviews with about 25 GPs. These GPs were interviewed about recognition of the needs for palliative care in their patients and how
Ulrich, Lisa-R; Gruber, Dania; Hach, Michaela; Boesner, Stefan; Haasenritter, Joerg; Kuss, Katrin; Seipp, Hannah; Gerlach, Ferdinand M; Erler, Antje
In 2007, the European Association of Palliative Care (EAPC) provided a comprehensive set of recommendations and standards for the provision of adequate pediatric palliative care. A number of studies have shown deficits in pediatric palliative care compared to EAPC standards. In Germany, pediatric palliative care patients can be referred to specialized outpatient palliative care (SOPC) services, which are known to enhance quality of life, e.g. by avoiding hospitalization. However, current regulations for the provision of SOPC in Germany do not account for the different circumstances and needs of children and their families compared to adult palliative care patients. The "Evaluation of specialized outpatient palliative care (SOPC) in the German state of Hesse (ELSAH)" study aims to perform a needs assessment for pediatric patients (children, adolescents and young adults) receiving SOPC. This paper presents the study protocol for this assessment (work package II). The study uses a sequential mixed-methods study design with a focus on qualitative research. Data collection from professional and family caregivers and, as far as possible, pediatric patients, will involve both a written questionnaire based on European recommendations for pediatric palliative care, and semi-structured interviews. Additionally, professional caregivers will take part in focus group discussions and participatory observations. Interviews and focus groups will be tape- or video-recorded, transcribed verbatim and analyzed in accordance with the principles of grounded theory (interviews) and content analysis (focus groups). A structured field note template will be used to record notes taken during the participatory observations. Statistical Package for Social Sciences (SPSS, version 22 or higher) will be used for descriptive statistical analyses. The qualitative data analyses will be software-assisted by MAXQDA (version 12 or higher). This study will provide important information on what matters
Milberg, Anna; Friedrichsen, Maria; Jakobsson, Maria; Nilsson, Eva-Carin; Niskala, Birgitta; Olsson, Maria; Wåhlberg, Rakel; Krevers, Barbro
Having a sense of security is vitally important to patients who have a limited life expectancy. We sought to identify the factors associated with patients' sense of security during the palliative care period. We recruited 174 adult patients (65% of those eligible) from six palliative home care units. The relationship between the patients' sense of security during palliative care and individual factors was evaluated in a stepwise procedure using the generalized linear model (ordinal multinomial distribution and logit link). Respondents' ratings of their sense of security ranged from 1 (never) to 6 (always), with a mean value of 4.6 (SD 1.19). Patients with lower feelings of security experienced higher stress; more worry about personal finances; lower feelings of self-efficacy; a lower sense of security with the palliative care provided (lower ratings on subscales of care interaction); mastery; prevailed own identity; higher symptom intensity (especially depression, anxiety, and lack of well-being); lower health-related quality of life; lower attachment anxiety and avoidance; less support from family, relatives, and friends; lower comfort for those closest to them; and more often had gynecological cancer. Six variables (mastery, nervousness and stress, gynecological cancer, self-efficacy, worrying about personal finances, and avoidance) were selected in building the stepwise model. These findings stress the importance of palliative care services in supporting dying patients' sense of security through symptom management with a wide scope and through supporting the patients' sense of mastery, identity, and perception of a secure care interaction and also through attention to the family members' situation. Copyright © 2014 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
Conclusion: Oncologists, oncology nurses, and patients felt that integration of early specialist palliative care in cancer improves symptom control, end-of-life care, health-related communication, and continuity of care. The perceptions of benefit of the palliative care intervention in the components surveyed, differed among the three groups.
Fox, Siobhan; Cashell, Alison; Kernohan, W George; Lynch, Marie; McGlade, Ciara; O'Brien, Tony; O'Sullivan, Sean S; Foley, Mary J; Timmons, Suzanne
Palliative care is recommended for non-malignant illnesses, including Parkinson's disease. However, past research with healthcare workers highlights unmet palliative needs in this population and referral rates to Specialist Palliative Care are low. Some healthcare workers perceive a 'fear' in their patients about introducing palliative care. However, less is known about the views of people with Parkinson's disease and their carers about palliative care. (1) To explore the palliative care and related issues most affecting people with Parkinson's disease and their families and (2) to examine perceptions about/understanding of palliative care. This was a qualitative study; semi-structured interviews were conducted, transcribed and analysed using thematic analysis. A total of 31 people participated, both people with Parkinson's disease ( n = 19) and carers ( n = 12), across three Movement Disorder Clinics in the Republic of Ireland. People with Parkinson's disease and their carers were unfamiliar with the term palliative care. When informed of the role of palliative care, most felt that they would benefit from this input. People with Parkinson's disease and carers experienced a high illness burden and wanted extra support. Crises requiring Specialist Palliative Care involvement may occur at diagnosis and later, with advancing illness. Participants wanted more information about palliative care and especially further supports to address their psychosocial needs. A holistic palliative care approach could address the complex physical and psychosocial symptoms experienced by people with Parkinson's disease and their carers, and people with Parkinson's disease and their carers are open to palliative care. Further research needs to explore how palliative care can be introduced into the routine care for people with Parkinson's disease.
Denvir, M A; Murray, S A; Boyd, K J
Palliative care is recommended for patients with end-stage heart failure with several recent, randomised trials showing improvements in symptoms and quality of life and more studies underway. Future care planning provides a framework for discussing a range of palliative care problems with patients and their families. This approach can be introduced at any time during the patient's journey of care and ideally well in advance of end-of-life care. Future care planning is applicable to a wide range of patients with advanced heart disease and could be delivered systematically by cardiology teams at the time of an unplanned hospital admission, akin to cardiac rehabilitation for myocardial infarction. Integrating cardiology care and palliative care can benefit many patients with advanced heart disease at increased risk of death or hospitalisation. Larger, randomised trials are needed to assess the impact on patient outcomes and experiences. 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.
Harden, Karen; Price, Deborah; Duffy, Elizabeth; Galunas, Laura; Rodgers, Cheryl
Oncology nurses affect patient care at every point along the cancer journey. This creates the perfect opportunity to educate patients and caregivers about palliative care early and often throughout treatment. However, healthcare providers frequently do not have the knowledge and confidence to engage in meaningful conversations about palliative care. . The specific aims were to improve oncology nurses' palliative care knowledge, attitudes, and behaviors by providing a palliative care nursing education program. An additional aim was to increase the number of conversations with patients and families about palliative care. . This project had a pre-/post-test design to assess knowledge, attitudes, and behaviors at baseline and one month after implementation of an established education curriculum. The teaching strategy included one four-hour class for oncology RNs with topics about the definition of palliative care, pain and symptom management, and how to have palliative care conversations. . Results showed a statistically significant difference after the educational intervention for knowledge, attitudes, and behaviors. The number of conversations with patients and caregivers about palliative and end-of-life care increased significantly.
Full Text Available Background. Despite its high prevalence, similar symptoms and symptom burden, people suffering from chronic heart failure receive less palliative care than patients with malignant diseases. Internationally, numerous barriers to palliative care of patients with chronic heart failure are known, however, there are no credible data regarding barriers and facilitators to palliative care of people suffering from chronic heart failure available for Germany. Design and Methods. Tripartite study. First part of this study evaluates health care providers’ (physicians and nurses perceived barriers and facilitators to palliative care of patients with chronic heart failure using a qualitative approach. At least 18 persons will be interviewed. In the second part, based on the results of part one, a questionnaire about barriers and facilitators to palliative care of patients with chronic heart failure will be designed and applied to at least 150 physicians and nurses. In the last part a classic Delphi method will be used to develop specific measures to improve the palliative care for chronic heart failure patients. Expected Impact for Public Health. The results of this study will help to understand why patients with heart failure are seldom referred to palliative care and will provide solutions to overcome these barriers. Developed solutions will be the first step to improve palliative care in patients with heart failure in Germany. In addition, the results will help health care providers in other countries to take action to improve palliative care situations for heart failure patients.
Dai, Ying-Xiu; Chen, Tzeng-Ji; Lin, Ming-Hwai
The term "palliative care" has a negative connotation and may act as a barrier to early patient referrals. Rebranding has thus been proposed as a strategy to reduce the negative perceptions associated with palliative care. For example, using the term "supportive care" instead of "palliative care" in naming palliative care units has been proposed in several studies. In Taiwan, terms other than "palliative" and "hospice" are already widely used in the names of palliative care units. With this in mind, this study investigated the characteristics of palliative care unit names in order to better understand the role of naming in palliative care. Relevant data were collected from the Taiwan Academy of Hospice Palliative Medicine, the National Health Insurance Administration of the Ministry of Health and Welfare, and the open database maintained by the government of Taiwan. We found a clear phenomenon of avoiding use of the terms "palliative" and "hospice" in the naming of palliative care units, a phenomenon that reflects the stigma attached to the terms "palliative" and "hospice" in Taiwan. At the time of the study (September, 2016), there were 55 palliative care units in Taiwan. Only 20.0% (n = 11) of the palliative care unit names included the term "palliative," while 25.2% (n = 14) included the term "hospice." Religiously affiliated hospitals were less likely to use the terms "palliative" and "hospice" (χ 2 = 11.461, P = .001). There was also a lower prevalence of use of the terms "palliative" and "hospice" for naming palliative care units in private hospitals than in public hospitals (χ 2 = 4.61, P = .032). This finding highlights the strong stigma attached to the terms "palliative" and "hospice" in Taiwan. It is hypothesized that sociocultural and religious factors may partially account for this phenomenon.
Philip, Jennifer; Crawford, Gregory; Brand, Caroline; Gold, Michelle; Miller, Belinda; Hudson, Peter; Smallwood, Natasha; Lau, Rosalind; Sundararajan, Vijaya
Despite significant needs, patients with chronic obstructive pulmonary disease (COPD) make limited use of palliative care, in part because the current models of palliative care do not address their key concerns. Our aim was to develop a tailored model of palliative care for patients with COPD and their family caregivers. Based on information gathered within a program of studies (qualitative research exploring experiences, a cohort study examining service use), an expert advisory committee evaluated and integrated data, developed responses, formulated principles to inform care, and made recommendations for practice. The informing studies were conducted in two Australian states: Victoria and South Australia. A series of principles underpinning the model were developed, including that it must be: (1) focused on patient and caregiver; (2) equitable, enabling access to components of palliative care for a group with significant needs; (3) accessible; and (4) less resource-intensive than expansion of usual palliative care service delivery. The recommended conceptual model was to have the following features: (a) entry to palliative care occurs routinely triggered by clinical transitions in care; (b) care is embedded in routine ambulatory respiratory care, ensuring that it is regarded as "usual" care by patients and clinicians alike; (c) the tasks include screening for physical and psychological symptoms, social and community support, provision of information, and discussions around goals and preferences for care; and (d) transition to usual palliative care services is facilitated as the patient nears death. Our proposed innovative and conceptual model for provision of palliative care requires future formal testing using rigorous mixed-methods approaches to determine if theoretical propositions translate into effectiveness, feasibility, and benefits (including economic benefits). There is reason to consider adaptation of the model for the palliative care of patients with
Full Text Available Introduction: Annually more than 27,000 persons die of cancer in the Czech Republic and the overall incidence of malignancies is still increasing. These data shows the need for affordable and good follow-up care especially for patients without any cancer treatment due to irreversible progression of tumor. Currently the outpatient palliative cancer care gets more into the forefront. Prerequisite for a well working outpatient palliative care is cooperation with general practitioners and home health care agencies. The purpose of the so called program of palliative cancer care is to guide a patient in palliative cancer care and to improve the cooperation among health care providers. Methods: During the period from January 2008 to October 2010 we evaluated in patient without any oncology treatment due to irreversible progression of tumor. Results: In palliative outpatient clinic we treated 446 patients, 119 of them received home care services with average length of 27.8 days. 77 patients died at home, 51 in health facilities and 41 in inpatient hospice care. Conclusion: We present pilot study focusing on outpatient palliative cancer care which shows the real benefit from early indication of palliative cancer care. This type of care allows patients to stay as long as possible at home among their close relatives.
Soares, Luiz Guilherme L; Japiassu, André M; Gomes, Lucia C; Pereira, Rogéria
Patients with complex palliative care needs can experience delayed discharge, which causes an inappropriate occupancy of hospital beds. Post-acute care facilities (PACFs) have emerged as an alternative discharge destination for some of these patients. The aim of this study was to investigate the frequency of admissions and characteristics of palliative care patients discharged from hospitals to a PACF. We conducted a retrospective analysis of PACF admissions between 2014 and 2016 that were linked to hospital discharge reports and electronic health records, to gather information about hospital-to-PACF transitions. In total, 205 consecutive patients were discharged from 6 different hospitals to our PACF. Palliative care patients were involved in 32% (n = 67) of these discharges. The most common conditions were terminal cancer (n = 42, 63%), advanced dementia (n = 17, 25%), and stroke (n = 5, 8%). During acute hospital stays, patients with cancer had significant shorter lengths of stay (13 vs 99 days, P = .004), a lower use of intensive care services (2% vs 64%, P care. Further studies are necessary to understand the trajectory of posthospitalized patients with life-limiting illnesses and what factors influence their decision to choose a PACF as a discharge destination and place of death. We advocate that palliative care should be integrated into the portfolio of post-acute services.
Boersma, Isabel; Miyasaki, Janis; Kutner, Jean; Kluger, Benzi
Palliative care is an approach to the care of patients and families facing progressive and chronic illnesses that focuses on the relief of suffering due to physical symptoms, psychosocial issues, and spiritual distress. As neurologists care for patients with chronic, progressive, life-limiting, and disabling conditions, it is important that they understand and learn to apply the principles of palliative medicine. In this article, we aim to provide a practical starting point in palliative medicine for neurologists by answering the following questions: (1) What is palliative care and what is hospice care? (2) What are the palliative care needs of neurology patients? (3) Do neurology patients have unique palliative care needs? and (4) How can palliative care be integrated into neurology practice? We cover several fundamental palliative care skills relevant to neurologists, including communication of bad news, symptom assessment and management, advance care planning, caregiver assessment, and appropriate referral to hospice and other palliative care services. We conclude by suggesting areas for future educational efforts and research. © 2014 American Academy of Neurology.
Effectiveness of palliative home-care services in reducing hospital admissions and determinants of hospitalization for terminally ill patients followed up by a palliative home-care team: a retrospective cohort study.
Riolfi, Mirko; Buja, Alessandra; Zanardo, Chiara; Marangon, Chiara Francesca; Manno, Pietro; Baldo, Vincenzo
It has been demonstrated that most patients in the terminal stages of cancer would benefit from palliative home-care services. The aim of this study was to assess the effectiveness of appropriate palliative home-care services in reducing hospital admissions, and to identify factors predicting the likelihood of patients treated at home being hospitalized. Retrospective cohort study. We enrolled all 402 patients listed by the Local Health Authority No. 5, Veneto Region (North-East Italy), as dying of cancer in 2011. Of the cohort considered, 39.9% patients had been taken into care by a palliative home-care team. Irrespective of age, gender, and type of tumor, patients taken into care by the palliative home-care team were more likely to die at home, less likely to be hospitalized, and spent fewer days in hospital in the last 2 months of their life. Among the patients taken into care by the palliative home-care team, those with hematological cancers and hepatocellular carcinoma were more likely to be hospitalized, and certain symptoms (such as dyspnea and delirium) were predictive of hospitalization. Our study confirms the effectiveness of palliative home care in enabling patients to spend the final period of their lives at home. The services of a palliative home-care team reduced the consumption of hospital resources. This study also provided evidence of some types of cancer (e.g. hematological cancers and hepatocellular carcinoma) being more likely to require hospitalization, suggesting the need to reconsider the pathways of care for these diseases.
Full Text Available Background. Palliative care in Slovene health care system isn’t developed. Comparison with other countries is not possible in many aspects. There is no complete or appropriately educated palliative care team in hospitals or in primary care. Palliative care departments in hospitals and nursing homes do not exist. Holistic palliative home care is offered only by Slovene association of hospice. The pressure on nursing homes and nursing service departments is getting stronger. Standards and norms for staff, for living conditions and medical equipment do not allow any more admittances of patients with the needs of high category of care in these institutions.Conclusions. Indirect indicators of level of palliative care (e.g. morphine consumption, palliative care departments, home care network, undergraduate education, specialisation and research put Slovenia at the bade of the Europe. Statistics predict aging of population and more patients are also living with consequences of progressive chronic diseases and cancer.In the new healthcare reform there is an opportunity for palliative care to get an equal place in healthcare system. With coordinated implementation of palliative care departments, consultant teams and mobile specialistic teams, palliative care could reach a better level of quality. At the same time, quality permanent education is essential.
Mahmut Yaşar Çeliker
Full Text Available Cancer care with curative intent remains difficult to manage in many resource-limited settings such as Cambodia. Cambodia has a small workforce with limited financial and health-care resources resulting in delayed diagnoses and availability of limited therapeutic tools. Thus, palliative care becomes the primary form of care in most cases. Although palliative care is becoming an integral part of medical care in developed countries, this concept remains poorly understood and utilized in developing countries. Angkor Hospital for Children serves a relatively large pediatric population in northern Cambodia. According to the modern definition of palliative care, approximately two-thirds of the patients admitted to the hospital were deemed candidates to receive palliative care. In an effort to develop a pediatric palliative care team utilizing existing resources and intensive training, our focus group recruited already existing teams with different health-care expertise and other motivated members of the hospital. During this process, we have also formed a palliative care training team of local experts to maintain ongoing palliative care education. Feedback from patients and health-care providers confirmed the effectiveness of these efforts. In conclusion, palliative and sustainable care was offered effectively in a resource-limited setting with adequately trained and motivated local providers. In this article, the steps and systems used to overcome challenges in Cambodia are summarized in the hope that our experience urges governmental and non-governmental agencies to support similar initiatives.
Çeliker, Mahmut Yaşar; Pagnarith, Yos; Akao, Kazumi; Sophearin, Dim; Sorn, Sokchea
Cancer care with curative intent remains difficult to manage in many resource-limited settings such as Cambodia. Cambodia has a small workforce with limited financial and health-care resources resulting in delayed diagnoses and availability of limited therapeutic tools. Thus, palliative care becomes the primary form of care in most cases. Although palliative care is becoming an integral part of medical care in developed countries, this concept remains poorly understood and utilized in developing countries. Angkor Hospital for Children serves a relatively large pediatric population in northern Cambodia. According to the modern definition of palliative care, approximately two-thirds of the patients admitted to the hospital were deemed candidates to receive palliative care. In an effort to develop a pediatric palliative care team utilizing existing resources and intensive training, our focus group recruited already existing teams with different health-care expertise and other motivated members of the hospital. During this process, we have also formed a palliative care training team of local experts to maintain ongoing palliative care education. Feedback from patients and health-care providers confirmed the effectiveness of these efforts. In conclusion, palliative and sustainable care was offered effectively in a resource-limited setting with adequately trained and motivated local providers. In this article, the steps and systems used to overcome challenges in Cambodia are summarized in the hope that our experience urges governmental and non-governmental agencies to support similar initiatives. PMID:28804708
Li, Lingsheng; Sloan, Danetta H; Mehta, Ambereen K; Willis, Gordon; Weaver, Meaghann S; Berger, Ann C
It is important to identify, from the patients' perspectives, the different factors that contribute toward psycho-social-spiritual healing. This was a qualitative study that took place at a large research center, an underserved clinic, and a community hospital. We used a needs assessment questionnaire and open-ended questions to assess the constituents of psycho-social-spiritual healing: (I) how previous life experiences affected patients' present situations in dealing with their illnesses; (II) barriers to palliative care, and (III) benefits of palliative care. Of a total of 30 participants from 3 different study sites, 24 (80%) were receiving inpatient or outpatient palliative care at a research center. Thirteen (43%) participants were female, 10 (33%) were Black/African American, and 16 (53%) reported being on disability. While the initial shock of the diagnosis made participants feel unprepared for their illnesses, many looked to role models, previous work experiences, and spiritual as well as religious support as sources of strength and coping mechanisms. Barriers to palliative care were identified as either external (lack of proper resources) or internal (symptom barriers and perceived self-limitations). The feeling of "being seen/being heard" was perceived by many participants as the most beneficial aspect of palliative care. The needs assessment questionnaire and open-ended questions presented in this study may be used in clinical settings to better help patients achieve psycho-social-spiritual healing through palliative care and to help clinicians learn about the person behind the patient.
Full Text Available Introduction. Man is a unique, unrepeatable whole in space and time and that is why he requires a holistic treatment, taking into account physical, psychological, social and spiritual factors. The balanced factors can ensure human well-being and his quality of life. Integrated treatment is especially important for patients in palliative care, which was the basic starting point of our research. In our research we wanted to establish whether the patients in palliative care are treated holistically from the perspective of the nurses and where are the specific aspects of palliative care (psychological, physical, social and spiritual more visible - in the hospitals or in the home environment.
Nagaviroj, Kittiphon; Anothaisintawee, Thunyarat
Many terminally ill patients would prefer to stay and die in their own homes, but unfortunately, some may not be able to do so. Although there are many factors associated with successful home deaths, receiving palliative home visits from the multidisciplinary care teams is one of the key factors that enable patients to die at home. Our study was aimed to find whether there was any association between our palliative home care program and home death. A retrospective study was conducted in the Department of Family Medicine at Ramathibodi Hospital between January 2012 and May 2014. All of the patients who were referred to multidisciplinary palliative care teams were included. The data set comprised of patient's profile, disease status, functional status, patient's symptoms, preferred place of death, frequency of home visits, types of team interventions, and patient's actual place of death. Multiple logistic regression was applied in order to determine the association between the variables and the probability of dying at home. A total of 142 patients were included into the study. At the end of the study, 50 (35.2%) patients died at home and 92 (64.8%) patients died in the hospital. The multivariate logistic regression analysis demonstrated a strong association between multidisciplinary home care and home death (odds ratio 6.57, 95% confidence interval [CI] 2.48-17.38). Palliative home care was a significant factor enabling patients who want to die at home. We encourage health policy makers to promote the development of community-based palliative care programs in Thailand.
Hay, Casey M; Lefkowits, Carolyn; Crowley-Matoka, Megan; Bakitas, Marie A; Clark, Leslie H; Duska, Linda R; Urban, Renata R; Creasy, Stephanie L; Schenker, Yael
Concern that patients will react negatively to the idea of palliative care is cited as a barrier to timely referral. Strategies to successfully introduce specialty palliative care to patients have not been well described. We sought to understand how gynecologic oncologists introduce outpatient specialty palliative care. We conducted a national qualitative interview study at six geographically diverse academic cancer centers with well-established palliative care clinics between September 2015 and March 2016. Thirty-four gynecologic oncologists participated in semistructured telephone interviews focusing on attitudes, experiences, and practices related to outpatient palliative care. A multidisciplinary team analyzed interview transcripts using constant comparative methods to inductively develop and refine a coding framework. This analysis focuses on practices for introducing palliative care. Mean participant age was 47 years (standard deviation, 10 years). Mean interview length was 25 minutes (standard deviation, 7 minutes). Gynecologic oncologists described the following three main strategies for introducing outpatient specialty palliative care: focus initial palliative care referral on symptom management to dissociate palliative care from end-of-life care and facilitate early relationship building with palliative care clinicians; use a strong physician-patient relationship and patient trust to increase acceptance of referral; and explain and normalize palliative care referral to address negative associations and decrease patient fear of abandonment. These strategies aim to decrease negative patient associations and encourage acceptance of early referral to palliative care specialists. Gynecologic oncologists have developed strategies for introducing palliative care services to alleviate patient concerns. These strategies provide groundwork for developing system-wide best practice approaches to the presentation of palliative care referral.
Kok, Maaike; van der Werff, Gertruud F M; Geerling, Jenske I; Ruivenkamp, Jaap; Groothoff, Wies; van der Velden, Annette W G; Thoma, Monique; Talsma, Jaap; Costongs, Louk G P; Gans, Reinold O B; de Graeff, Pauline; Reyners, Anna K L
Advance Care Planning (ACP) and its documentation, accessible to healthcare professionals regardless of where patients are staying, can improve palliative care. ACP is usually performed by trained facilitators. However, ACP conversations would be more tailored to a patient's specific situation if held by a patient's clinical healthcare team. This study assesses the feasibility of ACP by a patient's clinical healthcare team, and analyses the documented information including current and future problems within the palliative care domains. This multicentre study was conducted at the three Groningen Palliative Care Network hospitals in the Netherlands. Patients discharged from hospital with a terminal care indication received an ACP document from clinical staff (non-palliative care trained staff at hospitals I and II; specialist palliative care nurses at hospital III) after they had held ACP conversations. An anonymised copy of this ACP document was analysed. Documentation rates of patient and contact details were investigated, and documentation of current and future problems were analysed both quantitatively and qualitatively. One hundred sixty ACP documents were received between April 2013 and December 2014, with numbers increasing for each consecutive 3-month time period. Advance directives were frequently documented (82%). Documentation rates of current problems in the social (24%), psychological (27%) and spiritual (16%) domains were low compared to physical problems (85%) at hospital I and II, but consistently high (> 85%) at hospital III. Of 545 documented anticipated problems, 92% were physical or care related in nature, 2% social, 5% psychological, and will improve identification and documentation of non-physical problems remains to be investigated.
Full Text Available Heart failure is an important health problem since its incidence and prevalence is increasing year by year. Since symptom burden and mortality are high in heart failure, supportive and palliative care should be provided. However, very few patients are referred to palliative care services. In comparison with cancer patients, it is difficult to identify end of life care for patients with heart failure, because these patients are hospitalized when the signs of acute decompensation appear, and their symptoms decrease and functional status improve before they are discharged. Therefore, palliative care, which is a holistic approach aiming to improve patients’ quality of life, to detect and treat the attacks of the disease before they become severe, and to deal with patients’ physical, psychological, social, and mental health altogether during their care, should be integrated into heart failure patients’ care. [TAF Prev Med Bull 2012; 11(2.000: 217-222
It is estimated that in 2008 there were over 12 million new cancer diagnoses and 7 million cancer deaths worldwide. The World Health Organisation (WHO) predicts that cancer rates will increase from 10 million to 24 million in the next 50 years. More than half of cancer cases will be diagnosed in low income nations, where 80% or more of patients will have incurable disease at diagnosis. In situations where most patients are diagnosed with incurable disease or where curative treatment is logistically unavailable, as is the case in many low income countries, the allocation of limited health care resources should reflect a greater emphasis on palliative care. Ironically, access to palliative care is greater in health care systems with well developed infrastructures and facilities for prevention, early detection, and curative treatment of cancer. To provide comprehensive cancer care, a multidisciplinary approach is needed. This maximizes the available treatments and interventions, whilst ensuring a cost effective and ethically sound approach to the treatment of patients at each stage of the disease. Barriers to palliative care may result from its low prioritization in health care policy and education. The WHO expert committee on cancer pain and palliative care report of 1990 called for the integration of efforts directed at maintaining patient quality of life through all stages of cancer treatment. As a result supportive interventions aimed at improving quality of life are needed for patients undergoing both curative and palliative cancer treatment. The International Atomic Energy Agency is currently collaborating with the Open Society Institute to develop palliative care programmes in Eastern Europe, Africa and India, as well as supporting programmes in other regions of the world, through the International Palliative Care Initiative. OSI partners with the IAEA's Programme of Action for Cancer Therapy, the World Health Organization, the International Agency for Research
Rudilla, David; Galiana, Laura; Oliver, Amparo; Barreto, Pilar
Among the approaches to the demoralization syndrome, the one proposed by Kissane et al. is prevalent in the literature. These authors developed the Demoralization Scale (DS) to assess emotional distress, conceived as demoralization. To present the Spanish adaptation of the Demoralization Scale in palliative care patients, with a new and more comprehensive approach to its factorial structure. A cross-sectional study was carried out in 226 Spanish palliative care patients in three different settings: hospital, home care unit, and continued care unit. Outcome measures included the DS and the Hospital Anxiety and Depression Scale. Analyses comprised confirmatory factor analyses to test the original, German, and Irish structure of the DS, exploratory structural equation modeling (ESEM), estimations of internal consistency, and multivariate analyses of variance for criterion-related validity. The confirmatory factor analyses showed inappropriate fit for the previous structures when studied in the Spanish version of the DS. With ESEM, the best fitting structure was the five-factor solution, without item 18. Reliability results offered good estimations of internal consistency for all the dimensions except for sense of failure. Cronbach alpha coefficients were appropriate for the dimensions of loss of meaning (0.86), helplessness (0.79), disheartenment (0.88), and dysphoria (0.80), but low reliability was found for sense of failure (0.62). Convergent and discriminant validity showed positive correlations between demoralization, anxiety, and depression. Patients with higher levels of anxiety had higher scores on every dimension of demoralization, and those with higher levels of depression had higher scores on loss of meaning, disheartenment, and sense of failure, but not on dysphoria or helplessness. The Spanish adaptation of the DS has shown appropriate psychometric properties. It has been useful to differentiate between depression and the demoralization syndrome, pointing
Bouca-Machado, R.; Titova, N.; Chaudhuri, K.R.; Bloem, B.R.; Ferreira, J.J.
Parkinson's disease is the second most common neurodegenerative disease worldwide. There is widespread consensus that Parkinson patients, their carers, and clinicians involved in their care would benefit from a fully integrated, need-based provision of palliative care. However, the concept of
Gielen, Joris; Van den Branden, Stef; Van Iersel, Trudie; Broeckaert, Bert
Palliative sedation is an option of last resort to control refractory suffering. In order to better understand palliative-care nurses' attitudes to palliative sedation, an anonymous questionnaire was sent to all nurses (589) employed in palliative care in Flanders (Belgium). In all, 70.5% of the nurses (n = 415) responded. A large majority did not agree that euthanasia is preferable to palliative sedation, were against non-voluntary euthanasia in the case of a deeply and continuously sedated patient and considered it generally better not to administer artificial floods or fluids to such a patient. Two clusters were found: 58.5% belonged to the cluster of advocates of deep and continuous sedation and 41.5% belonged to the cluster of nurses restricting the application of deep and continuous sedation. These differences notwithstanding, overall the attitudes of the nurses are in accordance with the practice and policy of palliative sedation in Flemish palliative-care units.
Grande, G. E.; McKerral, A.; Todd, C. J.
Previous research has shown that palliative home care use is influenced by variables such as age, socioeconomic status, presence of an informal carer, diagnosis, and care dependency. However, there is little information on its association with other health service use. This study compared 121 cancer patients referred to Hospital at Home (HAH) for palliative care with a sample of 206 cancer patients not referred who died within the same period. Electronic record linkage of NHS databases enable...
Ensuring patients are comfortable in bed is key to effective palliative care, but when moving and positioning patients in bed, health professionals face an occupational risk of injury. The turning and positioning (TAP) system is a new method of moving patients in bed, that evidence has shown to reduce the risk of injury to caregivers. Providing the correct bed surface is another aspect of bed care essential to the comfort of the palliative patient, and to aid wound prevention and treatment. It is important to take a patient-centred approach when considering the most appropriate bed surface patients. This article provides an overview and discussion of these two aspects of bed care for palliative patients.
Mosoiu, Daniela; Mitrea, Nicoleta; Dumitrescu, Malina
HOSPICE Casa Sperantei has been pioneering palliative care development in Romania since 1992. The have developed specialist palliative care services in home-based settings, inpatient units, day care centers, and as hospital support teams. They have provided national and international education programs for professionals in the palliative care field, as well as promoting palliative care integration in the health care system. Legislative improvements were adopted, including funding mechanisms for the reimbursement of palliative care services through the health insurance funds, review of opioid policy, and quality standards of care. By the end of 2015, Romania had 115 specialist palliative care services (78 palliative care inpatient units, 24 home-based palliative care services, five outpatient palliative care clinics, four day care centers, and four hospital support teams). A palliative care subspecialty for doctors was recognized as early as 2000, and a multidisciplinary master's degree program has been available at Transilvania University since 2010, when the first palliative care academic position was established. Nursing education includes mandatory palliative care modules in nursing schools. For coordinated development of palliative care at the national level, a national strategy was proposed defining three levels of palliative care provision, local, district, and national. The implementation of the palliative care strategy is partially funded through a World Bank loan. Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
Hofmann, Sonja; Hess, Stephanie; Klein, Carsten; Lindena, Gabriele; Radbruch, Lukas; Ostgathe, Christoph
Anxiety is one of the most common psychological symptoms in patients in a palliative care situation. This study aims to develop a predictive model for anxiety using data from the standard documentation routine. Data sets of palliative care patients collected by the German quality management benchmarking system called Hospice and Palliative Care Evaluation (HOPE) from 2007 to 2011 were randomly divided into a training set containing two-thirds of the data and a test set with the remaining one-third. We dichotomized anxiety levels, proxy rated by medical staff using the validated HOPE Symptom and Problem Checklist, into two groups with no or mild anxiety versus moderate or severe anxiety. Using the training set, a multivariable logistic regression model was developed by backward stepwise selection. Predictive accuracy was evaluated by the area under the receiver operating characteristic curve (AUC) based on the test set. An analysis of 9924 data sets suggests a predictive model for anxiety in patients receiving palliative care which contains gender, age, ECOG, living situation, pain, nausea, dyspnea, loss of appetite, tiredness, need for assistance with activities of daily living, problems with organization of care, medication with sedatives/anxiolytics, antidepressants, antihypertensive drugs, laxatives, and antibiotics. It results in a fair predictive value (AUC = 0.72). Routinely collected data providing individual-, disease- and therapy-related information contain valuable information that is useful for the prediction of anxiety risks in patients receiving palliative care. These findings could thus be advantageous for providing appropriate support for patients in palliative care settings and should receive special attention in future research.
Fernández-Isla, L E; Conde-Valvis-Fraga, S; Fernández-Ruíz, J S
To determine the satisfaction of main caregivers of deceased patients followed-up by palliative care teams. Web research on electronic data bases: PubMed and MEDES, using "Palliative Care" and "Patient Satisfaction" as main descriptors, and "Family", "Professional-Family Relations", "Quality of Health Care" and "Quality Assurance, Health Care" as secondary descriptors. Studies written in Spanish and English were included. Profile of principal caregiver: a woman between her mid-forties and her mid-fifties, usually related with the patient as a daughter, and of primary educational level. The items that the main caregivers valued the most were: a kind manner, feeling free to ask questions about problems during the process, tactful explanations, receiving information, pain management, time for answering questions, interest for emotional problems, and information about treatment. The worse valued items were: symptoms control, lack of psychological support after death, preparation for a death of a relative, keeping in touch after death, help to resolve outstanding issues, and help during grief. In general, a great majority of palliative care teams achieved excellent results. In spite of the good results obtained in satisfaction surveys from caregivers with regard to palliative care teams, it is essential to improve the quality of scientific-technical training (both from the medical and the psychological point of view), as well as to improve communicational skills among palliative care staff. Copyright © 2016 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.
Ratcliff, Cathy; Thyle, Ann; Duomai, Savita; Manak, Manju
EMMS International and Emmanuel Hospital Association (EHA) implemented a pilot project, poverty reduction in India through palliative care (PRIPCare). A total of 129 interviews with patients and family enrolled in palliative care at three EHA hospitals (in Fatehpur, Lalitpur and Utraula) and staff discussions established that 66% of palliative care patients had lost livelihoods due to illness, 26% of patients' families had members who had lost livelihoods due to the illness, 98% of enrolled households had debts, 59% had loans for which they had sold assets, 69% of households took out debt after their family member fell ill, many patients do not know about government benefits and lack necessary documents, many village headmen require bribes to give people access to benefits, and many bereaved women and children lose everything. Palliative care enabled 85% of patients and families to spend less on medicines, 31% of patients received free medicines, all patients reduced use of out-patient departments (OPDs), 20% reduced use of inpatient departments (IPDs), and therefore spent less on travel, 8% of patients had started earning again due to improved health, members of 10% of families started earning again, and one hospital educated 171 village headmen and increased by 5% the number of patients and their families receiving government benefits. If only 0.7% of needy adults are receiving palliative care, these benefits could be delivered to 143 times more families, targeted effectively at poverty reduction. Palliative care has great scope to reduce that most desperate poverty in India caused by chronic illness. This article concerns a study by the UK NGO EMMS International and Indian NGO EHA, to assess whether palliative care reduces household poverty. EHA staff had noticed that many patients spend a lot on ineffective treatment before joining palliative care, many families do not know their entitlement to government healthcare subsidies or government pensions, and many
Lavesen, Marie; Marsa, Kristoffer Bastrup-Madsen; Bove, Dorthe Gaby
Patients with chronic obstructive pulmonary disease (COPD) often live with unmet palliative needs and low quality of life, although several guidelines recommend that those with COPD should be offered early and integrated palliative care. However, none of the guidelines describe how these recommendations can be operationalised and the current literature offers little information about experiences with developing and implementing new palliative care services. This article offers insight into the experience of developing and implementing a new palliative outpatient structure for patients with severe COPD. All patients are assigned to a nurse who has overall responsibility for establishing and maintaining an individualised relationship with the patient and identifying their needs for care and treatment. Routine outpatient visits are replaced by ad hoc consultations, and patients are seen by pulmonary specialists only when there is a need for medical assessment and treatment or a planned advanced care planning dialogue. The new service was succesfully implemented; however, the changes required good multidisciplinary collaboration, dedicated health professionals and managerial support. This paper highlights the need for further studies to investigate the effectiveness of new palliative care interventions for patients with COPD.
McConnell, Tracey; Porter, Sam
Music therapy has experienced a rising demand as an adjunct therapy for symptom management among palliative care patients. We conducted a realist review of the literature to develop a greater understanding of how music therapy might benefit palliative care patients and the contextual mechanisms that promote or inhibit its successful implementation. We searched electronic databases (CINAHL, Embase, Medline, and PsychINFO) for literature containing information on music therapy for palliative care. In keeping with the realist approach, we examined all relevant literature to develop theories that could explain how music therapy works. A total of 51 articles were included in the review. Music therapy was found to have a therapeutic effect on the physical, psychological, emotional, and spiritual suffering of palliative care patients. We also identified program mechanisms that help explain music therapy's therapeutic effects, along with facilitating contexts for implementation. Music therapy may be an effective nonpharmacological approach to managing distressing symptoms in palliative care patients. The findings also suggest that group music therapy may be a cost-efficient and effective way to support staff caring for palliative care patients. We encourage others to continue developing the evidence base in order to expand our understanding of how music therapy works, with the aim of informing and improving the provision of music therapy for palliative care patients.
Warmenhoven, F.C.; Rijswijk, H.C.A.M. van; Hoogstraten, E. van; Spaendonck, K.P.M. van; Lucassen, P.L.B.J.; Prins, J.B.; Vissers, K.; Weel, C. van
PURPOSE Depression is highly prevalent in palliative care patients. In clinical practice, there is concern about both insufficient and excessive diagnosis and treatment of depression. In the Netherlands, family physicians have a central role in delivering palliative care. We explored variation in
Full Text Available RG Duenk,1 C Verhagen,1 EM Bronkhorst,2 PJWB van Mierlo,3,4 MEAC Broeders,5 SM Collard,6 PNR Dekhuijzen,7 KCP Vissers,1 Y Heijdra,7,* Y Engels1,* 1Department of Anesthesiology, Pain and Palliative Medicine, 2Department of Health Evidence, Radboud University Medical Center, Nijmegen, 3Department of Supportive and Palliative Medicine, 4Department of Geriatric Medicine, Rijnstate Hospital, Arnhem, 5Department of Pulmonary Diseases, Jeroen Bosch Hospital, ‘s-Hertogenbosch, 6Department of Pulmonary Diseases, Meander Medical Center, Amersfoort, 7Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, the Netherlands *These authors contributed equally to this work Background and aim: Patients with advanced chronic obstructive pulmonary disease (COPD have poor quality of life. The aim of this study was to assess the effects of proactive palliative care on the well-being of these patients.Trial registration: This trial is registered with the Netherlands Trial Register, NTR4037.Patients and methods: A pragmatic cluster controlled trial (quasi-experimental design was performed with hospitals as cluster (three intervention and three control and a pretrial assessment was performed. Hospitals were selected for the intervention group based on the presence of a specialized palliative care team (SPCT. To control for confounders, a pretrial assessment was performed in which hospitals were compared on baseline characteristics. Patients with COPD with poor prognosis were recruited during hospitalization for acute exacerbation. All patients received usual care while patients in the intervention group received additional proactive palliative care in monthly meetings with an SPCT. Our primary outcome was change in quality of life score after 3 months, which was measured using the St George Respiratory Questionnaire (SGRQ. Secondary outcomes were, among others, quality of life at 6, 9 and 12 months; readmissions: survival; and having made
Slort, Willemjan; Blankenstein, Annette H; Deliens, Luc; van der Horst, Henriëtte E
Effective communication is considered to be essential for the delivery of high-quality care. Communication in palliative care may be particularly difficult, and there is still no accepted set of communication skills for GPs in providing palliative care. To obtain detailed information on facilitators and barriers for GP-patient communication in palliative care, with the aim to develop training programmes that enable GPs to improve their palliative care communication skills. Qualitative study with focus groups, interviews, and questionnaires. GPs with patients receiving palliative care at home, and end-of-life consultants in the Netherlands. GP (n = 20) focus groups discussing facilitators and barriers, palliative care patient (n = 6) interviews regarding facilitators, and end-of-life consultant (n = 22) questionnaires concerning barriers. Facilitators reported by both GPs and patients were accessibility, taking time, commitment, and listening carefully. GPs emphasise respect, while patients want GPs to behave in a friendly way, and to take the initiative to discuss end-of-life issues. Barriers reported by both GPs and end-of-life consultants were: difficulty in dealing with former doctors' delay and strong demands from patients' relatives. GPs report difficulty in dealing with strong emotions and troublesome doctor-patient relationships, while consultants report insufficient clarification of patients' problems, promises that could not be kept, helplessness, too close involvement, and insufficient anticipation of various scenarios. The study findings suggest that the quality of GP-patient communication in palliative care in the Netherlands can be improved. It is recommended that specific communication training programmes for GPs should be developed and evaluated.
Foxwell, Anessa M; Moyer, Mary E; Casarett, David J; O'Connor, Nina R
Palliative care programs are experiencing rapid growth, with demand for consults surpassing staffing. Innovative models are needed to equip nonpalliative care providers to manage basic palliative care issues. To develop a novel program of palliative care office hours for hematologic oncology advanced practice providers, and to evaluate its impact on palliative care consult volume and composition. A palliative care nurse practitioner or pharmacist was available for weekday office hours to all inpatient hematologic oncology advanced practice providers at an academic medical center to offer advice on pain, nonpain symptoms, and psychosocial distress. A retrospective study looking at outcome measures after six months of office hour utilization and palliative care consults from the hematologic oncology services. Palliative care office hours had a mean duration of 16 minutes per day (range 5 to 55). A mean of 11 patients were discussed per week (range 4 to 20). Pain, nausea, and anxiety were the issues most frequently raised. Of 299 patients discussed during office hours, 44 (14.7%) subsequently required a full palliative care consult. Overall, palliative care consults from the hematologic oncology services decreased from 19.6% to 10.2% of admissions (87/445 vs. 61/594, p Office hours are an efficient way to address palliative care needs when demand for palliative care consults exceeds capacity. Office hours may serve an educational function as well, enabling primary teams to manage basic palliative care issues with increasing independence over time.
Spaulding, Aaron; Harrison, Debra A; Harrison, Jeffrey P
Palliative care services are becoming more prevalent in the United States as greater portions of the population are requiring end-of-life services. Furthermore, recent policy changes and service foci have promoted more continuity and encompassing care. This study evaluates characteristics that distinguish hospitals with a palliative care program from hospitals without such a program in order to better define the markets and environments that promote the creation and usage of these programs. This study demonstrates that palliative care programs are more likely in communities with favorable economic factors and higher Medicare populations. Large hospitals with high occupancy rates and a high case mix index use palliative care programs to better meet patient needs and improve hospital efficiency. Managerial, nursing, and policy implications are discussed relating to further usage and implementation of palliative care programs.
Nordly, Mie; Vadstrup, Eva Soelberg; Sjøgren, Per
OBJECTIVE: Due to an urgent need for specialized palliative care (SPC) for patients with advanced cancer, an overview of available information on organization and outcomes of home-based SPC would be valuable. Our systematic review aims to give an overview of available information...... on the organization and outcomes of home-based SPC for patients with advanced cancer. Outcomes related to place of death, survival time, quality of life, performance status, and symptom management are included. METHOD: A PICO process search strategy consisting of terms related to cancer, palliation, and home care...... for patients with advanced cancer, resulting in poor information and a lack of evidence. Generally, home-based SPC seems to have some positive effect on pain and dyspnea, but more high-quality studies are required....
Full Text Available Cancer is the third highest cause of death in Kenya, preceded by infectious and cardiovascular diseases, and in most cases, diagnosed in later stages. Nurses are the primary caregivers, assessing and managing these patients in the clinic, in inpatient settings, and in rural and remote communities. While cancer rates remain high, the burden to the patient, the caregiver, and society as a whole continues to rise. Kenya's poverty complicates cancer even further. Many Kenyans are unaware of cancer's signs and symptoms, and limited diagnostic and treatment centers are available. Despite these barriers, there is still hope and help for those in Kenya, who suffer from cancer. The World Health Organization has stated that palliative care is a basic human right and nurses providing this care in Kenya are making efforts to support cancer patients' ongoing needs, in order to promote compassionate palliative care and prevent suffering. The purpose of this paper is to address the palliative care needs of patients with cancer in Kenya by providing education to nurses and influencing health-care policy and education at micro and macro levels. A case study weaved throughout will highlight these issues.
Norinder, Maria; Goliath, Ida; Alvariza, Anette
Patients who receive palliative home care are in need of support from family members, who take on great responsibility related to caregiving but who often feel unprepared for this task. Increasing numbers of interventions aimed at supporting family members in palliative care have been described and evaluated. It is not known whether and how these interventions actually affect the care or support provided to a patient, even though it has been suggested that family members would be likely to provide better care and support and thus allow for positive experiences for patients. However, this has not been studied from the perspective of the patients themselves. The objective of our study was to explore patients' experiences of care and support at home after family members' participation in a psychoeducational intervention during palliative care. Our study took a qualitative approach, and interviews were conducted with 11 patients whose family members had participated in a psychoeducational intervention during palliative home care. The interviews were analyzed employing interpretive description. Patients' experiences were represented by three themes: "safe at home," "facilitated and more honest communication," and "feeling like a unit of care." Patients felt that their needs were better met and that family members became more confident at home without risking their own health. Patients felt relieved when family members were given the opportunity to talk and reflect with others and hoped that the intervention would contribute to more honest communications between themselves and their family members. Further, it was of great importance to patients that family members receive attention from and be confirmed and supported by healthcare professionals. Our findings show how an intervention targeted at family members during palliative home care also benefits the patients.
Parra Palacio, Santiago; Giraldo Hoyos, Clara Elisa; Arias Rodríguez, Camilo; Mejía Arrieta, Daniel; Vargas Gómez, John Jairo; Krikorian, Alicia
To describe the practice of palliative sedation (PS) in patients with advanced cancer in a specialized palliative care (PC) unit in Colombia. Descriptive prospective study including all adults with cancer hospitalized under PS in a cancer institute between January and July 2015 in Colombia. Variables examined were diagnosis, physical functioning, symptoms at the start of sedation, medications and dosages used, and type, level, and time of sedation. Descriptive and correlational statistics were obtained. Sixty-six patients were included, 70% of which were women. The patients had an average age of 61 years (range 24-87), and 74% had a Karnofsky Index (KI) of 50% or less. The most frequent diagnosis was breast cancer (22%), and 82% had metastatic cancer. The prevalence of palliative sedation was 2% and the most common symptoms indicating it were dyspnea (59%), delirium (45%), and pain (32%). All patients received midazolam as a sedative. The average time between the interval start and culmination of sedation was 44 h. There was a significant and inverse relationship between functionality and time under sedation. Palliative sedation is a valid therapeutic option for refractory symptoms causing suffering. The results correspond to international reports and guidelines, which suggests that PS is tailored to the needs of the individual patient while maintaining a high scientific standard, even in a context where PC is under development. However, further development of strategies and clear indications towards the use of PS in Colombia are needed, given its still scarce use.
[Palliative home care in Westfalia-Lippe--baseline study 12 and 36 months after coming into effect of the "agreement to the implementation of ambulant home palliative careforterminally ill patients"].
Lux, E A; Althaus, A; Classen, B; Hilscher, H; Hofmeister, U; Holtappels, P; Mansfeld-Nies, R; Weller, H U
On 2009-04-01 the Association of Statutory Health Insurance Physicians Westfalia-Lippe and health insurance organizations made an agreement to implement palliative home care for terminally ill patients. Based on this agreement, family doctors and palliativecardoctorscooperate,supported by coordinators. 12 and 36 months after coming into effect of the agreement a questionnaire was sent to the regional palliative care networks to collect data about supply structure, number of patients and their place of death. In the year 2011 85,410 people died in Westfalia-Lippe, 9.0% of them were included in palliative care structures. 69.5% of the included patients died at home, 9.9% in hospital (in 2010: 68.7% at home, 14.7% in hospital). A correlation between the population density or the number of included patients per palliative networkcould not be detected. Low-threshold access to palliative care networks(bothfamilydoctorand patientcancontact the palliative care team at any time) improves ambulant palliative care. Non-bureaucratic change from general home palliative care (German abbreviation: AAPV) to specialized home palliative care (SAPV) has proven successful in Westfalia-Lippe. Well-trained and experienced coordinators guarantee multidisciplinary and multiprofessional working of palliative care teams. In order to enhance palliative care in Westfalia-Lippe, data for quality assurance should be defined, periodically collected and evaluated in the future.
Slort, W.; Schweitzer, B.P.M.; Blankenstein, A.H.; Abarshi, E.A.; Riphagen, I.I.; Echteld, M.A.; Aaronson, N.K.; van der Horst, H.E.; Deliens, L.
While effective general practitioner (GP)-patient communication is required for the provision of good palliative care, barriers and facilitators for this communication are largely unknown. We aimed to identify barriers and facilitators for GP-patient communication in palliative care. In a systematic
Slort, W.; Schweitzer, B.P.M.; Blankenstein, A.H.; Abarshi-Fatiregun, E.A.B.; Riphagen, I.; Echteld, M.A.; Aaronson, N.K.; van der Horst, H.E.; Deliens, L.
While effective general practitioner (GP)-patient communication is required for the provision of good palliative care, barriers and facilitators for this communication are largely unknown. We aimed to identify barriers and facilitators for GP-patient communication in palliative care. In a systematic
Slort, W; Schweitzer, B P M; Blankenstein, A H; Abarshi, E A; Riphagen, I I; Echteld, M A; Aaronson, N K; van der Horst, He; Deliens, L
While effective general practitioner (GP)-patient communication is required for the provision of good palliative care, barriers and facilitators for this communication are largely unknown. We aimed to identify barriers and facilitators for GP-patient communication in palliative care. In a systematic review seven computerized databases were searched to find empirical studies on GP-patient communication in palliative care. Fifteen qualitative studies and seven quantitative questionnaire studies were included. The main perceived barriers were GPs' lack of availability, and patients' and GPs' ambivalence to discuss 'bad prognosis'. Main perceived facilitators were GPs being available, initiating discussion about several end-of-life issues and anticipating various scenarios. Lack of availability and failure to discuss former mistakes appear to be blind spots of GPs. GPs should be more forthcoming to initiate discussions with palliative care patients about prognosis and end-of-life issues. Empirical studies are needed to investigate the effectiveness of the perceived barriers and facilitators.
Jayard, S Stephen; Irudayadason, Nishant A; Davis, J Charles
Death is inevitable, but that does not mean it can be planned or imposed. It is an ethical imperative that we attend to the unbearable pain and suffering of patients with incurable and terminal illnesses. This is where palliative care plays a vital role. Palliative care has been growing faster in the world of medicine since its emergence as a specialty in the last decade. Palliative care helps to reduce physical pain while affirming the aspect of human suffering and dying as a normal process. The goal of palliative care is to improve the quality of life both of the patient and the family. Palliative care resonates with the healing ministry of Christianity that affirms the sanctity and dignity of human life from the moment of conception to natural death. Christianity is convinced that patients at the very end of their lives, with all their ailments and agonies, are still people who have been created in the image and likeness of God. The human person is always precious, even when marked by age and sickness. This is one of the basic convictions that motivate Christians to take care of the sick and the dying. Palliative care is a great opportunity for Christians to manifest God's unfailing love for the terminally ill and the dying.
Slort, Willemjan; Blankenstein, Annette H; Deliens, Luc; van der Horst, Henriëtte E
Background Effective communication is considered to be essential for the delivery of high-quality care. Communication in palliative care may be particularly difficult, and there is still no accepted set of communication skills for GPs in providing palliative care. Aim To obtain detailed information on facilitators and barriers for GP–patient communication in palliative care, with the aim to develop training programmes that enable GPs to improve their palliative care communication skills. Design of study Qualitative study with focus groups, interviews, and questionnaires. Setting GPs with patients receiving palliative care at home, and end-of-life consultants in the Netherlands. Method GP (n = 20) focus groups discussing facilitators and barriers, palliative care patient (n = 6) interviews regarding facilitators, and end-of-life consultant (n = 22) questionnaires concerning barriers. Results Facilitators reported by both GPs and patients were accessibility, taking time, commitment, and listening carefully. GPs emphasise respect, while patients want GPs to behave in a friendly way, and to take the initiative to discuss end-of-life issues. Barriers reported by both GPs and end-of-life consultants were: difficulty in dealing with former doctors' delay and strong demands from patients' relatives. GPs report difficulty in dealing with strong emotions and troublesome doctor–patient relationships, while consultants report insufficient clarification of patients' problems, promises that could not be kept, helplessness, too close involvement, and insufficient anticipation of various scenarios. Conclusion The study findings suggest that the quality of GP–patient communication in palliative care in the Netherlands can be improved. It is recommended that specific communication training programmes for GPs should be developed and evaluated. PMID:21439174
Heins, Marianne; Hofstede, Jolien; Rijken, Mieke; Korevaar, Joke; Donker, Gé; Francke, Anneke
In many countries, GPs and home care nurses are involved in care for patients with advanced cancer. Given the varied and complex needs of these patients, providing satisfactory care is a major challenge for them. We therefore aimed to study which aspects of care patients, GPs and home care nurses consider important and whether patients receive these aspects. Seventy-two Dutch patients with advanced cancer, 87 GPs and 26 home care nurses rated the importance of support when experiencing symptoms, respect for patients' autonomy and information provision. Patients also rated whether they received these aspects. Questionnaires were based on the CQ index palliative care. Almost all patients rated information provision and respect for their autonomy as important. The majority also rated support when suffering from specific symptoms as important, especially support when in pain. In general, patients received the care they considered important. However, 49% of those who considered it important to receive support when suffering from fatigue and 23% of those who wanted to receive information on the expected course of their illness did not receive this or only did so sometimes. For most patients with advanced cancer, the palliative care that they receive matches what they consider important. Support for patients experiencing fatigue may need more attention. When symptoms are difficult to control, GPs and nurses may still provide emotional support and practical advice. Furthermore, we recommend that GPs discuss patients' need for information about the expected course of their illness.
Full Text Available ... it free Find out why Close Pediatric Palliative Care: A Personal Story NINRnews Loading... Unsubscribe from NINRnews? ... and her family. The story demonstrates how palliative care can positively influence a patient's and family's experience ...
Eva, Gail; Morgan, Deidre
Occupational therapists play an integral role in the care of people with life-limiting illnesses. However, little is known about the scope of occupational therapy service provision in palliative care across Europe and factors influencing service delivery. This study aimed to map the scope of occupational therapy palliative care interventions across Europe and to explore occupational therapists' perceptions of opportunities and challenges when delivering and developing palliative care services. A 49-item online cross-sectional survey comprised of fixed and free text responses was securely hosted via the European Association for Palliative Care website. Survey design, content and recruitment processes were reviewed and formally approved by the European Association for Palliative Care Board of Directors. Descriptive statistics and thematic analysis were used to analyse data. Setting/respondents: Respondents were European occupational therapists whose caseload included palliative care recipients (full-time or part-time). In total, 237 valid responses were analysed. Findings demonstrated a consistency in occupational therapy practice in palliative care between European countries. Clinician time was prioritised towards indirect patient care, with limited involvement in service development, leadership and research. A need for undergraduate and postgraduate education was identified. Organisational expectations and understanding of the scope of the occupational therapy role constrain the delivery of services to support patients and carers. Further development of occupational therapy in palliative care, particularly capacity building in leadership and research activities, is warranted. There is a need for continuing education and awareness raising of the role of occupational therapy in palliative care.
This thesis describes hope in palliative care patients, their family members and their healthcare professionals. An interpretative synthesis of the literature (chapter 2) and a metaphor analysis of semi-structured interviews with palliative care professionals (chapter 3) highlight palliative care
Full Text Available Abstract Background This paper describes the development of a new quality of life instrument in advanced cancer patients receiving palliative care. Methods The Palliative Care Quality of Life Instrument incorporates six multi-item and one single-item scale. The questionnaire was completed at baseline and one-week after. The final sample consisted of 120 patients. Results The average time required to complete the questionnaire, in both time points, was approximately 8 minutes. All multi-item scales met the minimal standards for reliability (Cronbach's alpha coefficient ≥.70 either before or during palliative treatment. Test-retest reliability in terms of Spearman-rho coefficient was also satisfactory (p Conclusion The PQLI is a reliable and valid measure for the assessment of quality of life in patients with advanced stage cancer.
Adsersen, Mathilde; Thygesen, Lau Caspar; Jensen, Anders Bonde
/units. Patients with brain cancer were more often admitted to hospices, whereas patients with prostate cancer were more often admitted to hospital-based palliative care teams/units. CONCLUSION: It is unlikely that the variations in relation to sex, age and cancer diagnoses can be fully explained by differences...... to investigate whether cancer patients' admittance to SPC in Denmark varied in relation to sex, age and diagnosis, and whether the patterns differed by type of institution (hospital-based palliative care team/unit, hospice, or both). METHODS: This was a register-based study of adult patients living in Denmark......BACKGROUND: Specialised palliative care (SPC) takes place in specialised services for patients with complex symptoms and problems. Little is known about what determines the admission of patients to SPC and whether there are differences in relation to institution type. The aims of the study were...
Patel, Preena; Koh, Michelle; Carr, Lucinda; McHugh, Kieran
Palliative care is an expanding specialty within paediatrics, which has attracted little attention in the paediatric radiological literature. Paediatric patients under a palliative care team will have numerous radiological tests which we traditionally categorise under organ systems rather than under the umbrella of palliative medicine. The prevalence of children with life-limiting illness is significant. It has been estimated to be one per thousand, and this may be an underestimate. In this review, we will focus on our experience at one institution, where radiology has proven to be an invaluable partner to palliative care. We will discuss examples of conditions commonly referred to our palliative care team and delineate the crucial role of diagnostic radiology in determining treatment options. (orig.)
Patel, Preena; Koh, Michelle; Carr, Lucinda; McHugh, Kieran [Great Ormond Street Hospital, Radiology Department, London (United Kingdom)
Palliative care is an expanding specialty within paediatrics, which has attracted little attention in the paediatric radiological literature. Paediatric patients under a palliative care team will have numerous radiological tests which we traditionally categorise under organ systems rather than under the umbrella of palliative medicine. The prevalence of children with life-limiting illness is significant. It has been estimated to be one per thousand, and this may be an underestimate. In this review, we will focus on our experience at one institution, where radiology has proven to be an invaluable partner to palliative care. We will discuss examples of conditions commonly referred to our palliative care team and delineate the crucial role of diagnostic radiology in determining treatment options. (orig.)
(UNAIDS 2004. The HIV/AIDS epidemic is devastating the African continent.In Africa poorly resourced health care infrastructure further impairs the quality of life in HIV sufferers. Palliative care is an approach that aims to improve the quality of life of people living with threatening diseases such as cancer and HIV/AIDS. This review aimed to determine the efficacy of palliative care. Complementary therapies such as Cognitive Behavioural Therapy, peer/counselling group therapy, massage therapy, and exercise therapy constitute palliative care. Seventeen articles published in peer reviewed journals during the period 1990-2005 were reviewed. The findings of our review demonstrate that there are indications that palliative care can be effective in improving the quality of life in patients with life threatening diseases such HIV/AIDS. Research in this field is complicated by the heterogeneity of study samples, difficulty in patient recruitment, and death before the end of the intervention period. Future research in this area should aim to include larger study samples, using valid tools to assess quality of life and to employ qualitative methods in studies to assess the effectiveness of palliative care.
Palliative care has its roots in hospice movement arising in the 1970s in Europe and later also in America. From its beginning it has had connection with patients in terminal phase of cancer disease who suffered from many serious symptoms. Nowadays palliative care is also being provided to patients in terminal phase of certain neurological disorders, AIDS, exceptionally for patients with heart, lung or kidney failure. It has become part of modern medicine and of good clinical practice. (author)
Goldschmidt, Dorthe; Groenvold, Mogens; Johnsen, Anna Thit
BACKGROUND: Palliative home-care teams often cooperate with general practitioners (GPs) and district nurses. Our aim was to evaluate a palliative home-care team from the viewpoint of GPs and district nurses. METHODS: GPs and district nurses received questionnaires at the start of home-care and one...... month later. Questions focussed on benefits to patients, training issues for professionals and cooperation between the home-care team and the GP/ district nurse. A combination of closed- and open-ended questions was used. RESULTS: Response rate was 84% (467/553). Benefits to patients were experienced...... by 91 %, mainly due to improvement in symptom management, 'security', and accessibility of specialists in palliative care. After one month, 57% of the participants reported to have learnt aspects of palliative care, primarily symptom control, and 89% of them found cooperation satisfactory...
Nelson, Judith E; Mathews, Kusum S; Weissman, David E; Brasel, Karen J; Campbell, Margaret; Curtis, J Randall; Frontera, Jennifer A; Gabriel, Michelle; Hays, Ross M; Mosenthal, Anne C; Mulkerin, Colleen; Puntillo, Kathleen A; Ray, Daniel E; Weiss, Stefanie P; Bassett, Rick; Boss, Renee D; Lustbader, Dana R
Rapid response teams (RRTs) can effectively foster discussions about appropriate goals of care and address other emergent palliative care needs of patients and families facing life-threatening illness on hospital wards. In this article, The Improving Palliative Care in the ICU (IPAL-ICU) Project brings together interdisciplinary expertise and existing data to address the following: special challenges for providing palliative care in the rapid response setting, knowledge and skills needed by RRTs for delivery of high-quality palliative care, and strategies for improving the integration of palliative care with rapid response critical care. We discuss key components of communication with patients, families, and primary clinicians to develop a goal-directed treatment approach during a rapid response event. We also highlight the need for RRT expertise to initiate symptom relief. Strategies including specific clinician training and system initiatives are then recommended for RRT care improvement. We conclude by suggesting that as evaluation of their impact on other outcomes continues, performance by RRTs in meeting palliative care needs of patients and families should also be measured and improved.
M.J. Uitdehaag (Madeleen)
textabstractThis thesis explores palliative care provided to patients with advanced upper gastrointestinal (GI) cancer. The 5-year survival rates for these cancer sites range between 4 and 17%, which implies that many of these patients require palliative care. Considering the fact that there is no
Mercadante, Sebastiano; Aielli, Federica; Adile, Claudio; Ferrera, Patrizia; Valle, Alessandro; Cartoni, Claudio; Pizzuto, Massimo; Caruselli, Amanda; Parsi, Renato; Cortegiani, Andrea; Masedu, Francesco; Valenti, Marco; Ficorella, Corrado; Porzio, Giampiero
Information regarding sleep disturbances in the population with advanced cancer is meager. To assess the prevalence of sleep disturbances and possible correlations with associated factors in a large number of patients with advanced cancer admitted to different palliative care settings. This was an observational study performed in different settings of palliative care. A consecutive sample of patients with advanced cancer was prospectively assessed for a period of six months. Epidemiological and clinical data, treatments received in the last month, Karnofsky status, Edmonton Symptom Assessment System scores, and concomitant medical treatment were recorded. Patients were administered the Athens Insomnia Scale and the Hospital Anxiety and Depression Scale (HADS). A total of 820 patients were surveyed. Mean age was 69.7 years (SD 12.7), and 429 patients were males. Consistent sleep disturbances (moderate to maximum) were found in 60.8% of patients. Aged patients were less likely to have sleep disturbances, whereas a poor Karnofsky level was significantly associated with sleep problems. Breast, gastrointestinal, head and neck, lung, and prostate cancers were associated with sleep problems. Patients who had a secondary school or undergraduate education had less sleep disturbances. Hormone therapy and use of opioids and corticosteroids were positively associated with sleep disturbances, and there was a positive correlation of HADS-Anxiety and HADS-Depression scores with sleep disturbances. More than 60% of palliative care patients have relevant sleep disturbances. Several factors associated with sleep disorders have been identified and should prompt physicians to make a careful examination and subsequent treatment of these disturbances. Copyright © 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
Full Text Available "If you want to travel quickly, go alone. But if you want to travel far, you must go together". African proverb. The delivery of palliative care is often complex and always involves a group of people, the team, gathered around the patient and those who are close to them. Effective communication and functional responsive systems of care are essential if palliative care is to be delivered in a timely and competent way. Creating and fostering an effective team is one of the greatest challenges for providers of palliative care. Teams are organic and can be life giving or life sapping for their members.
“If you want to travel quickly, go alone. But if you want to travel far, you must go together”. African proverb. The delivery of palliative care is often complex and always involves a group of people, the team, gathered around the patient and those who are close to them. Effective communication and functional responsive systems of care are essential if palliative care is to be delivered in a timely and competent way. Creating and fostering an effective team is one of the greatest challenges for providers of palliative care. Teams are organic and can be life giving or life sapping for their members. PMID:21811361
Lancaster, Harriet; Finlay, Ilora; Downman, Maxwell; Dumas, James
Some failures in end-of-life care have been attributed to inconsistent provision of palliative care across England. We aimed to explore the variation in commissioning of services by Clinical Commissioning Groups (CCGs) using a data collection exercise. We sent a Freedom of Information request in the form of an open questionnaire to all 209 CCGs in England to assess their commissioning of palliative and end-of-life care services, mainly focused on the provision of specialist palliative care services. 29 CCGs provided information about the number of patients with some form of palliative care needs in their population. For specialist palliative care services, CCGs allocated budgets ranging from £51.83 to £2329.19 per patient per annum. 163 CCGs (77.90%) currently commission 7-day admission to their specialist palliative care beds. 82.84% of CCGs commission 7-day specialist palliative care services in patients' own homes and out-of-hours services rely heavily on hospice provision. 64 CCGs (31.37%) commission pain control teams, the majority of whom only operate in regular working hours. 68.14% of CCGs reported commissioning palliative care education of any sort for healthcare professionals and 44.85% of CCGs had no plans to update or review their palliative care services. The most important finding from this exercise is that the information CCGs hold about their population and services is not standardised. However, information based on data that are more objective, for example, population and total budget for palliative care, demonstrate wide variations in commissioning. 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/.
Mercadante, Sebastiano; Masedu, Francesco; Balzani, Isabella; De Giovanni, Daniela; Montanari, Luigi; Pittureri, Cristina; Bertè, Raffaella; Russo, Domenico; Ursini, Laura; Marinangeli, Franco; Aielli, Federica
The aim of this study was to assess the prevalence of delirium in advanced cancer patients admitted to different palliative care services in Italy and possible related factors. The secondary outcome was to assess the changes of delirium after 1 week of palliative care. A consecutive sample of patients was screened for delirium in period of 1 year in seven palliative care services. General data, including primary tumor, age, gender, concomitant disease, palliative prognostic score (PaP), and Karnofsky status, were collected. Possible causes or factors associated with delirium were looked for. The Edmonton Symptom Assessment Scale was used to assess physical and psychological symptoms and the Memorial Delirium Assessment Scale (MDAS) to assess the cognitive status of patients, at admission (T0) and 1 week after palliative care (T7). Of 848 patients screened, 263 patients were evaluated. Sixty-six patients had only the initial evaluation. The mean Karnofsky status was 34.1 (SD = 6.69); the mean PaP score at admission was 6.9 (SD = 3.97). The mean duration of palliative care assistance, equivalent to survival, was 38.4 days (SD = 48, range 2-220). The mean MDAS values at admission and after 1 week of palliative care were 6.9 (SD = 6.71) and 8.8 (SD = 8.26), respectively. One hundred ten patients (41.8%) and 167 patients (67.3%) had MDAS values ≥ 7 at admission and after 1 week of palliative care, respectively. Age, dehydration, cachexia, chemotherapy in the last three months, and intensity of drowsiness and dyspnea were independently associated with a MDAS > 7. A worsening of drowsiness, the use of opioids, and the use of corticosteroids were independently associated with changes of MDAS from T0 to T7. Although the prevalence of delirium seems to be similar to that reported in other acute settings, delirium tended to worsen or poorly responded to a palliative care treatment. Some clinical factors were independently associated with delirium. This
Full Text Available Abstract Background According to the Word Health Organization, patients who can benefit from palliative care should be identified earlier to enable proactive palliative care. Up to now, this is not common practice and has hardly been addressed in scientific literature. Still, palliative care is limited to the terminal phase and restricted to patients with cancer. Therefore, we trained general practitioners (GPs in identifying palliative patients in an earlier phase of their disease trajectory and in delivering structured proactive palliative care. The aim of our study is to determine if this training, in combination with consulting an expert in palliative care regarding each palliative patient's tailored care plan, can improve different aspects of the quality of the remaining life of patients with severe chronic diseases such as chronic obstructive pulmonary disease, congestive heart failure and cancer. Methods/Design A two-armed randomized controlled trial was performed. As outcome variables we studied: place of death, number of hospital admissions and number of GP out of hours contacts. Discussion We expect that this study will increase the number of identified palliative care patients and improve different aspects of quality of palliative care. This is of importance to improve palliative care for patients with COPD, CHF and cancer and their informal caregivers, and to empower the GP. The study protocol is described and possible strengths and weaknesses and possible consequences have been outlined. Trial Registration The Netherlands National Trial Register: NTR2815
Full Text Available Critical junctures in patients′ lives such as chronic illnesses and advanced diseases may leave the persons in a state of imbalance or disharmony of body, mind and spirit. With regard to spirituality and healing, there is a consensus in literature about the influence of spirituality on recovery and the ability to cope with and adjust to the varying and demanding states of health and illness. Empirical evidence suggests that spiritual support may act as an adjunct to the palliative care of those facing advanced diseases and end of life. In this article, the author draws from his empirical work on spirituality and culture to develop a discourse on palliative care and spirituality in both secular and non-secular settings. In doing so, this paper offers some understanding into the concept of spirituality, spiritual needs and spiritual care interventions in palliative care in terms of empirical evidence. Responding to spiritual needs could be challenging, but at the same time it could be rewarding to both healthcare practitioner (HCP and patient in that they may experience spiritual growth and development. Patients may derive great health benefits with improvements in their quality of life, resolutions and meaning and purpose in life. It is hoped that the strategies for spiritual support outlined in this paper serve as practical guidelines to HCPs for development of palliative care in South Asia.
Provinciali, Leandro; Carlini, Giulia; Tarquini, Daniela; Defanti, Carlo Alberto; Veronese, Simone; Pucci, Eugenio
The new concept of palliative care supports the idea of palliation as an early approach to patients affected by disabling and life-limiting disease which focuses on the patient's quality of life along the entire course of disease. This model moves beyond the traditional concept of palliation as an approach restricted to the final stage of disease and widens the fields of intervention. There is a growing awareness of the importance of palliative care not only in oncological diseases but also in many other branches of medicine, and it appears particularly evident in the approach to many of the most frequent neurological diseases that are chronic, incurable and autonomy-impairing illnesses. The definition and implementation of palliative goals and procedures in neurology must take into account the specific features of these conditions in terms of the complexity and variability of symptoms, clinical course, disability and prognosis. The realization of an effective palliative approach to neurological diseases requires specific skills and expertise to adapt the concept of palliation to the peculiarities of these diseases; this approach should be realized through the cooperation of different services and the action of a multidisciplinary team in which the neurologist should play a central role to identify and face the patient's needs. In this view, it is paramount for the neurologist to be trained in these issues to promote the integration of palliative care in the care of neurological patients.
Kurita, Geana Paula; Benthien, Kirstine Skov; Sjøgren, Per
PURPOSE: Studies with neuropsychological assessments in patients with cancer are sparse, and the evidence is very limited regarding their status of cognitive function over time. This study aimed at assessing the prevalence and predictors of cognitive impairment in patients with cancer in palliative...... care. METHODS: Prospective longitudinal investigation derived from the European Palliative Care Cancer Symptom study (2011-2013) including patients with cancer in palliative care, ≥18 years, and with at least one assessment post-inclusion. For cognitive assessment, a 4-item version of the Mini Mental...... State Examination was applied at inclusion and after 4 to 16 weeks. Logistic regression model with multiple imputations was applied. RESULTS: The sample consisted of 1568 patients (50% male, mean age 65.5, 42% with 10-12 years schooling, mean Karnofsky Performance Status-KPS 68%). Longitudinal analysis...
Grant, Marcia; Elk, Ronit; Ferrell, Betty; Morrison, R Sean; von Gunten, Charles F
Palliative and end-of-life care is changing in the United States. This dynamic field is improving care for patients with serious and life-threatening cancer through creation of national guidelines for quality care, multidisciplinary educational offerings, research endeavors, and resources made available to clinicians. Barriers to implementing quality palliative care across cancer populations include a rapidly expanding population of older adults who will need cancer care and a decrease in the workforce available to give care. Methods of integrating current palliative care knowledge into care of patients include multidisciplinary national education and research endeavors, and clinician resources. Acceptance of palliative care as a recognized medical specialty provides a valuable resource for improvement of care. Although compilation of evidence for the importance of palliative care specialities is in its initial stages, national research grants have provided support to build the knowledge necessary for appropriate palliative care. Opportunities are available to clinicians for understanding and applying appropriate palliative and end-of-life care to patients with serious and life-threatening cancers. (c) 2009 American Cancer Society, Inc.
Wüller, Johannes; Küttner, Stefanie; Foldenauer, Ann Christina; Rolke, Roman; Pastrana, Tania
Our aim was to examine the accuracy of the German version of the Distress Thermometer (DT) compared with the Hospital Anxiety and Depression Scale (HADS) in patients with palliative care needs living at home. Ours was a 15-month cross-sectional study beginning in September of 2013 in Germany with consecutive patients cared for by a palliative home care service. The survey was implemented during the initial visit by a home care team. Patients were excluded if they were under 18 years of age, mentally or physically unable to complete the assessment questionnaires as judged by their healthcare worker, or unable to understand the German language. During the first encounter, the DT and HADS were applied, and sociodemographic and medical data were collected. A total of 89 persons completed both the HADS and DT questionnaires (response rate = 59.7%; mean age = 67 years; female = 55.1%; married = 65.2%; living home with relatives = 73.0%; oncological condition = 92.1%; Karnofsky Performance Scale [KPS] score: 0-40 = 30.3%, 50-70 = 57.3%, >80 = 6.7%). The mean DT score was 6.3 (±2.3), with 84.3% of participants scoring above the DT cutoff (≥4). The mean HADStotal score was 17.9 (±7.8), where 64% of participants had a total HADS score (HADStotal) ≥15, 51.7% reported anxiety (HADSanxiety ≥ 8), and 73% reported depression (HADSdepression ≥ 8). Using the HADS as a gold standard, a DT cutoff score ≥5 was optimal for identifying severe distress in patients with palliative care needs, with a sensitivity of 93.0%, a specificity of 34.4%, a positive predictive value (PPV) of 73.3%, and likelihood ratios LR+ = 1.42 (home with palliative care needs in order to offer adequate support.
AIMS: Studies suggest that patients with advanced heart failure (HF) have unmet palliative care (PC) needs. However, many of these studies have been retrospective or based on patients receiving poorly coordinated ad hoc care. We aimed to demonstrate whether the PC needs of patients with advanced HF receiving specialist multidisciplinary coordinated care are similar to cancer patients deemed to have specialist PC needs; thereby justifying the extension of specialist PC services to HF patients. METHODS AND RESULTS: This was a cross-sectional comparative cohort study of 50 HF patients and 50 cancer patients, using quantitative and qualitative methods. Both patient cohorts were statistically indistinguishable in terms of symptom burden, emotional wellbeing, and quality-of-life scores. HF patients had good access to community and social support. HF patients particularly valued the close supervision, medication monitoring, ease of access to service, telephone support, and key worker provided at the HF unit. A small subset of patients had unmet PC needs. A palliative transition point is described. CONCLUSION: HF patients should not be excluded from specialist PC services. However, the majority of their needs can be met at a HF unit. Recognition of the palliative transition point may be key to ensuring that end-of-life issues are addressed. The palliative transition point needs further evaluation.
Walling, Anne M; Tisnado, Diana; Ettner, Susan L; Asch, Steven M; Dy, Sydney M; Pantoja, Philip; Lee, Martin; Ahluwalia, Sangeeta C; Schreibeis-Baum, Hannah; Malin, Jennifer L; Lorenz, Karl A
Although recent randomized controlled trials support early palliative care for patients with advanced cancer, the specific processes of care associated with these findings and whether these improvements can be replicated in the broader health care system are uncertain. The aim of this study was to evaluate the occurrence of palliative care consultation and its association with specific processes of supportive care in a national cohort of Veterans using the Cancer Quality ASSIST (Assessing Symptoms Side Effects and Indicators of Supportive Treatment) measures. We abstracted data from 719 patients' medical records diagnosed with advanced lung, colorectal, or pancreatic cancer in 2008 over a period of three years or until death who received care in the Veterans Affairs Health System to evaluate the association of palliative care specialty consultation with the quality of supportive care overall and by domain using a multivariate regression model. All but 54 of 719 patients died within three years and 293 received at least one palliative care consult. Patients evaluated by a palliative care specialist at diagnosis scored seven percentage points higher overall (P specialist consultation is associated with better quality of supportive care in three advanced cancers, predominantly driven by improvements in information and care planning. This study supports the effectiveness of early palliative care consultation in three common advanced cancers within the Veterans Affairs Health System and provides a greater understanding of what care processes palliative care teams influence. Published by Elsevier Inc.
Beernaert, Kim; Haverbeke, Chloë; Van Belle, Simon; Deliens, Luc; Cohen, Joachim
We assessed information provision and information needs about illness course, treatments, palliative care and euthanasia in cancer patients. Cancer patients consulting a university hospital (N=620) filled out a questionnaire. Their cancer related data were collected through the treating oncologist. This study is performed in Belgium, where "palliative care for all" is a patient's right embedded in the law and euthanasia is possible under certain conditions. Around 80% received information about their illness course and treatments. Ten percent received information about palliative care and euthanasia. Most information about palliative care and euthanasia was given when the patient had a life expectancy of less than six months. However, a quarter of those in earlier phases in their illness trajectory, particularly those who experienced high pain, fatigue or nausea requested more information on these topics. Many patients want more information about palliative care and euthanasia than what is currently provided, also those in an earlier than terminal phase of their disease. Healthcare professionals should be more responsive, already from diagnosis, to the information needs about palliative care and possible end-of-life decisions. This should be patient-tailored, as some patients want more and some patients want less information. Copyright © 2017 Elsevier B.V. All rights reserved.
Miller, R S; Peterson, G M; Abbott, F; Maddocks, I; Parker, D; McLean, S
1. Plasma concentrations of fentanyl were measured by g.c. in 20 patients (median age: 75 years and range: 54-86 years; eight females) in palliative care receiving the drug by continuous s.c. infusion (median rate: 1200 micrograms day-1 and range: 100-5000 micrograms day-1). 2. The infusion rate was significantly related to the duration of therapy (Spearman rho = 0.56, P Infusion rates and both total and unbound plasma concentrations of fentanyl were correlated (Spearman rho = 0.92, P infusion in the palliative care setting, which necessitates careful titration of dosage according to individual clinical response.
Integrated palliative care is about professional networking rather than standardisation of care: A qualitative study with healthcare professionals in 19 integrated palliative care initiatives in five European countries.
den Herder-van der Eerden, Marlieke; van Wijngaarden, Jeroen; Payne, Sheila; Preston, Nancy; Linge-Dahl, Lisa; Radbruch, Lukas; Van Beek, Karen; Menten, Johan; Busa, Csilla; Csikos, Agnes; Vissers, Kris; van Gurp, Jelle; Hasselaar, Jeroen
Integrated palliative care aims at improving coordination of palliative care services around patients' anticipated needs. However, international comparisons of how integrated palliative care is implemented across four key domains of integrated care (content of care, patient flow, information logistics and availability of (human) resources and material) are lacking. To examine how integrated palliative care takes shape in practice across abovementioned key domains within several integrated palliative care initiatives in Europe. Qualitative group interview design. A total of 19 group interviews were conducted (2 in Belgium, 4 in the Netherlands, 4 in the United Kingdom, 4 in Germany and 5 in Hungary) with 142 healthcare professionals from several integrated palliative care initiatives in five European countries. The majority were nurses ( n = 66; 46%) and physicians ( n = 50; 35%). The dominant strategy for fostering integrated palliative care is building core teams of palliative care specialists and extended professional networks based on personal relationships, shared norms, values and mutual trust, rather than developing standardised information exchange and referral pathways. Providing integrated palliative care with healthcare professionals in the wider professional community appears difficult, as a shared proactive multidisciplinary palliative care approach is lacking, and healthcare professionals often do not know palliative care professionals or services. Achieving better palliative care integration into regular healthcare and convincing the wider professional community is a difficult task that will take time and effort. Enhancing standardisation of palliative care into education, referral pathways and guidelines and standardised information exchange may be necessary. External authority (policy makers, insurance companies and professional bodies) may be needed to support integrated palliative care practices across settings.
Larrañaga, Igor; Millas, Jesús; Soto-Gordoa, Myriam; Arrospide, Arantzazu; San Vicente, Ricardo; Irizar, Marisa; Lanzeta, Itziar; Mar, Javier
Evaluate the process and the economic impact of an integrated palliative care program. Comparative cross-sectional study. Integrated Healthcare Organizations of Alto Deba and Goierri Alto-Urola, Basque Country. Patients dead due to oncologic and non-oncologic causes in 2012 (control group) and 2015 (intervention group) liable to need palliative care according to McNamara criteria. Identification as palliative patients in primary care, use of common clinical pathways in primary and secondary care and arrange training courses for health professionals. Change in the resource use profile of patients in their last 3 months. Propensity score by genetic matching method was used to avoid non-randomization bias. The groups were compared by univariate analysis and the relationships between variables were analysed by logistic regressions and generalized linear models. One thousand and twenty-three patients were identified in 2012 and 1,142 patients in 2015. In 2015 doubled the probability of being identify as palliative patient in deaths due to oncologic (19-33%) and non-oncologic causes (7-16%). Prescriptions of opiates rise (25-68%) and deaths in hospital remained stable. Contacts per patient with primary care and home hospitalization increased, while contacts with hospital admissions decreased. Cost per patient rise 26%. The integrated palliative care model increased the identification of the target population. Relationships between variables showed that the identification had a positive impact on prescription of opiates, death outside the hospital and extension to non-oncologic diseases. Although the identification decreased admissions in hospital, costs per patient had a slight increase due to home hospitalizations. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.
Robinson, Jackie; Gott, Merryn; Gardiner, Clare; Ingleton, Christine
Nursing is the largest regulated health professional workforce providing palliative care across a range of clinical settings. Historically, palliative care nursing has been informed by a strong philosophy of care which is soundly articulated in palliative care policy, research and practice. Indeed, palliative care is now considered to be an integral component of nursing practice regardless of the specialty or clinical setting. However, there has been a change in the way palliative care is provided. Upstreaming and mainstreaming of palliative care and the dominance of a biomedical model with increasing medicalisation and specialisation are key factors in the evolution of contemporary palliative care and are likely to impact on nursing practice. Using a critical reflection of the authors own experiences and supported by literature and theory from seminal texts and contemporary academic, policy and clinical literature, this discussion paper will explore the influence of philosophy on nursing knowledge and theory in the context of an evolving model of palliative care.
Silbermann, Michael; Fink, Regina M; Min, Sung-Joon; Mancuso, Mary P; Brant, Jeannine; Hajjar, Ramzi; Al-Alfi, Nesreen; Baider, Lea; Turker, Ibrahim; ElShamy, Karima; Ghrayeb, Ibtisam; Al-Jadiry, Mazin; Khader, Khaled; Kav, Sultan; Charalambous, Haris; Uslu, Ruchan; Kebudi, Rejin; Barsela, Gil; Kuruku, Nilgün; Mutafoglu, Kamer; Ozalp-Senel, Gulsin; Oberman, Amitai; Kislev, Livia; Khleif, Mohammad; Keoppi, Neophyta; Nestoros, Sophia; Abdalla, Rasha Fahmi; Rassouli, Maryam; Morag, Amira; Sabar, Ron; Nimri, Omar; Al-Qadire, Mohammad; Al-Khalaileh, Murad; Tayyem, Mona; Doumit, Myrna; Punjwani, Rehana; Rasheed, Osaid; Fallatah, Fatimah; Can, Gulbeyaz; Ahmed, Jamila; Strode, Debbie
Cancer incidence in Middle Eastern countries, most categorized as low- and middle-income, is predicted to double in the next 10 years, greater than in any other part of the world. While progress has been made in cancer diagnosis/treatment, much remains to be done to improve palliative care for the majority of patients with cancer who present with advanced disease. To determine knowledge, beliefs, barriers, and resources regarding palliative care services in Middle Eastern countries and use findings to inform future educational and training activities. Descriptive survey. Fifteen Middle Eastern countries; convenience sample of 776 nurses (44.3%), physicians (38.3%) and psychosocial, academic, and other health care professionals (17.4%) employed in varied settings. Palliative care needs assessment. Improved pain management services are key facilitators. Top barriers include lack of designated palliative care beds/services, community awareness, staff training, access to hospice services, and personnel/time. The nonexistence of functioning home-based and hospice services leaves families/providers unable to honor patient wishes. Respondents were least satisfied with discussions around advance directives and wish to learn more about palliative care focusing on communication techniques. Populations requiring special consideration comprise: patients with ethnic diversity, language barriers, and low literacy; pediatric and young adults; and the elderly. The majority of Middle Eastern patients with cancer are treated in outlying regions; the community is pivotal and must be incorporated into future plans for developing palliative care services. Promoting palliative care education and certification for physicians and nurses is crucial; home-based and hospice services must be sustained.
Dzingina, Mendwas; Higginson, Irene J; McCrone, Paul; Murtagh, Fliss E M
Generic preference-based measures are commonly used to estimate quality-adjusted life-years (QALYs) to inform resource-allocation decisions. However, concerns have been raised that generic measures may be inappropriate in palliative care. Our objective was to derive a health-state classification system that is amenable to valuation from the ten-item Palliative Care Outcome Scale (POS), a widely used patient-reported outcome measure in palliative care. The dimensional structure of the original POS was assessed using factor analysis. Item performance was assessed, using Rasch analysis and psychometric criteria, to enable the selection of items that represent the dimensions covered by the POS. Data from six studies of patients receiving palliative care were combined (N = 1011) and randomly split into two halves for development and validation. Analysis was undertaken on the development data, and results were validated by repeating the analysis with the validation dataset. Following Rasch and factor analyses, a classification system of seven items was derived. Each item had two to three levels. Rasch threshold map helped identify a set of 14 plausible health states that can be used for the valuation of the instrument to derive a preference-based index. Combining factor analysis and Rasch analysis with psychometric criteria provides a valid method of constructing a classification system for a palliative care-specific preference-based measure. The next stage is to obtain preference weights so the measure can be used in economic evaluations in palliative care.
LeBlanc, Thomas W; Lodato, Jordan E; Currow, David C; Abernethy, Amy P
Palliative care is increasingly viewed as a necessary component of cancer care, especially for patients with advanced disease. Rigorous clinical trials are thus needed to build the palliative care evidence base, but clinical research-especially participant recruitment-is difficult. Major barriers include (1) patient factors, (2) "gatekeeping," and (3) ethical concerns. Here we discuss an approach to overcoming these barriers, using the Palliative Care Trial (PCT) as a case study. The PCT was a 2 × 2 × 2 factorial randomized controlled trial (RCT) of different service delivery models to improve pain control in the palliative setting. It used a recruitment protocol that fused evidence-based strategies with principles of "social marketing," an approach involving the systematic application of marketing techniques. Main components included (1) an inclusive triage algorithm, (2) information booklets targeting particular stakeholders, (3) a specialized recruitment nurse, and (4) standardization of wording across all study communications. From an eligible pool of 607 patients, the PCT enrolled 461 patients over 26 months. Twenty percent of patients referred to the palliative care service were enrolled (76% of those eligible after screening). Several common barriers were minimized; among those who declined participation, family disinterest was uncommon (5%), as was the perception of burden imposed (4%). Challenges to clinical trial recruitment in palliative care are significant but not insurmountable. A carefully crafted recruitment and retention protocol can be effective. Our experience with designing and deploying a social-marketing-based protocol shows the benefits of such an approach.
Schrader, Susan L; Horner, Arlene; Eidsness, LuAnn; Young, Sandy; Wright, Chris; Robinson, Michael
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.
Verpoort, Charlotte; Gastmans, Chris; Dierckx de Casterlé, Bernadette
In debates on euthanasia legalization in Belgium, the voices of nurses were scarcely heard. Yet studies have shown that nurses are involved in the caring process surrounding euthanasia. Consequently, they are in a position to offer valuable ideas about this problem. For this reason, the views of these nurses are important because of their palliative expertise and their daily confrontation with dying patients. The aim of this paper is to report a study of the views of palliative care nurses about euthanasia. A grounded theory approach was chosen, and interviews were carried out with a convenience sample of 12 palliative care nurses in Flanders (Belgium). The data were collected between December 2001 and April 2002. The majority of the nurses were not a priori for or against euthanasia, and their views were largely dependent on the situation. What counted was the degree of suffering and available palliative options. Depending on the situation, we noted both resistance and acceptance towards euthanasia. The underlying arguments for resistance included respect for life and belief in the capabilities of palliative care; arguments underlying acceptance included the quality of life and respect for patient autonomy. The nurses commented that working in palliative care had a considerable influence on one's opinion about euthanasia. In light of the worldwide debate on euthanasia, it is essential to know how nurses, who are confronted with terminally ill patients every day, think about it. Knowledge of these views can also contribute to a realistic and qualified view on euthanasia itself. This can be enlightening to the personal views of caregivers working in a diverse range of care settings.
Full Text Available Abstract Background In Germany, case management in a palliative care unit was first implemented in 2005 at the Department of Palliative Medicine at the University Hospital Cologne. One of the purposes of this case management is to deal with enquiries from patients and their relatives as well as medical professionals. Using the Case Management Process Model of the Case Management Society of America as a reference, this study analysed (a how this case management was used by different enquiring groups and (b how patients were identified for case management and for palliative care services. The first thousand enquiries were analysed considering patient variables, properties of the enquiring persons and the content of the consultations. Results Most enquiries to the case management were made by telephone. The majority of requests regarded patients with oncological disease (84.3 %. The largest enquiring group was composed of patients and relatives (40.8 %, followed by internal professionals of the hospital (36.1 %. Most of the enquiring persons asked for a patient’s admission to the palliative care ward (46.4 %. The second most frequent request was for consultation and advice (30.9 %, followed by requests for the palliative home care service (13.3 %. Frequent reasons for actual admissions were the need for the treatment of pain, the presence of symptoms and the need for nursing care. More than half of the enquiries concerning admission to the palliative care ward were followed by an admission. Conclusions Case management has been made public among the relevant target groups. Case management as described by the Case Management Process Model helps to identify patients likely to benefit from case management and palliative care services. In addition, with the help of case management palliative patients may be allocated to particular health care services.
Crul, B J; van Weel, C
Over the last few decades the attention devoted to the palliative aspects of medicine, particularly those in hospital care, has declined due to the emphasis on medical technology. In Anglo-Saxon countries a review of this development resulted in structured palliative care that benefited terminally ill patients with a progressive fatal disease, especially cancer patients. Due to increasing national and international criticism of both the practice of euthanasia (assumed to be too liberal) and the lack of attention devoted to structured palliative care in the Netherlands, the Dutch government decided to improve the structure of palliative care. The government's viewpoint is based on the assumption that good palliative care that includes adequate pain control benefits patient care and might eventually lead to fewer requests for euthanasia. The improvements to palliative care should be realised by means of improvements in the structure, training and knowledge. Six academic medical clusters have been designated as Centres for the Development of Palliative Care (Dutch acronym: COPZ) for a 5-year period. Each COPZ must develop the various aspects needed to improve palliative care within the region it serves and ensure that its activities are carefully coordinated with those in the other centres. Research will focus on measuring the efficacy of palliative care as well as ethical and epidemiological aspects. A government committee will assess the appropriateness of the activities undertaken by each of the centres.
Centeno, Carlos; Robinson, Carole; Noguera-Tejedor, Antonio; Arantzamendi, María; Echarri, Fernando; Pereira, José
Medical Schools are challenged to improve palliative care education and to find ways to introduce and nurture attitudes and behaviours such as empathy, patient-centred care and wholistic care. This paper describes the curriculum and evaluation results of a unique course centred on palliative care decision-making but aimed at introducing these other important competencies as well. The 20 h-long optional course, presented in an art museum, combined different learning methods, including reflections on art, case studies, didactic sessions, personal experiences of faculty, reflective trigger videos and group discussions. A mixed methods approach was used to evaluate the course, including a) a post-course reflective exercise; b) a standardized evaluation form used by the University for all courses; and c) a focus group. Twenty students (2nd to 6th years) participated. The course was rated highly by the students. Their understanding of palliative care changed and misconceptions were dispelled. They came to appreciate the multifaceted nature of decision-making in the palliative care setting and the need to individualize care plans. Moreover, the course resulted in a re-conceptualization of relationships with patients and families, as well as their role as future physicians. Palliative care decision-making therefore, augmented by the visual arts, can serve as a vehicle to address several competencies, including the introduction of competencies related to being patient-centred and empathic.
Davaasuren, Odontuya; Ferris, Frank D
Since the year 2000, Mongolia has established the foundation measures for a national palliative care program and has made several significant achievements. Systematic reviews and observational studies on palliative care development in Mongolia have taken place over the past 16 years. Mongolia began palliative care development in 2000 with the creation of the Mongolian Palliative Care Society and the Palliative Care Department. Palliative care is included in the Mongolia's Health Law, Health Insurance Law, Social Welfare Law, National Cancer Control Program, and the National Program for Non-Communicable Diseases, and has approved Palliative Care Standards and Pain Management Guidelines. Palliative care education is included in the undergraduate and postgraduate curriculum in all medical universities. Six hospice units in Ulaanbaatar have 50 beds; each of the nine districts and all 21 provinces have up to four to five palliative beds, and there are 36 palliative care units, for a total 190 beds for three million people. In 2014, a pediatric palliative care inpatient unit was established with five beds. Essential drugs for palliative care have been available in Mongolia since 2015. The pharmaceutical company IVCO produces morphine, codeine, pethidine, and oxycodone in Ulaanbaatar. Mongolia has made real progress in integrating palliative care into the health system. Copyright © 2017. Published by Elsevier Inc.
Nokwanda E. Bam
Full Text Available Background: Whilst the discourse of palliative care in HIV management is largely documented and regarded as being an essential component, various authors have further argued that within the context of HIV care in sub-Saharan Africa, palliative care and exploration of the dimensions thereof is largely lacking. This article presents the lived experiences of nurses involved in palliative care, thus providing the perspective of nurses and the multi-faceted dimensions of the nature of caring inherent.Objectives: This study explored the respondents’ understanding of the concepts ‘caring’ and ‘terminal patient’ and described the experiences of nurses caring for terminally-ill patients with HIV and how these experiences influence the nature of care rendered.Methods: Qualitative research using Husserl’s approach of phenomenology design underpinned the study and Giorgi’s steps of analysis were used to make meaning of the data.Results: The concept ‘caring’ was experienced by the nurses as transforming the patients’ quality of life through supportive care and hope for life. Palliative care made the nurses conscious of their own mortality, enabling them to be more sensitive, compassionate and dedicated to caring for their patients. The findings described the social networking that enabled nurses to collaborate with colleagues in the interdisciplinary teams and shared knowledge, skills and support within the palliative care team in order to optimise patient outcomes.Conclusion: Nurses with prolonged involvement in caring for terminally-ill patients with HIV experienced helplessness and emotional stress. Recommendations based on the results are that training in psychological and holistic care of the patient, professional counselling and stress management services are needed to support the nurse in this context.
Gielen, Joris; van den Branden, Stef; van Iersel, Trudie; Broeckaert, Bert
To adequately measure the attitudes of Flemish palliative care nurses toward euthanasia, and assess the relationship between these attitudes and demographic factors and the (perceived) influence of experience in palliative care on death anxiety. An anonymous questionnaire was sent to all nurses (n=589) employed in palliative care in Flanders, Belgium: 70.5% of the nurses (n=415) responded. A majority of the nurses supported the Belgian law regulating euthanasia but also believed that most euthanasia requests disappear as soon as a patient experiences the benefits of good palliative care. Three clusters were discovered: staunch advocates of euthanasia (150 nurses, 41.1%); moderate advocates of euthanasia (135 nurses, 37%); and (moderate) opponents of euthanasia (80 nurses, 21.9%). An absolute opposition between advocates and opponents of euthanasia was not observed. A statistically significant relationship was found between the euthanasia clusters and years of experience in palliative care, and (perceived) influence of experience in palliative care on anxiety when a patient dies. Flemish palliative care nurses' attitudes toward euthanasia are nuanced and contextual. By indicating that most euthanasia requests disappear as soon as a patient experiences the benefits of good palliative care, the nurses applied a 'palliative filter' a standard procedure in the case of a euthanasia request.
Adsersen, Mathilde; Thygesen, Lau Caspar; Neergaard, Mette Asbjoern
BACKGROUND: Admittance to specialized palliative care (SPC) has been discussed in the literature, but previous studies examined exclusively those admitted, not those with an assessed need for SPC but not admitted. The aim was to investigate whether admittance to SPC for referred adult patients...... with cancer was related to sex, age, diagnosis, geographic region or referral unit. MATERIAL AND METHODS: A register-based study with data from the Danish Palliative Care Database (DPD). From DPD we identified all adult patients with cancer, who died in 2010-2012 and who were referred to and assessed to have...
Glare, Paul A; Nikolova, Tanya; Alickaj, Alberta; Patil, Sujata; Blinder, Victoria
Employment-related issues have been largely overlooked in cancer patients needing palliative care. These issues may become more relevant as cancer evolves into more of a chronic illness and palliative care is provided independent of stage or prognosis. To characterize the employment situations of working-age palliative care patients. Cross-sectional survey setting/subjects: Consecutive sample of 112 patients followed in palliative care outpatient clinics at a comprehensive cancer center. Thirty-seven-item self-report questionnaire covering demographics, clinical status, and work experiences since diagnosis. The commonest cancer diagnoses were breast, colorectal, gynecological, and lung. Eighty-one percent had active disease. Seventy-four percent were on treatment. Eighty percent recalled being employed at the time of diagnosis, with 65% working full time. At the time of the survey, 44% were employed and 26% were working full time. Most participants said work was important, made them feel normal, and helped them feel they were "beating the cancer". Factors associated with being employed included male gender, self-employed, and taking less than three months off work. Respondents with pain and/or other symptoms were significantly less likely to be working. On multivariate analysis, only pain (odds ratio [OR] 8.16, p gender (OR 2.07), self-employed (OR 3.07), and current chemotherapy (OR 1.81) were included in the model, but were not statistically significant in this small sample. Work may be an important issue for some palliative care patients. Additional research is needed to facilitate ongoing employment for those who wish or need to continue working.
Full Text Available Background: The way that health care systems in developing countries like India care for dying patients, has an impact on the expectations of such care for those who migrate to other countries faces. At the end of life, cultural issues may impact on the quality of life remaining and for that reason, it is important that particular cultural practices are understood. This paper describes a study that investigated the cultural issues of access to palliative care services for Indian migrants in Australia. Purpose of the Study: To investigate the experiences of the family members of terminally ill Indian migrants in Victoria, Australia. Objective of the Study: To explore the issues related to accessing palliative care services for Indian migrants; to identify the effectiveness of palliative care in supporting the patient and family and to recommend strategies for improving this care. Materials and Methods: A qualitative descriptive design was utilized. Up to 6 family members were selected for in-depth interviews in understanding cultural issues related to the palliative care services for a family member. Results: Analysis of the interviews revealed that families of Indian patients experience difficulties whilst receiving palliative care services, which fell into three main categories: Indian support systems, cultural issues, and caring experiences. Although each of these issues had a direct influence on the experience of terminal care that their family member received, cultural issues and support systems also influenced the caring experiences. Conclusion: Despite the successful implementation of palliative care services across Australia, there are still problems in accessing and receiving the services among minority and disadvantaged groups like various cultural groups.
Neergaard, Mette Asbjørn; Olesen, Frede; Jensen, Anders Bonde
Little is known about the existing barriers to cooperation among health professionals in basic level palliative care for terminally ill patients with cancer in primary health care.......Little is known about the existing barriers to cooperation among health professionals in basic level palliative care for terminally ill patients with cancer in primary health care....
Madsen, Kirsten Halskov; Henriksen, Jette; Meldgaard, Anette
Chapter 11 by Kirsten Halskov Madsen, Anette Meldgaard and Jette Henriksen deals with the development of palliative care programmes aimed at the basic level of palliative care practice. The need to develop educational opportunities at particularly this level – described as ‘the basic inter......-professional level of palliative care’ – has been increasing for many years where palliative care has conventionally and primarily been associated with specialist training. As the authors show – based on a mapping out of existing educational initiatives in a region of Denmark, a reading of the curriculum...... and a description of the organization of palliative care – there is a need for such inter-professional palliative care that raises the level of competences at the basic level and the sharing of knowledge as well as securing the continuous qualifying of healthcare staff working with palliative care....
Full Text Available Ethical dilemmas that face heathcare team members referring patients to hospice programs include the ability of clinicians to predict accurately a patient bad prognosis. They affect day-to-day patient management in palliative care programs including healthcare team members concern over the use of morphine because possible respiratory depression in the patient, the question of providing enteral or parenteral nutritional support to patients who refuse to eat and the question of providing parenteral fluids to patients who are unable to take fluids during the terminal phrases of illness. A final ethical dilemma concerns the methodology for quality of life research in palliative care. Understanding and resolving these ethical dilemmas is an important factor determining the quality of the caring for the patient. The ethical dilemmas that are discussed in the article likely to occur in this period can be prevented through his/her participation in the decisions concerning his or her treatment. [Archives Medical Review Journal 2013; 22(1.000: 65-79
Levine, Deena R; Mandrell, Belinda N; Sykes, April; Pritchard, Michele; Gibson, Deborah; Symons, Heather J; Wendler, David; Baker, Justin N
Early palliative care integration for cancer patients is now touted as the optimal care model, yet significant barriers often prevent its implementation. A perceived barrier, especially for pediatric oncology patients, is the notion that patients and their families may not need or want palliative care involvement early in the disease trajectory. To determine the perception of symptom burden early in treatment and assess attitudes toward early integration of palliative care in pediatric oncology patient-parent pairs. Novel but pretested survey tools were administered to 129 patient-parent dyads of hospital-based pediatric oncology ambulatory clinics and inpatient units between September 2011 and January 2015. All patient participants were aged between 10 and 17 years and were diagnosed as having an oncologic condition 1 month to 1 year before enrollment. Both the patient and the parent in the dyad spoke English, and all participating parents provided written informed consent. A convenience sample was used for selection, with participants screened when otherwise presenting at a participating site. A total of 280 eligible participants were approached for study inclusion, 258 of whom were enrolled in the study (92.1% positive response-rate). Degree of perceived suffering from early symptom-related causes, attitudes toward early palliative care integration, and patient-parent concordance. Statistical analysis included descriptive statistics, calculation of concordance, McNemar test results, and Cochran-Armitage trend test results. Of the 129 patients in the dyads, 68 were boys, and 61 girls; of the 129 parents, 15 were men, and 114 women. Patients reported the following symptoms in the first month of cancer therapy: nausea (n = 109; 84.5%), loss of appetite (n = 97; 75.2%), pain (n = 96; 74.4%), anxiety (n = 77; 59.7%), constipation (n = 69; 53.5%), depression (n = 64; 49.6%), and diarrhea (n = 52; 40.3%). A large proportion of those
Hopprich, A; Günther, L D; Laufenberg-Feldmann, R; Reinholz, U; Weber, M
Palliative sedation (pS) is indicated in the presence of end-stage disease with treatment-refractory symptoms not tolerable for the patient. We investigated the practice of pS at a university palliative care unit. Before starting pS the following data were documented: indication and decision making, type of sedation, life expectancy evaluated by the physician using the palliative prognostic index. Over the time of pS communication skills, depth of sedation, relief in symptoms, substitution of fluid and nutrition and used medications were collected. During evaluation time 99 patients died. 34 patients received pS (34 %). All patients suffered from cancer. Indications for palliative sedation were: terminal restlessness (56 %), dyspnea (39 %), pain (32 %), psychological distress (15 %), agitated delir (9 %), vomiting (3 %) and bleeding (3 %) (multiple nominations possible). In 31 cases (91 %) nurses were included for decision making. In 33 cases continuous sedation were initiated immediately (median duration 27.5 hours). The most applied medication was midazolam (94 %), sometimes combined with neuroleptics (44 %) and propofol (15 %). 91 % of the patients additionally received opioids. Artificial fluid was substituted in two cases. Palliative sedation started in the median 27.5 hours before death. The final physician assessment revealed complete symptom relief in 12 patients (35 %), very strong symptom relief in 20 patients (59 %) and moderate symptom relief in 2 patients (6 %). pS was successfully used as last resort for relief of treatment-refractory symptoms in one third of decedents at the investigated palliative care unit. © Georg Thieme Verlag KG Stuttgart · New York.
José L. Teruel
Full Text Available Healthcare for patients with advanced chronic kidney disease (ACKD on conservative treatment very often poses healthcare problems that are difficult to solve. At the end of 2011, we began a program based on the care and monitoring of these patients by Primary Care Teams. ACKD patients who opted for conservative treatment were offered the chance to be cared for mainly at home by the Primary Care doctor and nurse, under the coordination of the Palliative Care Unit and the Nephrology Department. During 2012, 2013, and 2014, 76 patients received treatment in this program (mean age: 81 years; mean Charlson age-comorbidity index: 10, and mean glomerular filtration rate: 12.4 mL/min/1.73 m2. The median patient follow-up time (until death or until 31 December 2014 was 165 days. During this period, 51% of patients did not have to visit the hospital’s emergency department and 58% did not require hospitalization. Forty-eight of the 76 patients died after a median time of 135 days in the program; 24 (50% died at home. Our experience indicates that with the support of the Palliative Care Unit and the Nephrology Department, ACKD patients who are not dialysis candidates may be monitored at home by Primary Care Teams.
Teruel, José L.; Rexach, Lourdes; Burguera, Victor; Gomis, Antonio; Fernandez-Lucas, Milagros; Rivera, Maite; Diaz, Alicia; Collazo, Sergio; Liaño, Fernando
Healthcare for patients with advanced chronic kidney disease (ACKD) on conservative treatment very often poses healthcare problems that are difficult to solve. At the end of 2011, we began a program based on the care and monitoring of these patients by Primary Care Teams. ACKD patients who opted for conservative treatment were offered the chance to be cared for mainly at home by the Primary Care doctor and nurse, under the coordination of the Palliative Care Unit and the Nephrology Department. During 2012, 2013, and 2014, 76 patients received treatment in this program (mean age: 81 years; mean Charlson age-comorbidity index: 10, and mean glomerular filtration rate: 12.4 mL/min/1.73 m2). The median patient follow-up time (until death or until 31 December 2014) was 165 days. During this period, 51% of patients did not have to visit the hospital’s emergency department and 58% did not require hospitalization. Forty-eight of the 76 patients died after a median time of 135 days in the program; 24 (50%) died at home. Our experience indicates that with the support of the Palliative Care Unit and the Nephrology Department, ACKD patients who are not dialysis candidates may be monitored at home by Primary Care Teams. PMID:27417813
Klarare, Anna; Rasmussen, Birgit H; Fossum, Bjöörn; Fürst, Carl Johan; Hansson, Johan; Hagelin, Carina Lundh
Those who are seriously ill and facing death are often living with physical, emotional, social, and spiritual suffering. Teamwork is considered to be necessary to holistically meet the diverse needs of patients in palliative care. Reviews of studies regarding palliative care team outcomes have concluded that teams provide benefits, especially regarding pain and symptom management. Much of the research concerning palliative care teams has been performed from the perspective of the service providers and has less often focused on patients' and families' experiences of care. Our aim was to investigate how the team's work is manifested in care episodes narrated by patients and families in specialized palliative home care (SPHC). A total of 13 interviews were conducted with patients and families receiving specialized home care. Six patients and seven family members were recruited through SPHC team leaders. Interviews were transcribed verbatim and the transcripts qualitatively analyzed into themes. Two themes were constructed through thematic analysis: (1) security ("They are always available," "I get the help I need quickly"); and (2) continuity of care ("They know me/us, our whole situation and they really care"). Of the 74 care episodes, 50 were descriptions of regularly scheduled visits, while 24 related to acute care visits and/or interventions. Patients' and family members' descriptions of the work of SPHC teams are conceptualized through experiences of security and continuity of care. Experiences of security are fostered through the 24/7 availability of the team, sensitivity and flexibility in meeting patients' and families' needs, and practical adjustments to enable care at home. Experiences of continuity of care are fostered through the team's collective approach, where the individual team member knows the patients and family members, including their whole situation, and cares about the little things in life as well as caring for the family unit.
Vernooy-Dassen, M.J.F.J.; Osse, B.H.P.; Schade, E.; Grol, R.P.T.M.
No instrument to assess autonomy problems in palliative care is currently available. The purpose of this study was to develop a comprehensive and concise questionnaire to measure autonomy problems in palliative cancer patients and to study its validity and reliability. We systematically developed a
Full Text Available Abstract Background Over recent years there has been an increase in teaching of both palliative care and reflective practice in UK medical schools. The palliative care teaching at the University of Cambridge School of Clinical Medicine is multi-faceted and involves students writing reflective essays after individually meeting patients approaching the end of life during their final year general practice and hospital medicine placements. This paper draws on two studies examining this teaching element to analyse what the students found valuable about it and to comment on the practice of meeting patients and subsequent reflective writing. Methods Two studies have explored students’ perceptions of these course components. The first was a thematic analysis of 234 reflective essays from 123 students written in 2007-2008, including examining what students wrote about the exercise itself. The second project involved a semi-structured questionnaire that students completed anonymously; this paper reports on the free text elements of that study [sample size =107]. Since similar themes were found in both studies, the coding structures from each project were compared and combined, enabling triangulation of the findings around what the students found valuable from the palliative care teaching involving meeting patients and reflective writing. Results Overall, students reported that these components of the palliative care teaching are valuable. Four main themes were identified as aspects that students valued: (1 dedicated time with patients, (2 learning about wider elements of treatment and holistic care, (3 practicing communication skills, and (4 learning about themselves through reflective writing. Some students expressed a dislike for having to formally write a reflective essay. Conclusion It is possible to arrange for all of the medical students to individually meet at least two patients receiving palliative or end of life care. Students found these
Full Text Available Aim: Advanced cancer, irrespective of the site of the cancer, is characterized by a number of associated symptoms that impair the quality of life of patients. The management of these symptoms guides palliative care. The present study aims to describe the symptoms and appropriate palliation provided in patients with advanced cancer in a tertiary care hospital in Uttarakhand. Methods: This was an observational study. A total of 100 patients with advanced cancer were included in the study. The data obtained from the patients included symptoms reported by the patients, currently prescribed treatments and the site of cancer. Results: The average number of symptoms reported per patient was 5.33 ± 0.67 (mean ± SE. The most common symptoms were pain, weakness/fatigue, anorexia, insomnia, nausea/vomiting, dyspnea, constipation and cough. Polypharmacy was frequent. Patients consumed approximately 8.7 ± 0.38 (mean ± SE drugs on average during the 2-month period of follow-up. Conclusion: The result gives insight into the varied symptomatology of patients with advanced cancer. Polypharmacy was quite common in patients with advanced cancer, predisposing them to complicated drug interactions and adverse drug reactions.
Ciałkowska-Rysz, Aleksandra D; Pokropska, Wieslawa; Łuczak, Jacek; Kaptacz, Anna; Stachowiak, Andrzej; Hurich, Krystyna; Koszela, Monika
The main task of palliative care units is to provide a dignified life for people with advanced progressive chronic disease through appropriate symptom management, communication between medical specialists and the patient and his family, as well as the coordination of care. Many palliative care units struggle with low incomes from the National Health Fund (NHF), which causes serious economic problems. The aim of the study was to estimate of direct and administrative costs of care and the actual cost per patient per day in selected palliative care units and comparison of the results to the valuation of the NHF. The study of the costs of hospitalization of 175 patients was conducted prospectively in five palliative care units (PCUs). The costs directly associated with care were recorded on the specially prepared forms in each unit and also personnel and administrative costs provided by the accounting departments. The total costs of analyzed units amounted to 209 002 EUR (898 712 PLN), while the payment for palliative care services from the NHF amounted to 126 010 EUR (541 844 PLN), which accounted for only 60% of the costs incurred by the units. The average cost per person per day of hospitalization, calculated according to the actual duration of hospitalization in the unit, was 83 EUR (357 PLN), and the average payment from the NHF was 52.8 EUR (227 PLN). Underpayment per person per day was approximately 29.2 EUR (125 PLN). The study showed a significant difference between the actual cost of palliative care units and the level of refund from the NHF. Based on the analysis of costs, the application has been submitted to the NHF to change the reimbursement amount of palliative care services in 2013.
... is not under control Need help understanding your situation and coordinating care PALLIATIVE CARE Often a team of specialists provides palliative care. The team usually includes: Palliative care doctors and nurses Social workers and chaplains Pharmacists and nutritionists Counselors and others ...
Ansari, Mojgan; Rassouli, Maryam; Akbari, Mohamad Esmaiel; Abbaszadeh, Abbas; Akbari Sari, Ali
By acceptance of palliative care as a part of health system of each country and due to increasing prevalence of cancer, special focus on stakeholder's educational needs is of vital importance so that palliative care services are improved and the quality of life of patients is enhanced. This study was conducted to explore the educational needs of stakeholders of palliative care for cancer patients in Iran. This qualitative study with 20 semi-structured interviews was conducted from August 2016 to February 2017 in Shohadaye Tajrish and Emam Khomeini Hospitals of Tehran. Participants were selected through purposive sampling and included cancer patients and their family caregivers as well as healthcare providers, experts and policy-makers. The data were analyzed through Conventional Content Analysis of Landman and Graneheim using MAXQDA10 software. Statements of each main category of the study were summarized in SWOT categorizes. A total of 546 codes were extracted from the analysis of the interviews and four main categories and four subcategories were identified. The four main identified categories included: "academic education planning", "workforce education", "public awareness", and "patient and caregiver empowerment" that contained our subcategories as follows: "strengths", "weaknesses", "opportunities" and "threats" (SWOT). Meeting the educational needs of the stakeholders of palliative care requires policy-makers to identify the factors leading to strategies that are based on the use of opportunities, the removal of weaknesses, and coping with the threats to which the organization is faced.
Schmid, W; Rosland, J H; von Hofacker, S; Hunskår, I; Bruvik, F
The use of music as therapy in multidisciplinary end-of-life care dates back to the 1970s and nowadays music therapy (MT) is one of the most frequently used complementary therapy in in-patient palliative care in the US. However existing research investigated music therapy's potential impact mainly from one perspective, referring to either a quantitative or qualitative paradigm. The aim of this review is to provide an overview of the users' and providers' perspectives on music therapy in palliative care within one research article. A systematic literature search was conducted using several databases supplemented with a hand-search of journals between November 1978 and December 2016. Inclusion criteria were: Music therapy with adults in palliative care conducted by a certified music therapist. Both quantitative and qualitative studies in English, German or a Scandinavian language published in peer reviewed journals were included. We aimed to identify and discuss the perspectives of both patients and health care providers on music therapy's impact in palliative care to forward a comprehensive understanding of it's effectiveness, benefits and limitations. We investigated themes mentioned by patients within qualitative studies, as well as commonly chosen outcome measures in quantitative research. A qualitative approach utilizing inductive content analysis was carried out to analyze and categorize the data. Twelve articles, reporting on nine quantitative and three qualitative research studies were included. Seven out of the nine quantitative studies investigated pain as an outcome. All of the included quantitative studies reported positive effects of the music therapy. Patients themselves associated MT with the expression of positive as well as challenging emotions and increased well-being. An overarching theme in both types of research is a psycho-physiological change through music therapy. Both quantitative as well as qualitative research showed positive changes in
Full Text Available Abstract Background The care of palliative patients challenges the health care system in both quantity and quality. Especially the role of primary care givers needs to be strengthened to provide them with the knowledge and the confidence of applying an appropriate end-of-life care to palliative patients. To improve health care services for palliative patients in primary care, interested physicians in and around Heidelberg, Germany, are enabled to participate in the community-based program 'Palliative Medical Initiative North Baden (PAMINO' to improve their knowledge in dealing with palliative patients. The impact of this program on patients' health and quality of life remains to be evaluated. Methods/Design The evaluation of PAMINO is a non-randomized, controlled study. Out of the group of primary care physicians who took part in the PAMINO program, a sample of 45 physicians and their palliative patients will be compared to a sample of palliative patients of 45 physicians who did not take part in the program. Every four weeks for 6 months or until death, patients, physicians, and the patients' family caregivers in both groups answer questions to therapy strategies, quality of life (QLQ-C15-PAL, POS, pain (VAS, and burden for family caregivers (BSFC. The inclusion of physicians and patients in the study starts in March 2007. Discussion Although participating physicians value the increase in knowledge they receive from PAMINO, the effects on patients remain unclear. If the evaluation reveals a clear benefit for patients' quality of life, a larger-scale implementation of the program is considered. Trial registration: The study was registered at ‘current controlled trials (CCT’, registration number: ISRCTN78021852.
Yardley, Iain; Yardley, Sarah; Williams, Huw; Carson-Stevens, Andrew; Donaldson, Liam J
Patients receiving palliative care are vulnerable to patient safety incidents but little is known about the extent of harm caused or the origins of unsafe care in this population. To quantify and qualitatively analyse serious incident reports in order to understand the causes and impact of unsafe care in a population receiving palliative care. A mixed-methods approach was used. Following quantification of type of incidents and their location, a qualitative analysis using a modified framework method was used to interpret themes in reports to examine the underlying causes and the nature of resultant harms. Reports to a national database of 'serious incidents requiring investigation' involving patients receiving palliative care in the National Health Service (NHS) in England during the 12-year period, April 2002 to March 2014. A total of 475 reports were identified: 266 related to pressure ulcers, 91 to medication errors, 46 to falls, 21 to healthcare-associated infections (HCAIs), 18 were other instances of disturbed dying, 14 were allegations against health professions, 8 transfer incidents, 6 suicides and 5 other concerns. The frequency of report types differed according to the care setting. Underlying causes included lack of palliative care experience, under-resourcing and poor service coordination. Resultant harms included worsened symptoms, disrupted dying, serious injury and hastened death. Unsafe care presents a risk of significant harm to patients receiving palliative care. Improvements in the coordination of care delivery alongside wider availability of specialist palliative care support may reduce this risk.
Momm, F.; Frommhold, H.; Becker, G.; Ewald, H.; Baumgartner, J.; Adamietz, I.A.
Background: in Germany, a sufficient system of palliative care does not exist. Possibilities for participation of radiooncologists in the further development of this promising part of medical action are reported. Material and methods: experiences from interdisciplinary work in the field of palliative care are described. This experience is communicated for use in the actual discussion about the future of palliative care in Germany, especially in the field of radiooncology. Results: a palliative care unit can only work in a team of different professions, which means different physicians, but also nurses, social workers, psychologists or pastors. A palliative care unit will benefit from working with radiooncologists as well as radiooncologists will do from working in the field of palliative care. Conclusion: in times of growing interest in and need for palliative care, radiooncologists should actively participate in the development of palliative care units in Germany. The aim of this participation should be to reasonably arrange the treatment of incurably ill patients with the chances of modern radiotherapy. Another aim should be to improve the treatment of ''classic'' radiation oncology patients by ideas of pallative care. The further development of palliative care in Germany should not take place without the participation of radiooncologists. This will meet the interests of palliative care and radiotherapy and - most importantly - the patients' interests. (orig.) [de
Oude Engberink, Agnès; Badin, Mélanie; Serayet, Philippe; Pavageau, Sylvain; Lucas, François; Bourrel, Gérard; Norton, Joanna; Ninot, Grégory; Senesse, Pierre
The development of end-of-life primary care is a socio-medical and ethical challenge. However, general practitioners (GPs) face many difficulties when initiating appropriate discussion on proactive shared palliative care. Anticipating palliative care is increasingly important given the ageing population and is an aim shared by many countries. We aimed to examine how French GPs approached and provided at-home palliative care. We inquired about their strategy for delivering care, and the skills and resources they used to devise new care strategies. Twenty-one GPs from the South of France recruited by phone according to their various experiences of palliative care agreed to participate. Semi-structured interview transcripts were examined using a phenomenological approach inspired by Grounded theory, and further studied with semiopragmatic analysis. Offering palliative care was perceived by GPs as a moral obligation. They felt vindicated in a process rooted in the paradigm values of their profession. This study results in two key findings: firstly, their patient-centred approach facilitated the anticipatory discussions of any potential event or intervention, which the GPs openly discussed with patients and their relatives; secondly, this approach contributed to build an "end-of-life project" meeting patients' wishes and needs. The GPs all shared the idea that the end-of-life process required human presence and recommended that at-home care be coordinated and shared by multi-professional referring teams. The main tenets of palliative care as provided by GPs are a patient-centred approach in the anticipatory discussion of potential events, personalized follow-up with referring multi-professional teams, and the collaborative design of an end-of-life project meeting the aspirations of the patient and his or her family. Consequently, coordination strategies involving specialized teams, GPs and families should be modelled according to the specificities of each care system.
Rhodes, Rosamond; Strain, James J
Palliative care has had a long-standing commitment to teaching medical students and other medical professionals about pain management, communication, supporting patients in their decisions, and providing compassionate end-of-life care. Palliative care programs also have a critical role in helping patients understand medical conditions, and in supporting them in dealing with pain, fear of dying, and the experiences of the terminal phase of their lives. We applaud their efforts to provide that critical training and fully support their continued important work in meeting the needs of patients and families. Although we appreciate the contributions of palliative care services, we have noted a problem involving some palliative care professionals' attitudes, methods of decisionmaking, and use of language. In this article we explain these problems by discussing two cases that we encountered.
Menezes, Vishma Hydie; Nair, Shoba N; Soumya, M S; Tarey, S D
Drugs used in the palliative care unit for managing symptoms are major contributors toward the expenditure occurring in palliative care. This study was conducted to understand the prescription pattern of analgesic drugs in the patients who are receiving palliative care in a teaching hospital in India by a retrospective study of case records. Case record based, retrospective, descriptive study was conducted at the Pain and Palliative Care Department of St. John's Medical College Hospital, Bengaluru. Case record files of all patients referred to Pain and Palliative Care Department for the treatment of pain in the year of 2012 were studied. Patients' age, gender, diagnoses, numerical pain rating scale (0-10), drugs prescribed, dosage, frequency, route of administration were recorded. The difference in drug utilization between the genders was done using Chi-square test. Data were collected from 502 patients of which 280 (56%) were males and 222 (44%) were females. Twelve percent of patients had mild pain (1-3), 34% had moderate pain (4-6), and 54% had severe pain (7-10). The most commonly used analgesic drugs were opioids (47%), followed by nonsteroidal anti-inflammatory drugs (36%). The opioids used were tramadol (56%), and morphine (38%). Ninety percent of patients with numerical pain scale more than 6 received morphine. There was no difference in analgesic drug utilization with regards to gender. Prescription pattern differed depending on the severity of pain. Opioids were the most commonly used drugs for pain management. The study shows that prescription pattern in palliative care unit of this hospital was in accordance with WHO pain management guidelines. The study showed the current trend in prescription of analgesic drugs in the teaching hospital where the study was conducted.
Dhollander, Naomi; Deliens, Luc; Van Belle, Simon; De Vleminck, Aline; Pardon, Koen
To date, no randomised controlled trials on the integration of specialised palliative home care into oncology care have been identified. Information on whether existing models of integrated care are applicable to the home care system and how working procedures and skills of the palliative care teams might require adaptation is missing. To gain insight into differences between early and late involvement and the effect on existing working procedures and skills as perceived by palliative home care teams. Qualitative study - focus group interviews. Six palliative home care teams in Flanders, Belgium. Participants included physicians, nurses and psychologists. Differences were found concerning (1) reasons for initiation, (2) planning of care process, (3) focus on future goals versus problems, (4) opportunity to provide holistic care, (5) empowerment of patients and (6) empowerment of professional caregivers. A shift from a medical approach to a more holistic approach is the most noticeable. Being involved earlier also results in a more structured follow-up and in empowering the patient to be part of the decision-making process. Early involvement creates the need for transmural collaboration, which leads to the teams taking on more supporting and coordinating tasks. Being involved earlier leads to different tasks and working procedures and to the need for transmural collaboration. Future research might focus on the development of an intervention model for the early integration of palliative home care into oncology care. To develop this model, components of existing models might need to be adapted or extended.
Scaccabarozzi, Gianlorenzo; Lovaglio, Pietro Giorgio; Limonta, Fabrizio; Floriani, Maddalena; Pellegrini, Giacomo
The complexity of end-of-life care, represented by a large number of units caring for dying patients, of different types of organizations motivates the importance of measure the quality of provided care. Despite the law 38/2010 promulgated to remove the barriers and provide affordable access to palliative care, measurement, and monitoring of processes of home care providers in Italy has not been attempted. Using data drawn by an institutional voluntary observatory established in Italy in 2013, collecting home palliative care units caring for people between January and December 2013, we assess the degree to which Italian home palliative care teams endorse a set of standards required by the 38/2010 law and best practices as emerged from the literature. The evaluation strategy is based on Rasch analysis, allowing to objectively measuring both performances of facilities and quality indicators' difficulty on the same metric, using 14 quality indicators identified by the observatory's steering committee. Globally, 195 home care teams were registered in the observatory reporting globally 40 955 cured patients in 2013 representing 66% of the population of home palliative care units active in Italy in 2013. Rasch analysis identifies 5 indicators ("interview" with caregivers, continuous training provided to medical and nursing staff, provision of specialized multidisciplinary interventions, psychological support to the patient and family, and drug supply at home) easy to endorse by health care providers and 3 problematic indicators (presence of a formally established Local Network of Palliative care in the area of reference, provision of the care for most problematic patient requiring high intensity of the care, and the percentage of cancer patient dying at Home). The lack of Local Network of Palliative care, required by law 38/2010, is, at the present, the main barrier to its application. However, the adopted methodology suggests that a clear roadmap for health facilities
van Gurp, J.; van Selm, M.; Vissers, K.; van Leeuwen, E.; Hasselaar, J.
Objective The problems and needs of advanced cancer patients and proxies normally increase as the disease progresses. Home-based advanced cancer patients and their proxies benefit from collaborations between primary care physicians and hospital-based palliative care specialists when confronted with
Claessen, S.J.J.; Francke, A.L.; Engels, Y.; Deliens, L.
Background: Little is known about how GPs determine whether and when patients need palliative care. Little research has been done regarding the assumption underpinning Lynn and Adamson’s model that palliative care may start early in the course of the disease. This study was conducted to explore how
Eagar, Kathy; Green, Janette; Gordon, Robert
To develop a palliative care casemix classification for use in all settings including hospital, hospice and home-based care. 3866 palliative care patients who, in a three-month period, had 4596 episodes of care provided by 58 palliative care services in Australia and New Zealand. A detailed clinical and service utilization profile was collected on each patient with staff time and other resources measured on a daily basis. Each day of care was costed using actual cost data from each study site. Regression tree analysis was used to group episodes of care with similar costs and clinical characteristics. In the resulting classification, the Australian National Sub-acute and Non-acute Patient (AN-SNAP) Classification Version 1, the branch for classifying inpatient palliative care episodes (including hospice care) has 11 classes and explains 20.98% of the variance in inpatient palliative care phase costs using trimmed data. There are 22 classes in the ambulatory palliative care branch that explains 17.14% variation in ambulatory phase cost using trimmed data. The term 'subacute' is used in Australia to describe health care in which the goal--a change in functional status or improvement in quality of life--is a better predictor of the need for, and the cost of, care than the patient's underlying diagnosis. The results suggest that phase of care (stage of illness) is the best predictor of the cost of Australian palliative care. Other predictors of cost are functional status and age. In the ambulatory setting, symptom severity and the model of palliative care are also predictive of cost. These variables are used in the AN-SNAP Version 1 classification to create 33 palliative care classes. The classification has clinical meaning but the overall statistical performance is only moderate. The structure of the classification allows for it to be improved over time as models of palliative care service delivery develop.
Rani P Mol
Full Text Available The palliative doctor gives the ′touch of God′ as he/she takes care of the terminally ill patient. The oncologist encounters great difficulties in managing oral cavity problems of these patients. A trained dental doctor can help other doctors in dealing with these situations. But the general dental surgeon does not have enough idea about his part in these treatments. The community is also unaware of the role that a nearby dentist can play. Adequate training programs have to be conducted and awareness has to be created. A trained dentist will be a good team mate for the oncologist or radiotherapist or other doctors of the palliative care team. In this paper, a brief attempt is made to list a few areas in which a palliative care dentist can help other members of the palliative care team and also the patient in leading a better life.
Palliative care for patients with advanced illness is a subject of growing importance in health services, policy and research. In 2001 Ireland became one of the first nations to publish a dedicated national palliative care policy. This paper uses the \\'policy analysis triangle\\' as a framework to examine what the policy entailed, where the key ideas originated, why the policy process was activated, who were the key actors, and what were the main consequences. Although palliative care provision expanded following publication, priorities that were unaddressed or not fully embraced on the national policy agenda are identified. The factors underlying areas of non-fulfilment of policy are then discussed. In particular, the analysis highlights that policy initiatives in a relatively new field of healthcare face a trade-off between ambition and feasibility. Key policy goals could not be realised given the large resource commitments required; the competition for resources from other, better-established healthcare sectors; and challenges in expanding workforce and capacity. Additionally, the inherently cross-sectoral nature of palliative care complicated the co-ordination of support for the policy. Policy initiatives in emerging fields such as palliative care should address carefully feasibility and support in their conception and implementation.
Blacquiere, Dylan; Bhimji, Khadija; Meggison, Hilary; Sinclair, John; Sharma, Michael
The determinants of satisfaction for families of acute stroke patients receiving palliative care have not been extensively studied. We surveyed families to determine how they perceived palliative care after stroke. Families of patients palliated after ischemic stroke, intracerebral, or subarachnoid hemorrhage were approached. Four weeks after the patient's death, families were administered the After-Death Bereaved Family Member Interview to determine satisfaction with the care provided. Fifteen families participated. Families were most satisfied with participation in decision making and least satisfied with attention to emotional needs. In stroke-specific domains, families had less satisfaction with artificial feeding, hydration, and communication. Overall satisfaction was high (9.04 out of 10). Families of patients receiving palliative care at our institution showed generally high satisfaction with palliation after stroke; specific domains were identified for improvement. Further study in larger populations is required.
Schulz-Quach, Christian; Wenzel-Meyburg, Ursula; Fetz, Katharina
Undergraduate palliative care education (UPCE) was mandatorily incorporated in medical education in Germany in 2009. Implementation of the new cross-sectional examination subject of palliative care (QB13) continues to be a major challenge for medical schools. It is clear that there is a need among students for more UPCE. On the other hand, there is a lack of teaching resources and patient availabilities for the practical lessons. Digital media and elearning might be one solution to this problem. The primary objective of this study is to evaluate the elearning course Palliative Care Basics, with regard to students' acceptance of this teaching method and their performance in the written examination on the topic of palliative care. In addition, students' self-estimation in competence in palliative care was assessed. To investigate students' acceptance of the elearning course Palliative Care Basics, we conducted a cross-sectional study that is appropriate for proof-of-concept evaluation. The sample consisted of three cohorts of medical students of Heinrich Heine University Dusseldorf (N = 670). The acceptance of the elearning approach was investigated by means of the standard evaluation of Heinrich Heine University. The effect of elearning on students' self-estimation in palliative care competencies was measured by means of the German revised version of the Program in Palliative Care Education and Practice Questionnaire (PCEP-GR). The elearning course Palliative Care Basics was well-received by medical students. The data yielded no significant effects of the elearning course on students' self-estimation in palliative care competencies. There was a trend of the elearning course having a positive effect on the mark in written exam. Elearning is a promising approach in UPCE and well-accepted by medical students. It may be able to increase students' knowledge in palliative care. However, it is likely that there are other approaches needed to change students' self
Burton Christopher R
Full Text Available Abstract Background Palliative care should be integrated early into the care trajectories of people with life threatening illness such as stroke. However published guidance focuses primarily on the end of life, and there is a gap in the evidence about how the palliative care needs of acute stroke patients and families should be addressed. Synthesising data across a programme of related studies, this paper presents an explanatory framework for the integration of palliative and acute stroke care. Methods Data from a survey (n=191 of patient-reported palliative care needs and interviews (n=53 exploring experiences with patients and family members were explored in group interviews with 29 staff from 3 United Kingdom stroke services. A realist approach to theory building was used, constructed around the mechanisms that characterise integration, their impacts, and mediating, contextual influences. Results The framework includes two cognitive mechanisms (the legitimacy of palliative care and individual capacity, and behavioural mechanisms (engaging with family; the timing of intervention; working with complexity; and the recognition of dying through which staff integrate palliative and stroke care. A range of clinical (whether patients are being ‘actively treated’, and prognostic uncertainty and service (leadership, specialty status and neurological focus factors appear to influence how palliative care needs are attended to. Conclusions Our framework is the first, empirical explanation of the integration of palliative and acute stroke care. The specification in the framework of factors that mediate integration can inform service development to improve the outcomes and experiences of patients and families.
Ansari, Mojgan; Rassouli, Maryam; Akbari, Mohamad Esmaiel; Abbaszadeh, Abbas; Akbari Sari, Ali
ABSTRACT Background: By acceptance of palliative care as a part of health system of each country and due to increasing prevalence of cancer, special focus on stakeholder’s educational needs is of vital importance so that palliative care services are improved and the quality of life of patients is enhanced. This study was conducted to explore the educational needs of stakeholders of palliative care for cancer patients in Iran. Methods: This qualitative study with 20 semi-structured interviews was conducted from August 2016 to February 2017 in Shohadaye Tajrish and Emam Khomeini Hospitals of Tehran. Participants were selected through purposive sampling and included cancer patients and their family caregivers as well as healthcare providers, experts and policy-makers. The data were analyzed through Conventional Content Analysis of Landman and Graneheim using MAXQDA10 software. Statements of each main category of the study were summarized in SWOT categorizes. Result: A total of 546 codes were extracted from the analysis of the interviews and four main categories and four subcategories were identified. The four main identified categories included: ”academic education planning”, “workforce education”, “public awareness”, and “patient and caregiver empowerment” that contained our subcategories as follows: “strengths”, “weaknesses”, “opportunities” and “threats” (SWOT). Conclusion: Meeting the educational needs of the stakeholders of palliative care requires policy-makers to identify the factors leading to strategies that are based on the use of opportunities, the removal of weaknesses, and coping with the threats to which the organization is faced. PMID:29607340
Full Text Available Background: By acceptance of palliative care as a part of health system of each country and due to increasing prevalence of cancer, special focus on stakeholder’s educational needs is of vital importance so that palliative care services are improved and the quality of life of patients is enhanced. This study was conducted to explore the educational needs of stakeholders of palliative care for cancer patients in Iran. Methods: This qualitative study with 20 semi-structured interviews was conducted from August 2016 to February 2017 in Shohadaye Tajrish and Emam Khomeini Hospitals of Tehran. Participants were selected through purposive sampling and included cancer patients and their family caregivers as well as healthcare providers, experts and policy-makers. The data were analyzed through Conventional Content Analysis of Landman and Graneheim using MAXQDA10 software. Statements of each main category of the study were summarized in SWOT categorizes. Result: A total of 546 codes were extracted from the analysis of the interviews and four main categories and four subcategories were identified. The four main identified categories included:”academic education planning”, “workforce education”, “public awareness”, and “patient and caregiver empowerment” that contained our subcategories as follows: “strengths”, “weaknesses”, “opportunities” and “threats” (SWOT. Conclusion: Meeting the educational needs of the stakeholders of palliative care requires policy-makers to identify the factors leading to strategies that are based on the use of opportunities, the removal of weaknesses, and coping with the threats to which the organization is faced.
Full Text Available Background: The goal of palliative care is not to cure, but to provide comfort and maintain the highest possible quality of life for as long as life remains. The knowledge of nurses influences the quality of care provided to these patients. The present study aimed at identifying the level of knowledge and attitude of nursing students who are the future caretakers of patients, which helps to make recommendations in incorporating palliative care concepts in the nursing curriculum. Objectives: (1 To assess the level of knowledge of nursing students on palliative care; (2 To identify the attitude of nursing students towards palliative care; (3 To find the correlation between the knowledge and attitude of nursing students; (4 To find the association between nursing students′ knowledge, attitude and selected demographic variables. Materials and Methods: A correlative survey was carried out among 83 third-year Diploma Nursing students by using cluster sampling method from selected nursing schools of Udupi district. Results: The data analyzed showed that the majority (51% of them was in the age group of 21years and 92% of them were females. Only 43.4% of them were aware of the term palliative care and it was during their training period. The data showed that 79.5% of students had poor knowledge (6.4± 1.64 on palliative care and 92.8% of them had favorable attitude (56.7± 8.5 towards palliative care. The chi-square showed a significant association between knowledge and age (χ2 =18.52,P<0.01 of the nursing students. Conclusion: Palliative care aspects should be incorporated in the diploma nursing curriculum.
Lai, Claudia Kam-Yuk; Lau, Carmen Ka-Yan; Kan, Wai Yin; Lam, Wai Man; Fung, Connie Yuen Yee
Palliative care patients experience a variety of needs and perceive their quality of life as being only fair. This study adopted a single-group repeated-measure design to investigate the effect of horticultural therapy on the quality of life of palliative care patients using the Quality of Life Concern in End of Life Questionnaire. Significant differences in the domains of "existential distress" and "health care concern" were observed immediately postintervention and at 4 weeks postintervention, respectively. No other significant differences were seen in the other domains or in the total mean score of the outcome measure.
Cassel, J Brian; Bowman, Brynn; Rogers, Maggie; Spragens, Lynn H; Meier, Diane E
Between 2000 and 2015 the proportion of US hospitals with more than fifty beds that had palliative care programs tripled, from 25 percent to 75 percent. The rapid adoption of this high-value program, which is voluntary and runs counter to the dominant culture in US hospitals, was catalyzed by tens of millions of dollars in philanthropic support for innovation, dissemination, and professionalization in the palliative care field. We describe the dissemination strategies of the Center to Advance Palliative Care in the context of the principles of social entrepreneurship, and we provide an in-depth look at its hallmark training initiative, Palliative Care Leadership Centers. Over 1,240 hospital palliative care teams have trained at the Leadership Centers to date, with 80 percent of them instituting palliative care services within two years. We conclude with lessons learned about the role of purposeful technical assistance in promoting the rapid diffusion of high-value health care innovation.
Nisha Rani Jamwal
Full Text Available Smartphones are technologically advanced mobile phone devices which use software similar to computer-based devices as a user-friendly interface. This review article is aimed to inform the palliative care professionals, cancer patients and their caregivers about the role of smartphone applications (apps in the delivery of palliative care services, through a brief review of existing literature on the development, feasibility, analysis, and effectiveness of such apps. There is a dearth need for sincere palliative care clinicians to work together with software professionals to develop the suitable smartphone apps in accordance with the family/caregivers' necessities and patients' biopsychosocial characteristics that influence the technology driven evidence informed palliative cancer care.
® ™ ® Pediatric Palliative Care at a Glance A child’s serious illness affects the entire family. Pediatric palliative (pal-lee-uh-tiv) care can support ... extra support, palliative care can help. What is pediatric palliative care? Pediatric palliative care is supportive care ...
Khan, Robyna Irshad
Pakistan is a developing country of South East Asia, with all the incumbent difficulties currently being faced by the region. Insufficient public healthcare facilities, poorly regulated private health sector, low budgetary allocation for health, improper priority setting while allocating limited resources, have resulted essentially in an absence of palliative care from the healthcare scene. Almost 90% of healthcare expenditure is out of the patient's pocket with more than 45% of population living below the poverty line. All these factors have a collective potential to translate into an end-of-life care disaster as a large percentage of population is suffering from chronic debilitating/terminal diseases. So far, such a disaster has not materialised, the reason being a family based culture emphasising the care of the sick and old at home, supported by religious teachings. This culture is not limited to Pakistan but subsists in the entire sub-continent, where looking after the sick/elderly at home is considered to be the duty of the younger generation. With effects of globalisation, more and more older people are living alone and an increasing need for palliative care is being realised. However, there does not seem to be any plan on the part of the public or private sectors to initiate palliative care services. This paper seeks to trace the social and cultural perspectives in Pakistan with regards to accessing palliative care in the context of healthcare facilities available.
Sarmento, Vera P; Gysels, Marjolein; Higginson, Irene J; Gomes, Barbara
To understand patients and family caregivers' experiences with home palliative care services, in order to identify, explore and integrate the key components of care that shape the experiences of service users. We performed a meta-ethnography of qualitative evidence following PRISMA recommendations for reporting systematic reviews. The studies were retrieved in 5 electronic databases (MEDLINE, EMBASE, PsycInfo, BNI, CINAHL) using 3 terms and its equivalents ('Palliative', 'Home care', 'Qualitative research') combined with 'AND', complemented with other search strategies. We included original qualitative studies exploring experiences of adult patients and/or their family caregivers (≥18 years) facing life-limiting diseases with palliative care needs, being cared for at home by specialist or intermediate home palliative care services. 28 papers reporting 19 studies were included, with 814 participants. Of these, 765 were family caregivers and 90% were affected by advanced cancer. According to participants' accounts, there are 2 overarching components of home palliative care: presence (24/7 availability and home visits) and competence (effective symptom control and skilful communication), contributing to meet the core need for security. Feeling secure is central to the benefits experienced with each component, allowing patients and family caregivers to focus on the dual process of living life and preparing death at home. Home palliative care teams improve patients and caregivers experience of security when facing life-limiting illnesses at home, by providing competent care and being present. These teams should therefore be widely available and empowered with the resources to be present and provide competent care. 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/.
Ntizimira, Christian R; Nkurikiyimfura, Jean Luc; Mukeshimana, Olive; Ngizwenayo, Scholastique; Mukasahaha, Diane; Clancy, Clare
We are often asked what challenges Rwanda has faced in the development of palliative care and its integration into the healthcare system. In the past, patients have been barred from accessing strong analgesics to treat moderate to severe pain, but thanks to health initiatives, this is slowly changing. Rwanda is an example of a country where only a few years ago, access to morphine was almost impossible. Albert Einsten said 'in the middle of difficulty lies opportunity' and this sentiment could not be more relevant to the development of palliative care programmes. Through advocacy, policy, and staunch commitment to compassion, Rwandan healthcare workers are proving how palliative care can be successfully integrated into a healthcare system. As a global healthcare community, we should be asking what opportunities exist to do this across the African continent. Champions of palliative care have a chance to forge lasting collaborations between international experts and African healthcare workers. This global network could not only advocate for palliative care programmes but it would also help to create a culture where palliative care is viewed as a necessary part of all healthcare systems.
Full Text Available Diminishing treatment alternatives, losing hope for a possible recovery, insufficient control of pain and inability to provide the necessary technical support lead palliative care to bring multiple problems with itself. Along with technical and professional challenges, palliative care can put a humanitarian strain on the nurse. Caring for a dying patient is a worrisome experience which causes spiritual pain. An increase in nurses’ death anxiety may cause unwillingness to be together with a dying patient. In terms of the end of life, it is expected that the nurse stands by patient’s family to help them in sustaining their psychosocial wellness. In order to meet this expectation, nurses should get a qualitative training for end of life care along with good interpersonal communication skills and coping strategies.
van den Heuvel, Wim J. A.; Olaroiu, Marinela
Palliative care is directed to maintenance of quality of life and to prevent and to relief suffering of those with a life-threatening disease. Palliative care does not only concern the patient, but also the quality of life of family members and it deals with physical symptoms as well as with
Freeman, Lindsay; Caserta, Michael; Lund, Dale; Rossa, Shirley; Dowdy, Ann; Partenheimer, Andrea
Music thanatology represents an emerging area in which the raw materials of music, usually harp and/or voice, assist and comfort the dying patient. During prescriptive "music vigils, " the clinician-musician carefully observes physiological changes, cues, and breathing patterns, thereby synchronizing the music to reflect or support the patient's physiology and overall condition. Using data collected from 65 patients, this study was designed to assess the effectiveness of prescriptive harp music on selected palliative care outcomes using a sample of de-identified data forms from past music vigils. Patients were administered a 25- to 95-minute intervention of prescriptive harp music. Data collected included vital signs and observational indicators before (Ti) and after (T2) the vigil. Patients were more likely to experience decreased levels of agitation and wakefulness while also breathing more slowly and deeply with less effort at the conclusion of the music vigil. Results from this study suggest that a prescriptive vigil conducted by a trained music thanatologist could provide an effective form of palliative care for dying patients.
Sandsdalen, Tuva; Høye, Sevald; Rystedt, Ingrid; Grøndahl, Vigdis Abrahamsen; Hov, Reidun; Wilde-Larsson, Bodil
Little is known about the combination of person- and organization- related conditions and the relationships with patients' perspectives of care quality. Such a combination could contribute knowledge reflecting the complexity of clinical practice, and enhance individualized care. The aim was to investigate the relationships between the combination of person- and organization-related conditions and patients' perceptions of palliative care quality. A cross-sectional study, including 191 patients in the late palliative phase (73% response rate) admitted to hospice inpatient care (n = 72), hospice day care (n = 51), palliative units in nursing homes (n = 30) and home care (n = 38), was conducted between November 2013 and December 2014, using the instrument Quality from the Patients' Perspective specific to palliative care (QPP-PC). Data were analysed, using analysis of covariance, to explore the amount of the variance in the dependent variables (QPP-PC) that could be explained by combination of the independent variables - Person- and organization-related conditions, - while controlling for differences in covariates. Patients scored the care received and the subjective importance as moderate to high. The combination of person- and organization - related conditions revealed that patients with a high sense of coherence, lower age (person - related conditions) and being in a ward with access to and availability of physicians (organization-related condition) might be associated with significantly higher scores for the quality of care received. Gender (women), daily contact with family and friends, and low health-related quality of life (person-related conditions) might be associated with higher scores for subjective importance of the aspects of care quality. Healthcare personnel, leaders and policy makers need to pay attention to person- and organization-related conditions in order to provide person-centered palliative care of high quality. Further studies from
Romanò, Massimo; Bertona, Roberta; Zorzoli, Federica; Villani, Rosvaldo
Admissions to the intensive care unit at the end of life of patients with chronic non-malignant diseases are increasing. This involves the need for the development of palliative care culture and competence, also in the field of intensive cardiology. Palliative care should be implemented in the treatment of all patients with critical stages of disease, irrespective of prognosis, in order to improve the quality of care at the end of life.This review analyzes in detail the main clinical, ethical and communicational issues to move toward the introduction of basics of palliative care in cardiac intensive care units. It outlines the importance of shared decision-making with the patient and his family, with special attention to withholding/withdrawing of life-sustaining treatments, palliative sedation, main symptom control, patient and family psychological support.
Thompson, Jo; Brown, Jayne; Davies, Andrew
Introduction: This report describes a service evaluation of the 'added value' of routine specialist palliative care team (SPCT) involvement with patients on the Liverpool Care Pathway for the Dying Patient (LCP). Methods: In the authors' hospital, patients that are commenced on the LCP are routinely referred to the SPCT. They are reviewed on the day of referral and then at least every other day, depending on the clinical situation. The data for this report was obtained by reviewing the S...
Johnson, Stephanie B; Butow, Phyllis N; Kerridge, Ian; Tattersall, Martin H N
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
Ikenaga, M; Tsuneto, S
In the medical environment, information disclosure to patients and respect of autonomy have spread rapidly. Today, many terminally-ill cancer patients wish to spend as much time at home as possible. In such situations the patient who has been informed that curative treatments are no longer expected to be beneficial can now hope to receive home care and visiting care from hospice/palliative care services. The essential concepts of hospice/palliative care are symptom management, communication, family care and a multidisciplinary approach. These concepts are also important in the outpatient department. In particular, medical staff need to understand and utilize management strategies for common symptoms from which terminally-ill cancer patients suffer (ex. cancer pain, anorexia/fatigue, dyspnea, nausea/vomiting, constipation, hypercalcemia and psychological symptoms). They also need to know how to use continuous subcutaneous infusion for symptom management in the patients last few days. The present paper explains the clinical practices of hospice/palliative care in the outpatient department. Also discussed is support of individual lives so that maximum QOL is provided for patients kept at home.
Philip, Rekha Rachel; Philip, Sairu; Tripathy, Jaya Prasad; Manima, Abdulla; Venables, Emilie
The well lauded community-based palliative care programme of Kerala, India provides medical and social support, through home-based care, for patients with terminal illness and diseases requiring long-term support. There is, however, limited information on patient characteristics, caregivers and programme performance. This study was carried out to describe: i) the patients enrolled in the programme from 1996 to 2016 and their diagnosis, and ii) the care-giver characteristics and palliative care support from nurses and doctors in a cohort of patients registered during 2013-2015. A descriptive study was conducted in the oldest community-based palliative clinic in Kerala. Data were collected from annual patient registers from 1996 to 2016 and patient case records during the period 2013-2015. While 91% of the patients registered in the clinic in 1996 had cancer, its relative proportion came down to 32% in 2016 with the inclusion of dementia-related illness (19%) cardiovascular accidents (17%) and severe mental illness (5%).Among patients registered during 2013-15, the median number of home visits from nurses and doctors in 12 months were five and one respectively. In the same cohort, twelve months' post-enrolment, 56% of patients died, 30% were in continuing in active care and 7% opted out. Those who opted out of care were likely to be aged care-giver at home, 85% of these care-givers being female. The changing dynamics over a 20-year period of this palliative care programme in Kerala, India, highlights the need for similar programmes to remain flexible and adapt their services in response to a growing global burden of Non Communicable Diseases. While a high death rate is expected in this population, the high proportion of patients choosing to stay in the programme suggests that home-based care is valued within this particular group. A diverse range of clinical and psycho-social support skills are required to assist families and their caregivers when caring for a
Dumitrescu, Luminita; van den Heuvel-Olaroiu, Marinela; van den Heuvel, Wim J. A.
This study describes the activities and interventions carried out by an at-home palliative care team treating cancer patients who died within two years of being enrolled in a palliative care program. It analyzes which changes in symptoms and pain occurred and which sociodemographic and medical
Worster, Brooke; Swartz, Kristine
With the emergence of telemedicine as a routine form of care in various venues, the opportunities to use technology to care for the most vulnerable, most ill cancer patients are extremely appealing. Increasingly, evidence supports early integration of palliative care with standard oncologic care, supported by recent NCCN guidelines to increase and improve access to palliative care. This review looks at the use of telemedicine to expand access to palliative care as well as provide better care for patients and families where travel is difficult, if not impossible. When telemedicine has been used, often in Europe, for palliative care, the results show improvements in symptom management, comfort with care as well as patient and family satisfaction. One barrier to use of telemedicine is the concerns with technology and technology-related complications in population that is often elderly, frail and not always comfortable with non-face-to-face physician care. There remain significant opportunities to explore this intersection of supportive care and telemedicine.
van de Geer, Joep; Groot, Marieke; Andela, Richtsje; Leget, Carlo; Prins, Jelle; Vissers, Kris; Zock, Hetty
Background: Spiritual care is reported to be important to palliative patients. There is an increasing need for education in spiritual care. Aim: To measure the effects of a specific spiritual care training on patients' reports of their perceived care and treatment. Design: A pragmatic controlled
van de Geer, Joep; Groot, Marieke; Andela, Richtsje; Leget, Carlo; Prins, Jelle; Vissers, Kris; Zock, Hetty
Spiritual care is reported to be important to palliative patients. There is an increasing need for education in spiritual care. To measure the effects of a specific spiritual care training on patients' reports of their perceived care and treatment. A pragmatic controlled trial conducted between February 2014 and March 2015. The intervention was a specific spiritual care training implemented by healthcare chaplains to eight multidisciplinary teams in six hospitals on regular wards in which patients resided in both curative and palliative trajectories. In total, 85 patients were included based on the Dutch translation of the Supportive and Palliative Care Indicators Tool. Data were collected in the intervention and control wards pre- and post-training using questionnaires on physical symptoms, spiritual distress, involvement and attitudes (Spiritual Attitude and Involvement List) and on the perceived focus of healthcare professionals on patients' spiritual needs. All 85 patients had high scores on spiritual themes and involvement. Patients reported that attention to their spiritual needs was very important. We found a significant ( p = 0.008) effect on healthcare professionals' attention to patients' spiritual and existential needs and a significant ( p = 0.020) effect in favour of patients' sleep. No effect on the spiritual distress of patients or their proxies was found. The effects of spiritual care training can be measured using patient-reported outcomes and seemed to indicate a positive effect on the quality of care. Future research should focus on optimizing the spiritual care training to identify the most effective elements and developing strategies to ensure long-term positive effects. This study was registered at the Dutch Trial Register: NTR4559.
Hosie, Annmarie; Agar, Meera; Lobb, Elizabeth; Davidson, Patricia M; Phillips, Jane
Delirium is prevalent in palliative care inpatient settings and management is often challenging. Despite nurses' integral patient care role, little is known about palliative care nurses' capacity to recognise, assess and respond to patients' delirium symptoms. To explore the experiences, views and practices of inpatient palliative care nurses in delirium recognition and assessment. 30 nurses from nine Australian specialist palliative care inpatient services. Critical incident technique (CIT) guided a series of semi-structured interviews. Prior to interviews participants were given a vignette of a palliative care inpatient with an unrecognised hypoactive delirium, to prompt their recollection and recounting of a similar clinical incident. Clearly recalled and described incidents were analysed using thematic content analysis. 20 of 30 participants recalled and described 28 relevant delirium incidents. Two themes and six sub-themes provide a general description of participants' experiences, views and practice in delirium recognition and assessment. Participants experience distress related to caring for patients with delirium and express compassion and empathy for delirious patients. Enhancing their delirium knowledge, strengthening collaborative multidisciplinary team relationships and better communication are important supports. Some participants, usually those in advance practice roles, describe more comprehensive assessment capabilities that incorporate clinical expertise with whole person awareness, yet systematic and structured delirium screening and assessment processes and application of the delirium diagnosis criteria are largely missing. Use of ambiguous terminology to describe delirium symptoms contributes to ineffective practice. The findings of this study expands our understanding of how palliative care nurses' capacity to recognise and assess patients' delirium symptoms in the inpatient setting could be strengthened. Copyright © 2014 Elsevier Ltd. All
Allsop, Matthew J; Taylor, Sally; Bennett, Michael I; Bewick, Bridgette M
Approaches to pain management using electronic systems are being developed for use in palliative care. This article explores palliative care patients' perspectives on managing and talking about pain, the role of technology in their lives and how technology could support pain management. Face-to-face interviews were used to understand patient needs and concerns to inform how electronic systems are developed. A total of 13 interviews took place with a convenience sample of community-based patients with advanced cancer receiving palliative care through a hospice. Data were analysed using framework analysis. Four meta-themes emerged: Technology could be part of my care; I'm trying to understand what is going on; My pain is ever-changing and difficult to control; and I'm selective about who to tell about pain. Patients described technology as peripheral to existing processes of care. To be relevant, systems may need to take account of the complexity of a patient's pain experience alongside existing relationships with health professionals.
Morita, Tatsuya; Oyama, Yasuhiro; Cheng, Shao-Yi; Suh, Sang-Yeon; Koh, Su Jin; Kim, Hyun Sook; Chiu, Tai-Yuan; Hwang, Shinn-Jang; Shirado, Akemi; Tsuneto, Satoru
Clarification of the potential differences in end-of-life care among East Asian countries is necessary to provide palliative care that is individualized for each patient. The aim was to explore the differences in attitude toward patient autonomy and a good death among East Asian palliative care physicians. A cross-sectional survey was performed involving palliative care physicians in Japan, Taiwan, and Korea. Physicians' attitudes toward patient autonomy and physician-perceived good death were assessed. A total of 505, 207, and 211 responses were obtained from Japanese, Taiwanese, and Korean physicians, respectively. Japanese (82%) and Taiwanese (93%) physicians were significantly more likely to agree that the patient should be informed first of a serious medical condition than Korean physicians (74%). Moreover, 41% and 49% of Korean and Taiwanese physicians agreed that the family should be told first, respectively; whereas 7.4% of Japanese physicians agreed. Physicians' attitudes with respect to patient autonomy were significantly correlated with the country (Japan), male sex, physician specialties of surgery and oncology, longer clinical experience, and physicians having no religion but a specific philosophy. In all 12 components of a good death, there were significant differences by country. Japanese physicians regarded physical comfort and autonomy as significantly more important and regarded preparation, religion, not being a burden to others, receiving maximum treatment, and dying at home as less important. Taiwanese physicians regarded life completion and being free from tubes and machines as significantly more important. Korean physicians regarded being cognitively intact as significantly more important. There are considerable intercountry differences in physicians' attitudes toward autonomy and physician-perceived good death. East Asia is not culturally the same; thus, palliative care should be provided in a culturally acceptable manner for each country
Davies, Elizabeth A
Although many well-known poems consider illness, loss and bereavement, medicine tends to view poetry more as an extracurricular than as a mainstream pursuit. Within palliative care, however, there has been a long-standing interest in how poetry may help patients and health professionals find meaning, solace and enjoyment. The objective of this paper is to identify the different ways in which poetry has been used in palliative care and reflect on their further potential for education, practice and research. A narrative review approach was used, drawing on searches of the academic literature through Medline and on professional, policy and poetry websites to identify themes for using poetry in palliative care. I identified four themes for using poetry in palliative care. These concerned (1) leadership, (2) developing organisational culture, (3) the training of health professionals and (4) the support of people with serious illness or nearing the end of life. The academic literature was mostly made up of practitioner perspectives, case examples or conceptual pieces on poetry therapy. Patients' accounts were rare but suggested poetry can help some people express powerful thoughts and emotions, create something new and feel part of a community. Poetry is one way in which many people, including patients and palliative care professionals, may seek meaning from and make sense of serious illnesses and losses towards the end of life. It may have untapped potential for developing person-centred organisations, training health professionals, supporting patients and for promoting public engagement in palliative 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.
Balkin, Emily M; Thompson, Daria; Colson, K Ellicott; Lam, Catherine G; Matthay, Katherine K
Studies have shown that children with cancer globally lack access to palliative care. Little is known regarding physicians' perceptions of palliative care, treatment access, and self-reported competence in providing palliative care. Members of the Global Neuroblastoma Network (online tumor board) were surveyed. Eighty-three respondents met inclusion criteria; 53 (64%) completed the survey. Most respondents trained in high-income countries (HIC) but practice in low- and middle-income countries (LMIC), and care for more than five patients with neuroblastoma annually. WHO Essential Medicines in palliative care varied in availability, with incomplete access across LMIC centers. Nonpharmacologic therapies were inconsistently available. Contrary to international definitions, 17% of respondents inappropriately considered palliative care as that initiated only after curative therapy is stopped. Mean physician competence composite score (Likert scale 1-5, 5 = very competent) in providing symptomatic relief and palliative care across phases of care was 2.93 (95% CI 2.71-3.22). Physicians reported significantly greater competence in symptom management during cure-directed therapy than during end-of-life (P = 0.02) or when patients are actively dying (P = 0.007). Practicing in HIC, prior palliative care training, having access to radiotherapy, and not having to turn patients away due to bed shortages were significantly predictive of perceived competence in providing palliative care at end of life. An international sample identified gaps in treatment and palliative care service availability, in understanding the definition of palliative care, and in self-reported competence in providing palliative care. Increased perceived competence was associated with training, which supports the need for increased palliative care education and advocacy, especially in LMIC. © 2016 Wiley Periodicals, Inc.
Simon, Steffen T; Ramsenthaler, Christina; Bausewein, Claudia; Krischke, Norbert; Geiss, Gerlinde
Self-awareness of one's own reactions towards patients and their relatives is of paramount importance for all professionals in palliative care. 'Core attitude' describes the way in which a person perceives himself and the world, and forms the basis for his actions and thoughts. The aim of this study is to explore what core attitude means for palliative care professionals and whether there is a specific core attitude in palliative care. Qualitative study with 10 face-to-face in-depth interviews with experts in palliative care (nurses, physicians, social workers, psychologists, chaplain) in Germany. Core attitude in palliative care can be best described with the following three domains: 1) personal characteristics; 2) experience of care; and 3) competence in care. Authenticity is the most important characteristic of professionals, along with honesty and mindfulness. Core attitude primarily becomes apparent in the relationship with the patient. Perception and listening are key competences. The experts emphasized the universality of the core attitude in the care of ill people. They stressed the importance and relevance of teaching core attitudes in palliative care education. In the field of palliative care, core attitude consists predominately of authenticity, manifests itself in relationships, and requires a high degree of perceptiveness.
Mantovan, Franco; Rauter, Elisabeth; Müller, Irene
In palliative care between 13.9 and 25 percent of all patients suffering from cancer show signs of anxiety disorders. Up to 75 percent of these patients suffer from non-pathologic anxiety, which has a negative impact on the patients' quality of life. Therefore it is important to provide interventions that are able to reduce anxiety of cancer patients. Massage and music therapy are effective interventions for minimizing anxiety of cancer patients in palliative care. An empathic attitude of the nurse increases the effect of the mentioned interventions. While there is evidence of the interventions mentioned it is yet necessary to further explore these in additional clinical trials to consolidate the already existing results.
Alfaya Góngora, Maria Del Mar; Bueno Pernias, Maria José; Hueso Montoro, César; Guardia Mancilla, Plácido; Montoya Juárez, Rafael; García Caro, Maria Paz
To describe the clinical encounters that occur when a palliative care team provides patient care and the features that influence these encounters and indicate whether they are favorable or unfavorable depending on the expectations and feelings of the various participants. A qualitative case study conducted via participant observation. A total of 12 observations of the meetings of palliative care teams with patients and families in different settings (home, hospital and consultation room) were performed. The visits were follow-up or first visits, either scheduled or on demand. Content analysis of the observation was performed. The analysis showed the normal follow-up activity of the palliative care unit that was focused on controlling symptoms, sharing information and providing advice on therapeutic regimens and care. The environment appeared to condition the patients' expressions and the type of patient relationship. Favorable clinical encounter conditions included kindness and gratitude. Unfavorable conditions were deterioration caused by approaching death, unrealistic family objectives and limited resources. Home visits from basic palliative care teams play an important role in patient and family well-being. The visits seem to focus on controlling symptoms and are conditioned by available resources.
As palliative care units continue to develop, the provision of end-of-life care for patients with a chronic mental illness needs to be addressed. Aside from the somatic comorbidities to which these patients are particularly exposed and in view of the specificity of psychiatric treatment, the forms of end-of-life support for a patient with schizophrenia are described here, based on the experience of a psychiatric unit in the Var region. Copyright © 2017 Elsevier Masson SAS. All rights reserved.
Turriziani, Adriana; Attanasio, Gennaro; Scarcella, Francesco; Sangalli, Luisa; Scopa, Anna; Genualdo, Alessandra; Quici, Stefano; Nazzicone, Giulia; Ricciotti, Maria Adelaide; La Commare, Francesco
In the last decades, palliative care has been more and more focused on the evaluation of patients' and families' satisfaction with care. However, the evaluation of customer satisfaction in palliative care presents a number of issues such as the presence of both patients and their families, the frail condition of the patients and the complexity of their needs, and the lack of standard quality indicators and appropriate measurement tools. In this manuscript, we critically review existing evidence and literature on the evaluation of satisfaction in the palliative care context. Moreover, we provide - as a practical example - the preliminary results of our experience in this setting with the development of a dedicated tool for the measurement of satisfaction.
I. P. Рonomareva
Full Text Available The purpose of the study is to identify the main problems and prospects of development of palliative care in geriatrics at the present stage. Method of research was to analyze the printed and electronic databases that meet the stated issues. The results of the study highlight the problems of the development of palliative care in geriatric practice: the lack of a developed procedure of rendering palliative care and adequate elderly patient selection criteria, the lack of trained professional staff. The main prospects-association of palliative practices and concepts of modern geriatrics required specialized geriatric assessment and the provision of clinical, medical, social and socio-psychological geriatric syndromes. While promising option for the development of palliative care geriatrics is the integration into the existing health care system, acceptance of the fact that it is a part of the specialized geriatric care. This requires the involvement and training of not only specialists with medical education, but also persons without medical training from among social workers and volunteers working in palliative care. Therefore, the obtained data allowed to conclude that topical is the development of palliative care in geriatrics, taking into account not only clinical but medico-social, socio-psychological features.
De Simone, Gustavo G
Argentina is a large South American country with a high prevalence of chronic disease-related mortality and a clear need for implementation of palliative care. Primary concerns related to palliative care are cultural, socio-economic and educational. Increasing poverty, patients and families receiving inadequate information about their diagnosis or prognosis, drug availability and costs, and insufficient knowledge by health care providers are obstacles to palliative care. Palliative care programs are developing throughout the country and methods by which they are meeting their needs are described. Several Argentinean palliative care initiatives are described and the role of the Pallium Latinomérica training program is discussed.
Full Text Available Spiritual care is a vital part of holistic patient care. Awareness of common patient beliefs will facilitate discussions about spirituality. Such conversations are inherently good for the patient, deepen the caring staff-patient-family relationship, and enhance understanding of how beliefs influence care decisions. All healthcare providers are likely to encounter Muslim patients, yet many lack basic knowledge of the Muslim faith and of the applications of Islamic teachings to palliative care. Similarly, some of the concepts underlying positive Jewish approaches to palliative care are not well known. We outline Jewish and Islamic attitudes toward suffering, treatment, and the end of life. We discuss our religions' approaches to treatments deemed unnecessary by medical staff, and consider some of the cultural reasons that patients and family members might object to palliative care, concluding with specific suggestions for the medical team.
Midorikawa, Yasuhiko; Iiduka, Masashi
The problems we have identified to overcome for a betterment of home palliative care were as follows:(1) Staffs' low level of knowledge and a lack of interest in home care, (2) Lack of cooperation between hospital and clinic, (3) Hard to keep the medical and caregiver staffs employed in the home care settings and a technical training is behind, (4) Insufficient cooperative networks for elderly care and welfare in the region, and (5) Misunderstanding of home palliative care by patient, family and people in the region. It is important to solve these problems one by one for a betterment of home palliative care. In this paper, we reported these problems through actual activities of our hospital and Iwaki city, and we propose to deal with them.
Shipman Cathy; Gysels Marjolein; Higginson Irene J
Abstract Background Contradictory evidence exists about the emotional burden of participating in qualitative research for palliative care patients and carers and this raises questions about whether this type of research is ethically justified in a vulnerable population. This study aimed to investigate palliative care patients' and carers' perceptions of the benefits and problems associated with open interviews and to understand what causes distress and what is helpful about participation in a...
van Gurp, J.; van Selm, M.; van Leeuwen, E.; Vissers, K.; Hasselaar, J.
Background: Interprofessional consultation contributes to symptom control for home-based palliative care patients and improves advance care planning. Distance and travel time, however, complicate the integration of primary care and specialist palliative care. Expert online audiovisual
Skrbina, Dijana; Simunović, Dubravka; Santek, Vjerocka; Njegovan-Zvonarević, Tatjana
Man is mortal, which means that as the earthly body perishes being, final. Disease and death will always be an inevitable and integral part of human experience. The way in which we try to identify and respond to the unique and individual needs of the dying is an indication of our maturity as a society. The number of people requiring palliative care is growing. Palliative care does not intend to either accelerate or postpone death she emphasizes the life and looks at dying as a normal process. It is an active form of care for patients with advanced, progressive illness, with the aim of suppressing pain and other symptoms in addition to providing psychological, social and spiritual support which ensures the best possible quality of life for patients and their families. Therefore requires a coordinated and interdisciplinary contribution team. The variety of professions in a team, and determine the needs of patients should be ready to provide physical, psychological, social and spiritual support using methods that result from an interdisciplinary, collaborative team approach. Development of a holistic approach and awareness in the medical and allied professions has led to a renewal of interest in the inclusion of music and other expressive media in contemporary concepts of palliative care, which are consistent with problem areas, clinical manifestations and the needs of patients. Music offers a direct and uncomplicated medium of intimacy, living in a man who listens to her, has a place where words lose their power. Music is like our existence, constantly polarizing and emotionally stimulating, as it touches the medium of the earliest layers of our becoming. The use of music in palliative care has proved very effective for a variety of effects that music creates in patients. These effects are achieved through the use of various musical techniques, such as musical improvisation, songwriting, receiving creative techniques, guided by imagination and music. These techniques
Maltoni, Marco; Setola, Elisabetta
Palliative sedation involves the use of sedative medication to relieve refractory symptoms in patients by reducing their level of consciousness. Although it is considered an acceptable clinical practice from most ethical points of view, palliative sedation is still a widely debated procedure and merits better understanding. The relevant medical literature pertaining to palliative sedation was analyzed and reviewed from various technical, relational, and bioethical perspectives. Proportionate palliative sedation is considered to be the most clinically appropriate modality for performing palliative sedation. However, guidelines must be followed to ensure that it is performed correctly. Benzodiazepines represent the first therapeutic option and careful monitoring of dosages is essential to avoid oversedation or undersedation. Proportionate palliative sedation is used to manage and relieve refractory symptoms in patients with cancer during their last days or hours of life. Evidence suggests that its use has no detrimental effect on survival. A different decision-making process is used to manage the withdrawal of hydration than the process used to determine whether proportionate palliative sedation is appropriate. Communication between patients, their relatives, and the health care staff is important during this medical intervention.
Osse, B.H.P.; Vernooy-Dassen, M.J.F.J.; Schade, E.; Grol, R.P.T.M.
OBJECTIVES: To investigate the problems that patients experience and their met- and unmet needs for professional help. This information is necessary to tailor palliative care to patient needs. PATIENTS AND METHODS: Patients (n=94) with disseminated cancer completed a validated checklist with 90
McCaffrey, Nikki; Agar, Meera; Harlum, Janeane; Karnon, Jonathon; Currow, David; Eckermann, Simon
The aim of this study was to evaluate the cost-effectiveness of a home-based palliative care model relative to usual care in expediting discharge or enabling patients to remain at home. Economic evaluation of a pilot randomised controlled trial with 28 days follow-up. Mean costs and effectiveness were calculated for the Palliative Care Extended Packages at Home (PEACH) and usual care arms including: days at home; place of death; PEACH intervention costs; specialist palliative care service use; acute hospital and palliative care unit inpatient stays; and outpatient visits. PEACH mean intervention costs per patient ($3489) were largely offset by lower mean inpatient care costs ($2450) and in this arm, participants were at home for one additional day on average. Consequently, PEACH is cost-effective relative to usual care when the threshold value for one extra day at home exceeds $1068, or $2547 if only within-study days of hospital admission are costed. All estimates are high uncertainty. The results of this small pilot study point to the potential of PEACH as a cost-effective end-of-life care model relative to usual care. Findings support the feasibility of conducting a definitive, fully powered study with longer follow-up and comprehensive economic evaluation.
Prabhu, Arpan V; Crihalmeanu, Tudor; Hansberry, David R; Agarwal, Nitin; Glaser, Christine; Clump, David A; Heron, Dwight E; Beriwal, Sushil
The Google search engine is a resource commonly used by patients to access health-related patient education information. The American Medical Association and National Institutes of Health recommend that patient education resources be written at a level between the third and seventh grade reading levels. We assessed the readability levels of online palliative care patient education resources using 10 readability algorithms widely accepted in the medical literature. In October 2016, searches were conducted for 10 individual terms pertaining to palliative care and oncology using the Google search engine; the first 10 articles written for the public for each term were downloaded for a total of 100 articles. The terms included palliative care, hospice, advance directive, cancer pain management, treatment of metastatic disease, treatment of brain metastasis, treatment of bone metastasis, palliative radiation therapy, palliative chemotherapy, and end-of-life care. We determined the average reading level of the articles by readability scale and Web site domain. Nine readability assessments with scores equivalent to academic grade level found that the 100 palliative care education articles were collectively written at a 12.1 reading level (standard deviation, 2.1; range, 7.6-17.3). Zero articles were written below a seventh grade level. Forty-nine (49%) articles were written above a high school graduate reading level. The Flesch Reading Ease scale classified the articles as "difficult" to read with a score of 45.6 of 100. The articles were collected from 62 Web site domains. Seven domains were accessed 3 or more times; among these, www.mskcc.org had the highest average reading level at a 14.5 grade level (standard deviation, 1.4; range, 13.4-16.1). Most palliative care education articles readily available on Google are written above national health literacy recommendations. There is need to revise these resources to allow patients and their families to derive the most
Buckley de Meritens, Alexandre; Margolis, Benjamin; Blinderman, Craig; Prigerson, Holly G; Maciejewski, Paul K; Shen, Megan J; Hou, June Y; Burke, William M; Wright, Jason D; Tergas, Ana I
We sought to describe practice patterns, attitudes, and barriers to the integration of palliative care services by gynecologic oncologists. Members of the Society of Gynecologic Oncology were electronically surveyed regarding their practice of incorporating palliative care services and to identify barriers for consultation. Descriptive statistics were used, and two-sample z-tests of proportions were performed to compare responses to related questions. Of the 145 respondents, 71% were attending physicians and 58% worked at an academic medical center. The vast majority (92%) had palliative care services available for consultation at their hospital; 48% thought that palliative care services were appropriately used, 51% thought they were underused, and 1% thought they were overused. Thirty percent of respondents thought that palliative care services should be incorporated at first recurrence, whereas 42% thought palliative care should be incorporated when prognosis for life expectancy is ≤ 6 months. Most participants (75%) responded that palliative care consultation is reasonable for symptom control at any stage of disease. Respondents were most likely to consult palliative care services for pain control (53%) and other symptoms (63%). Eighty-three percent of respondents thought that communicating prognosis is the primary team's responsibility, whereas the responsibilities for pain and symptom control, resuscitation status, and goals of care discussions were split between the primary team only and both teams. The main barrier for consulting palliative care services was the concern that patients and families would feel abandoned by the primary oncologist (73%). Ninety-seven percent of respondents answered that palliative care services are useful to improve patient care. The majority of gynecologic oncologists perceived palliative care as a useful collaboration that is underused. Fear of perceived abandonment by the patient and family members was identified as a
Lisa M. Linge-Dahl
Full Text Available Background: The central goal of palliative care is to optimize the quality of life of patients suffering from life-limiting illnesses, which includes psychosocial and spiritual wellbeing. Research has demonstrated positive correlations between humor and laughter with life satisfaction and other aspects of wellbeing, and physiological symptoms can be improved by humorous stimuli.Objectives: The aim of this review is to evaluate humor interventions and assessments that have been applied in palliative care and to derive implications for future research.Methods: A systematic review of four databases identified 13 included studies. Criteria for inclusion were peer-reviewed English-language studies on humor interventions or assessments in a palliative care context.Results: Two studies on humor interventions and 11 studies on humor assessment were included in the systematic review. Most of these studies were about the patients' perspective on humor in palliative care. Findings showed that humor had a positive effect on patients, their relatives, and professional caregivers. Humor was widely perceived as appropriate and seen as beneficial to care in all studies.Conclusions: Even though humor interventions seem to be potentially useful in palliative care, descriptions evaluating their use are scarce. Overall, research on humor assessment and interventions in palliative care has remained limited in terms of quantity and quality. More research activities are needed to build a solid empirical foundation for implementing humor and laughter as part of regular palliative care activities.
Full Text Available RG Duenk,1 C Verhagen,1 EM Bronkhorst,2 RS Djamin,3 GJ Bosman,4 E Lammers,5 PNR Dekhuijzen,6 KCP Vissers,1 Y Engels,1,* Y Heijdra6,* 1Department of Anesthesiology, Pain and Palliative Medicine, 2Department of Health Evidence, Radboud University Medical Center, Nijmegen, 3Department of Respiratory Medicine, Amphia Hospital, Breda, 4Department of Respiratory Medicine, Slingeland Hospital, Doetinchem, 5Department of Respiratory Medicine, Gelre Hospitals, Zutphen, 6Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, the Netherlands *These authors contributed equally to this work Background: Our objective was to develop a tool to identify patients with COPD for proactive palliative care. Since palliative care needs increase during the disease course of COPD, the prediction of mortality within 1 year, measured during hospitalizations for acute exacerbation COPD (AECOPD, was used as a proxy for the need of proactive palliative care.Patients and methods: Patients were recruited from three general hospitals in the Netherlands in 2014. Data of 11 potential predictors, a priori selected based on literature, were collected during hospitalization for AECOPD. After 1 year, the medical files were explored for the date of death. An optimal prediction model was assessed by Lasso logistic regression, with 20-fold cross-validation for optimal shrinkage. Missing data were handled using complete case analysis.Results: Of 174 patients, 155 patients were included; of those 30 (19.4% died within 1 year. The optimal prediction model was internally validated and had good discriminating power (AUC =0.82, 95% CI 0.81–0.82. This model relied on the following seven predictors: the surprise question, Medical Research Council dyspnea questionnaire (MRC dyspnea, Clinical COPD Questionnaire (CCQ, FEV1% of predicted value, body mass index, previous hospitalizations for AECOPD and specific comorbidities. To ensure minimal miss out of patients in need
Jarrett, N; Porter, K; Davis, C; Lathlean, J; Duke, S; Corner, J; Addington-Hall, J
To explore the work carried out for cancer palliative care patients in understanding and dealing with the often large network of care provision surrounding them. Qualitative thematic analysis of interviews with 24 patients (aged 48-85 years) with 15 different types/sites of cancer and palliative care needs. The main theme of 'patient work-their strategies and project management' is presented. Subthemes included: being organised and keeping records; planning ahead and coordinating care; information gathering; understanding the hierarchy and knowing who the key people are; strategies to remember names and roles; understanding and 'working the system'. Insights are given into the work carried out on patients' behalf by family, although it was unclear who would do this work if no family was available. Some of the challenges faced by patients and families are identified. These included limited information; uncertainty when care is transferred between different teams or locations; deciding who to contact and how; and negotiating through gatekeepers. The number and variety of people contributing to the care of a cancer palliative care patient can be difficult for patients and family to comprehend. Work is required by patients or family on their behalf to achieve the level of understanding required to become accomplished at navigating the system and project managing their care organisation, and is probably influenced by role expectations and previous experience. Much of this additional, often hidden, workload for patients and family could probably be reduced with clear, timely information provision by health professionals. 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.
Ticiane Dionizio de Sousa Matos
Full Text Available ABSTRACT Objectives: to compare the quality of life and religious-spiritual coping of palliative cancer care patients with a group of healthy participants; assess whether the perceived quality of life is associated with the religious-spiritual coping strategies; identify the clinical and sociodemographic variables related to quality of life and religious-spiritual coping. Method: cross-sectional study involving 96 palliative outpatient care patient at a public hospital in the interior of the state of São Paulo and 96 healthy volunteers, using a sociodemographic questionnaire, the McGill Quality of Life Questionnaire and the Brief Religious-Spiritual Coping scale. Results: 192 participants were interviewed who presented good quality of life and high use of Religious-Spiritual Coping. Greater use of negative Religious-Spiritual Coping was found in Group A, as well as lesser physical and psychological wellbeing and quality of life. An association was observed between quality of life scores and Religious-Spiritual Coping (p<0.01 in both groups. Male sex, Catholic religion and the Brief Religious-Spiritual Coping score independently influenced the quality of life scores (p<0.01. Conclusion: both groups presented high quality of life and Religious-Spiritual Coping scores. Male participants who were active Catholics with higher Religious-Spiritual Coping scores presented a better perceived quality of life, suggesting that this coping strategy can be stimulated in palliative care patients.
Minton, Mary E; Kerkvliet, Jennifer L; Mitchell, Amanda; Fahrenwald, Nancy L
Geographical disparities play a significant role in palliative and end-of-life care access. This study assessed availability of palliative and end of life (hospice) care in South Dakota. Grounded in a conceptual model of advance care planning, this assessment explored whether South Dakota health care facilities had contact persons for palliative care, hospice services, and advance directives; health care providers with specialized training in palliative and hospice care; and a process for advance directives and advance care planning. Trained research assistants conducted a brief telephone survey. Of 668 health care eligible facilities, 455 completed the survey for a response rate of 68 percent (455 out of 668). Over one-half of facilities had no specific contact person for palliative care, hospice services and advance directives. Nursing homes reported the highest percentage of contacts for palliative care, hospice services and advance directives. Despite a lack of a specific contact person, nearly 75 percent of facilities reported having a process in place for addressing advance directives with patients; slightly over one-half (53 percent) reported having a process in place for advance care planning. Of participating facilities, 80 percent had no staff members with palliative care training, and 73 percent identified lack of staff members with end-of-life care training. Palliative care training was most commonly reported among hospice/home health facilities (45 percent). The results of this study demonstrate a clear need for a health care and allied health care workforce with specialized training in palliative and end-of-life care.
Lim, Christopher T; Tadmor, Avia; Fujisawa, Daisuke; MacDonald, James J; Gallagher, Emily R; Eusebio, Justin; Jackson, Vicki A; Temel, Jennifer S; Greer, Joseph A; Hagan, Teresa; Park, Elyse R
While vast opportunities for using qualitative methods exist within palliative care research, few studies provide practical advice for researchers and clinicians as a roadmap to identify and utilize such opportunities. To provide palliative care clinicians and researchers descriptions of qualitative methodology applied to innovative research questions relative to palliative care research and define basic concepts in qualitative research. Body: We describe three qualitative projects as exemplars to describe major concepts in qualitative analysis of early palliative care: (1) a descriptive analysis of clinician documentation in the electronic health record, (2) a thematic content analysis of palliative care clinician focus groups, and (3) a framework analysis of audio-recorded encounters between patients and clinicians as part of a clinical trial. This study provides a foundation for undertaking qualitative research within palliative care and serves as a framework for use by other palliative care researchers interested in qualitative methodologies.
Vladimir Araujo de Silva
Full Text Available This phenomenological study was structured on Heidegger’s theoretical-philosophical framework, with the objective of unveiling the significances and meanings of the musical identity of patients and relatives under oncological palliative care. Individual interviews were performed with 12 clients (seven patients and five relatives staying at the support residence of the Maringa Female Network Against Cancer. A total of eight musical meetings were performed between January and February of 2011. I understood that the musical identity of the evidenced beings refers to the religious and country music styles, that their significances and meanings are connected to their spirituality and the significant events of their historicity, and that their mood and reflection intermediated by music can influence their musical choice. I gave evidence to the need to consider the music identity and empowerment in musical choices, which carries existential, social, cultural, spiritual and family aspects as qualifying elements of nursing in palliative care. Descriptors: Nursing Care; Oncology Nursing; Music; Music Therapy; Palliative Care.
Henk van Rijswijk; Esther Stoffers; Anna Beurskens; M. Beckers; F.A. Haarsma; Albine Moser
Background and objective Public involvement in palliative care is challenging and difficult, because people in need of palliative care are often not capable of speaking up for themselves. Patient representatives advocate for their common interests. The aim of our study was to examine in depth the
Every people wants to best care and to die painless in their end-stage of life. This is a human right. Therefore, end-of-life care is considered an indicator of health quality all over the world. The ultimate goal of palliative care is to relieve the suffering of patients and their families by the comprehensive assessment and treatment of physical, psychosocial, and spiritual symptoms experienced by patients. After the patient\\s death, palliative care focuses primarily on bereavement of the family. T.C. Ministry of Health to find a solution of this important issue as a first step, the preparations for the establishment of palliative care centers and units, training of health personnel started. S.B. Ulus State Hospital as a team we have set out to open a comprehensive palliative care center. Our goal is to contribute on take place of palliative care organization in health system and to the spread across the country. [J Contemp Med 2012; 2(2.000: 122-126
Bickel, Kathleen E; McNiff, Kristen; Buss, Mary K; Kamal, Arif; Lupu, Dale; Abernethy, Amy P; Broder, Michael S; Shapiro, Charles L; Acheson, Anupama Kurup; Malin, Jennifer; Evans, Tracey; Krzyzanowska, Monika K
Integrated into routine oncology care, palliative care can improve symptom burden, quality of life, and patient and caregiver satisfaction. However, not all oncology practices have access to specialist palliative medicine. This project endeavored to define what constitutes high-quality primary palliative care as delivered by medical oncology practices. An expert steering committee outlined 966 palliative care service items, in nine domains, each describing a candidate element of primary palliative care delivery for patients with advanced cancer or high symptom burden. Using modified Delphi methodology, 31 multidisciplinary panelists rated each service item on three constructs: importance, feasibility, and scope within medical oncology practice. Panelists endorsed the highest proportion of palliative care service items in the domains of End-of-Life Care (81%); Communication and Shared Decision Making (79%); and Advance Care Planning (78%). The lowest proportions were in Spiritual and Cultural Assessment and Management (35%) and Psychosocial Assessment and Management (39%). In the largest domain, Symptom Assessment and Management, there was consensus that all symptoms should be assessed and managed at a basic level, with more comprehensive management for common symptoms such as nausea, vomiting, diarrhea, dyspnea, and pain. Within the Appropriate Palliative Care and Hospice Referral domain, there was consensus that oncology practices should be able to describe the difference between palliative care and hospice to patients and refer patients appropriately. This statement describes the elements comprising high-quality primary palliative care for patients with advanced cancer or high symptom burden, as delivered by oncology practices. Oncology providers wishing to enhance palliative care delivery may find this information useful to inform operational changes and quality improvement efforts. Copyright © 2016 by American Society of Clinical Oncology.
Lavesen, Marie; Marsa, Kristoffer Bastrup-Madsen; Bove, Dorthe Gaby
Patients with chronic obstructive pulmonary disease (COPD) often live with unmet palliative needs and low quality of life, although several guidelines recommend that those with COPD should be offered early and integrated palliative care. However, none of the guidelines describe how...... COPD. All patients are assigned to a nurse who has overall responsibility for establishing and maintaining an individualised relationship with the patient and identifying their needs for care and treatment. Routine outpatient visits are replaced by ad hoc consultations, and patients are seen...... by pulmonary specialists only when there is a need for medical assessment and treatment or a planned advanced care planning dialogue. The new service was succesfully implemented; however, the changes required good multidisciplinary collaboration, dedicated health professionals and managerial support...
Full Text Available Gail Houseman,1 Mary Kelley2 1The ALS Association Greater Philadelphia Chapter, Ambler, PA, USA; 2Department of Neurology, ALS Center at Penn Medicine, Philadelphia, PA, USA Abstract: Amyotrophic lateral sclerosis (ALS is a motor neuron disease that results in eventual paralysis of all voluntary muscles. Cognitive impairment may be a co-occurring condition with the ALS patient. Palliative care, which involves symptom management, is the most utilized treatment of choice. Managing the symptoms of ALS can be challenging. This paper provides experience-based facts on daily care provision in the USA and some practical guidelines. Keywords: amyotrophic lateral sclerosis, ALS, palliative care, challenges, symptom management
Conclusions : Medical problems with poor symptom control were the commonest problems, followed by socioeconomic issues related to no income, poor living conditions and fears for the future of their children. Spiritual and psychological issues were surprisingly less of a problem possibly because the immediacy and severity of the demands of day-to-day survival. As a result of the needs identified among these patients, it became apparent that a palliative care ward catering to these needs was needed. The guiding principles in the development of this ward were the need for privacy, for a teamwork approach and for meticulous medical care, all of which underpin good palliative care.
Fukui, Sakiko; Fujita, Junko; Tsujimura, Mayuko; Sumikawa, Yuka; Hayashi, Yayoi
To identify factors influencing the place of death among home palliative cancer care patients, focusing on the role of nurses in terms of pre- and post-discharge from hospital to home care settings. A cross-sectional nationwide questionnaire survey was conducted at 1000 randomly selected homecare agencies in Japan. The questionnaires were completed by primary community nurses of home palliative patients just after their discharge. A total of 568 responses were analyzed (effective response rate, 69%). Multivariate logistic regression analysis revealed the following independent factors of place of death among those patients: desire for home death at referral by both patient and family caregiver; caregiver relationship to patient as daughter or daughter-in-law; totally bedridden functional status of patient; patient not suffering from depression and/or anxiety at referral; patients and caregivers duly informed about the dying process/death in detail, as well as instructed by community nurses about pain management and how to treat/prevent bedsores in home care settings. This study demonstrated the importance of both the hospital and community nurses' role in increasing the patients' chance of dying at home. Hospital nurses should support early transfer to home palliative care according to their assessment of the desire of patient/family caregiver for home death, the patients' clinical status, and caregivers' ability to provide patient care at home. Community nurses should inform patients/family caregiver in detail about the dying process/death just after discharge, relieve patient pain, treat/prevent bedsores, and instruct family caregivers on their symptom control. Crown Copyright © 2011. Published by Elsevier Ltd. All rights reserved.
Full Text Available The purpose for this observational research was to understand how Can Support provides palliative care at home and analyze its strengths and weaknesses in various socioeconomic scenarios for future development. In the period of 2 weeks, patients and their caregivers were silently observed in their natural surroundings during home care visits in order to listen their problems, identify the pattern of questions for the home care team, their natural way of storytelling, organizational techniques for medicines and medical reports, care givers lives, patient journey, etc. Such observations have enabled the understanding of the phenomena of home palliative care and have led to the identification of certain influential variables of the practice.
Olsman, Erik; Duggleby, Wendy; Nekolaichuk, Cheryl; Willems, Dick; Gagnon, Judith; Kruizinga, Renske; Leget, Carlo
Hope is important in palliative care. However, palliative care professionals' perspectives on hope are not well understood. Metaphors of hope are a way of better understanding these perspectives. To describe palliative care professionals' perspectives on hope by examining the hope metaphors they spontaneously used to describe their own hope and their perspectives on the hope of patients and their families. Semistructured interviews with palliative care professionals were recorded, transcribed, and analyzed using a narrative approach. Results were discussed until the researchers reached consensus and reinforced by other health-care professionals and by observing several palliative care settings. The 64 participants (mean (SD) age, 48.42 (9.27) years and 72% female) were physicians (41%), nurses (34%), chaplains (20%), or other professionals (5%), working in Canada (19%) or The Netherlands (81%). Participants described the hope of patients, their families, or themselves as a 1) grip, which implied safety; 2) source, which implied strength; 3) tune, which implied harmony; and 4) vision, which implied a positive perspective. Compared with Dutch participants, Canadian participants generally put more emphasis on spirituality and letting go of their own hope as a grip (safety). Compared with other included professionals, physicians used hope as a grip (safety) most often, whereas chaplains used hope as a tune (harmony) most often. Our findings help to increase the understanding of hope and contribute to improving communication skills in palliative care professionals. Copyright © 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
Dabbouseh, Noura M; Kaushal, Shivtej; Peltier, Wendy; Johnston, Fabian M
To address perspectives of cardiology fellows on the current state of palliative education and palliative and hospice resource utilization within their fellowship experiences. We conducted an online national survey of cardiology fellows during the 2015 to 2016 academic year. Survey questions aimed to assess perceived importance of palliative care education, level of palliative care education during fellowship, and the structure of palliative care support at respondent institutions. Responses were collected anonymously. A total of 519 programs, including subspecialty programs, were contacted. We received 365 responses, a number that represents roughly 14% of all cardiology fellows nationwide during the 2015 to 2016 academic year. Fellows reported discordance in the quality of education between general cardiology and palliative care principles as it relates to care of the patient approaching the end of life. Fellows infrequently received explicit training nor were observed or mentored in delivering end-of-life discussions. Respondents reported an underutilization of palliative care and hospice resources during fellowship training and also a perception that attending faculty were not routinely addressing goals of care. Our survey results highlight a need for enhanced palliative care and end-of-life training experiences for cardiology fellows and also suggest underutilization of hospice and palliative care resources for patients with advanced cardiac diseases. These findings create a platform for future work that might: (1) confirm this training deficit, (2) lead to exploration of educational models that could reconcile this deficit, and (3) potentially help improve palliative care support for patients and families facing advanced heart disease.
care. The confident and safe use of opioids in palliative care is an essential skill required by all. d o c t o r s . ... patient for ongoing clinical review. Start the elderly and frail .... (24 hour subcutaneous infusion ... (nursing or medical), pain special-.
Groenvold, Mogens; Petersen, Morten Aa; Aaronson, Neil K.; Arraras, Juan I.; Blazeby, Jane M.; Bottomley, Andrew; Fayers, Peter M.; de Graeff, Alexander; Hammerlid, Eva; Kaasa, Stein; Sprangers, Mirjam A. G.; Bjorner, Jakob B.
This study aimed at developing a shortened version of the EORTC QLQ-C30, one of the most widely used health-related quality of life questionnaires in oncology, for palliative care research. The study included interviews with 41 patients and 66 health care professionals in palliative care to
McIlfatrick, Sonja; Hasson, Felicity
To evaluate a holistic assessment tool for palliative care practice. This included identifying patients' needs using the holistic tool and exploring the usability, applicability and barriers and facilitators towards implementation in practice. The delivery of effective holistic palliative care requires a careful assessment of the patients' needs and circumstances. Whilst holistic assessment of palliative care needs is advocated, questions exist around the appropriateness of tools to assist this process. Mixed-method research design. Data collection involved an analysis of piloted holistic assessments undertaken using the tool (n = 132) and two focus groups with healthcare professionals (n = 10). The tool enabled health professionals to identify and gain an understanding of the needs of the patients, specifically in relation to the physical healthcare needs. Differences, however, between the analysis of the tool documentation and focus group responses were identified in particular areas. For example, 59 (68·8%) respondents had discussed preferred priorities of care with the patient; however, focus group comments revealed participants had concerns around this. Similarly, whilst over half of responses (n = 50; 57·5%) had considered a prognostic clinical indicator for the patient as an action, focus group results indicated questions around healthcare professionals' knowledge and perceived usefulness of such indicators. Positive aspects of the tool were that it was easy to understand and captured the needs of individuals. Negative aspects of the tool were that it was repetitive and the experience of assessors required consideration. The tool evaluation identified questions regarding holistic assessment in palliative care practice and the importance of communication. A holistic assessment tool can support patient assessment and identification of patients' needs in the 'real world' of palliative care practice, but the 'tool' is merely an aid to assist professionals to
Bullen, Tracey; Rosenberg, John P; Smith, Bradley; Maher, Kate
Improving symptom management for palliative care patients has obvious benefits for patients and advantages for the clinicians, as workload demands and work-related stress can be reduced when the emergent symptoms of patients are managed in a timely manner. The use of emergency medication kits (EMKs) can provide such timely symptom relief. The purpose of this study was to conduct a survey of a local service to examine views on medication management before and after the implementation of an EMK and to conduct a nationwide prevalence survey examining the use of EMKs in Australia. Most respondents from community palliative care services indicated that EMKs were not being supplied to palliative care patients but believed such an intervention could improve patient care. © The Author(s) 2014.
Freire de Castro Silva, Sandro Luís; Gonçalves, Antônio Augusto; Cheng, Cezar; Fernandes Martins, Carlos Henrique
Mobile devices frequently used in other specialties can find great utility in palliative care. For healthcare professionals, the use of mobile technology not only can bring additional resources to the care, but it can actually radically change the cancer remote care practices. The Brazilian National Cancer Institute (INCA) has developed the largest cancer home care program in Latin America, which currently benefits more than 500 patients. The purpose of this paper is to show the development of an ICT environment of mobile applications developed to support the palliative cancer care program at INCA.
Mousing, Camilla Askov; Timm, Helle; Lomborg, Kirsten
. Non-awareness and organisational barriers led to difficulties in identifying PC needs and reluctance to initiate conversations about PC. CONCLUSION: The findings indicate a need for education, training and reflection among professional caregivers in home care. Also, organisational changes may...... vague understanding of palliative care and lack of knowledge about the disease. Organisational barriers, such as lack of time and continuity in patient care and lack of opportunity to discuss palliative care and lack of peer learning were experienced as challenging in the provision of palliative care...... be needed to reduce the barriers to palliative care. This article is protected by copyright. All rights reserved....
Einstein, David J; DeSanto-Madeya, Susan; Gregas, Matthew; Lynch, Jessica; McDermott, David F; Buss, Mary K
Patients with advanced cancer benefit from early involvement of palliative care. The ideal method of palliative care integration remains to be determined, as does its effectiveness for patients treated with targeted and immune-based therapies. We studied the impact of an embedded palliative care team that saw patients in an academic oncology clinic specializing in targeted and immune-based therapies. Patients seen on a specific day accessed the embedded model, on the basis of automatic criteria; patients seen other days could be referred to a separate palliative care clinic (usual care). We abstracted data from the medical records of 114 patients who died during the 3 years after this model's implementation. Compared with usual care (n = 88), patients with access to the embedded model (n = 26) encountered palliative care as outpatients more often ( P = .003) and earlier (mean, 231 v 109 days before death; P 7 days before death-a core Quality Oncology Practice Initiative metric-was higher in the embedded model (odds ratio, 5.60; P = .034). Place of death ( P = .505) and end-of-life chemotherapy (odds ratio, 0.361; P = .204) did not differ between the two arms. A model of embedded and automatically triggered palliative care among patients treated exclusively with targeted and immune-based therapies was associated with significant improvements in use and timing of palliative care and hospice, compared with usual practice.
Pain and palliative care in HIV/AIDS patients. Olaitan A Soyannwo. Abstract. No Abstract. Discovery and Innovation Vol. 17, 2005: 50-51. Full Text: EMAIL FULL TEXT EMAIL FULL TEXT · DOWNLOAD FULL TEXT DOWNLOAD FULL TEXT · http://dx.doi.org/10.4314/dai.v17i2.15704 · AJOL African Journals Online. HOW TO ...
Pidgeon, Tanya M; Johnson, Claire E; Lester, Leanne; Currow, David; Yates, Patsy; Allingham, Samuel F; Bird, Sonia; Eagar, Kathy
ABSTRACTBackground:Caregiver satisfaction and experience surveys help health professionals to understand, measure, and improve the quality of care provided for patients and their families. Our aim was to explore caregiver perceptions of the care received from Australian specialist palliative care services. Caregivers of patients receiving palliative care in services registered with Australia's Palliative Care Outcomes Collaboration were invited to participate in a caregiver survey. The survey included the FAMCARE-2 and four items from the Ongoing Needs Identification: Caregiver Profile questionnaire. Surveys were completed by 1,592 caregivers from 49 services. Most respondents reported high satisfaction and positive experiences. Caregivers receiving care from community-based palliative care teams were less satisfied with the management of physical symptoms and comfort (odds ratio [OR] = 0.29; 95% confidence interval [CI95%] = 0.14, 0.59), with patient psychological care (OR = 0.56; CI95% = 0.32, 0.98), and with family support (OR = 0.52; CI95% = 0.35, 0.77) than caregivers of patients in an inpatient setting. If aged over 60 years, caregivers were less likely to have their information needs met regarding available support services (OR = 0.98; CI95% = 0.97, 0.98) and carer payments (OR = 0.99; CI95% = 0.98, 1.00). Also, caregivers were less likely to receive adequate information about carer payments if located in an outer regional area (OR = 0.41; CI95% = 0.25, 0.64). With practical training, caregivers receiving care from community services reported inadequate information provision to support them in caring for patients (OR = 0.60; CI95% = 0.45, 0.81). While our study identified caregivers as having positive and satisfactory experiences across all domains of care, there is room for improvement in the delivery of palliative care across symptom management, as well as patient and caregiver support, especially in community settings. Caregiver surveys can facilitate the
van Deijck, Rogier H P D; Hasselaar, Jeroen G J; Verhagen, Stans C A H H V M; Vissers, Kris C P; Koopmans, Raymond T C M
Knowledge of determinants that are associated with the administration of continuous palliative sedation (CPS) helps physicians identify patients who are at risk of developing refractory symptoms, thereby enabling proactive care planning. This study aims to explore which patient-related factors at admission are associated with receiving CPS later in the terminal phase of life. A prospective multicenter observational study was performed in six Dutch hospices and three nursing home-based palliative care units. The association between patient-related variables at admission (age, gender, diagnosis, use of opioids or psycholeptics, number of medications, Karnofsky Performance Status scale score, Edmonton Symptom Assessment System distress score, and Glasgow Coma Scale score) and the administration of CPS at the end of life was analyzed. A total of 467 patients died during the study period, of whom 130 received CPS. In univariate analysis, statistically significant differences were noted between the sedated and nonsedated patients with respect to younger age (P = 0.009), malignancy as a diagnosis (P = 0.05), higher Karnofsky Performance Status score (P = 0.03), the use of opioids (P Palliative Medicine. Published by Elsevier Inc. All rights reserved.
Swart, Siebe J; Rietjens, Judith A C; van Zuylen, Lia; Zuurmond, Wouter W A; Perez, Roberto S G M; van der Maas, Paul J; van Delden, Johannes J M; van der Heide, Agnes
Palliative care is often focused on cancer patients. Palliative sedation at the end of life is an intervention to address severe suffering in the last stage of life. To study the practice of continuous palliative sedation for both cancer and noncancer patients. In 2008, a structured questionnaire was sent to 1580 physicians regarding their last patient receiving continuous sedation until death. A total of 606 physicians (38%) filled out the questionnaire, of whom 370 (61%) reported on their last case of continuous sedation (cancer patients: n=282 [76%] and noncancer patients: n=88 [24%]). More often, noncancer patients were older, female, and not fully competent. Dyspnea (odds ratio [OR]=2.13; 95% confidence interval [CI]: 1.22, 3.72) and psychological exhaustion (OR=2.64; 95% CI: 1.26, 5.55) were more often a decisive indication for continuous sedation for these patients. A palliative care team was consulted less often for noncancer patients (OR=0.45; 95% CI: 0.21, 0.96). Also, preceding sedation, euthanasia was discussed less often with noncancer patients (OR=0.42; 95% CI: 0.24, 0.73), whereas their relatives more often initiated discussion about euthanasia than relatives of cancer patients (OR=3.75; 95% CI: 1.26, 11.20). The practice of continuous palliative sedation in patients dying of cancer differs from patients dying of other diseases. These differences seem to be related to the less predictable course of noncancer diseases, which may reduce physicians' awareness of the imminence of death. Increased attention to noncancer diseases in palliative care practice and research is, therefore, crucial as is more attention to the potential benefits of palliative care consultation. Copyright © 2012 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
Shahid, Shaouli; Bessarab, Dawn; van Schaik, Katherine D; Aoun, Samar M; Thompson, Sandra C
Aboriginal Australians have a lower rate of utilisation of palliative care services than the general population. This study aimed to explore care providers' experiences and concerns in providing palliative care for Aboriginal people, and to identify opportunities for overcoming gaps in understanding between them and their Aboriginal patients and families. In-depth, qualitative interviews with urban, rural and remote palliative care providers were undertaken in inpatient and community settings in Western Australia. Interviews were audio-recorded, transcribed verbatim and coded independently by two researchers with QSR NVivo 10 software used to help manage data. Data analysis was informed by multiple theoretical standpoints, including the social ecological model, critical cultural theories and the 'cultural security' framework. Thematic analysis was carried out that identified patterns within data. Fifteen palliative care providers were interviewed. Overall they reported lack of understanding of Aboriginal culture and being uncertain of the needs and priorities of Aboriginal people during end-of-life care. According to several participants, very few Aboriginal people had an understanding of palliative care. Managing issues such as anger, denial, the need for non-medical support due to socioeconomic disadvantage, and dealing with crises and conflicts over funeral arrangements were reported as some of the tensions between Aboriginal patients and families and the service providers. Early referral to palliative care is important in demonstrating and maintaining a caring therapeutic relationship. Paramount to meeting the needs for Aboriginal patients was access to appropriate information and logistical, psychological and emotional support. These were often seen as essential but additional to standard palliative care services. The broader context of Aboriginal history and historical distrust of mainstream services was seen to impinge on Aboriginal people's willingness and
Background Aboriginal Australians have a lower rate of utilisation of palliative care services than the general population. This study aimed to explore care providers’ experiences and concerns in providing palliative care for Aboriginal people, and to identify opportunities for overcoming gaps in understanding between them and their Aboriginal patients and families. Methods In-depth, qualitative interviews with urban, rural and remote palliative care providers were undertaken in inpatient and community settings in Western Australia. Interviews were audio-recorded, transcribed verbatim and coded independently by two researchers with QSR NVivo 10 software used to help manage data. Data analysis was informed by multiple theoretical standpoints, including the social ecological model, critical cultural theories and the ‘cultural security’ framework. Thematic analysis was carried out that identified patterns within data. Results Fifteen palliative care providers were interviewed. Overall they reported lack of understanding of Aboriginal culture and being uncertain of the needs and priorities of Aboriginal people during end-of-life care. According to several participants, very few Aboriginal people had an understanding of palliative care. Managing issues such as anger, denial, the need for non-medical support due to socioeconomic disadvantage, and dealing with crises and conflicts over funeral arrangements were reported as some of the tensions between Aboriginal patients and families and the service providers. Conclusion Early referral to palliative care is important in demonstrating and maintaining a caring therapeutic relationship. Paramount to meeting the needs for Aboriginal patients was access to appropriate information and logistical, psychological and emotional support. These were often seen as essential but additional to standard palliative care services. The broader context of Aboriginal history and historical distrust of mainstream services was seen to
Aldridge, Melissa D; Hasselaar, Jeroen; Garralda, Eduardo; van der Eerden, Marlieke; Stevenson, David; McKendrick, Karen; Centeno, Carlos; Meier, Diane E
Early integration of palliative care into the management of patients with serious disease has the potential to both improve quality of life of patients and families and reduce healthcare costs. Despite these benefits, significant barriers exist in the United States to the early integration of palliative care in the disease trajectory of individuals with serious illness. To provide an overview of the barriers to more widespread palliative care integration in the United States. A literature review using PubMed from 2005 to March 2015 augmented by primary data collected from 405 hospitals included in the Center to Advance Palliative Care's National Palliative Care Registry for years 2012 and 2013. We use the World Health Organization's Public Health Strategy for Palliative Care as a framework for analyzing barriers to palliative care integration. We identified key barriers to palliative care integration across three World Health Organization domains: (1) education domain: lack of adequate education/training and perception of palliative care as end-of-life care; (2) implementation domain: inadequate size of palliative medicine-trained workforce, challenge of identifying patients appropriate for palliative care referral, and need for culture change across settings; (3) policy domain: fragmented healthcare system, need for greater funding for research, lack of adequate reimbursement for palliative care, and regulatory barriers. We describe the key policy and educational opportunities in the United States to address and potentially overcome the barriers to greater integration of palliative care into the healthcare of Americans with serious illness. © The Author(s) 2015.
based palliative care (including paediatric palliative care) is available to patients in rural ... reported that one of the most distressing tasks a nurse has to carry out is telling any .... die, as a miracle (such as a cure) is presented as a possibility.
Thompson, Jo; Brown, Jayne; Davies, Andrew
This report describes a service evaluation of the 'added value' of routine specialist palliative care team (SPCT) involvement with patients on the Liverpool Care Pathway for the Dying Patient (LCP). In the authors' hospital, patients that are commenced on the LCP are routinely referred to the SPCT. They are reviewed on the day of referral and then at least every other day, depending on the clinical situation. The data for this report was obtained by reviewing the SPCT's clinical database and the patients' LCP proformas. The SPCT intervened in the care of 80% of 158 newly referred patients, e.g. for alteration of continuous subcutaneous infusion (23%) or alteration of use of non-pharmacological interventions (21%). Furthermore, 11% of patients were taken off the LCP, around one quarter of whom were later put back on. The authors' model of care could overcome many of the issues relating to the LCP and would ameliorate the developing vacuum of care for patients at the end of life.
Klop, Hanna T; de Veer, Anke J E; van Dongen, Sophie I; Francke, Anneke L; Rietjens, Judith A C; Onwuteaka-Philipsen, Bregje D
Homeless people often suffer from complex and chronic comorbidities, have high rates of morbidity and die at much younger ages than the general population. Due to a complex combination of physical, psychosocial and addiction problems at the end of life, they often have limited access to palliative care. Both the homeless and healthcare providers experience a lot of barriers. Therefore, providing palliative care that fits the needs and concerns of the homeless is a challenge to healthcare providers. This systematic review aims to summarize evidence about the concerns, palliative care needs and preferences of homeless people, as well as barriers and facilitators for delivering high quality palliative care. PubMed, Embase, PsycINFO, CINAHL and Web of Science were searched up to 10 May 2016. Included were studies about homeless people with a short life expectancy, their palliative care needs and the palliative care provided, that were conducted in Western countries. Data were independently extracted by two researchers using a predefined extraction form. Quality was assessed using a Critical Appraisal instrument. The systematic literature review was based on the PRISMA statement. Twenty-seven publications from 23 different studies met the inclusion criteria; 15 studies were qualitative and eight were quantitative. Concerns of the homeless often related to end-of-life care not being a priority, drug dependence hindering adequate care, limited insight into their condition and little support from family and relatives. Barriers and facilitators often concerned the attitude of healthcare professionals towards homeless people. A respectful approach and respect for dignity proved to be important in good quality palliative care. A patient-centred, flexible and low-threshold approach embodying awareness of the concerns of homeless people is needed so that appropriate palliative care can be provided timely. Training, education and experience of professionals can help to
Hallford, David J; McCabe, Marita P; Mellor, David; Davison, Tanya E; Goldhammer, Denisa L; George, Kuruvilla; Storer, Shane
Clinical depression is highly prevalent yet under-detected and under-treated in palliative care settings and is associated with a number of adverse medical and psychological outcomes for patients and their family members. This article presents a study protocol to evaluate a training intervention for non-physician palliative care staff to improve the recognition of depression and provide support for depressed patients and their family members. Details of the hypotheses and expected outcomes, study design, training program development and evaluation measures are described. A randomised controlled trial will be implemented across two palliative care services to evaluate the "Training program for professional carers to recognise and manage depression in palliative care settings". Pre-, post- and three-month follow-up data will be collected to assess: the impact of the training on the knowledge, attitudes, self-efficacy and perceived barriers of palliative care staff when working with depression; referral rates for depression; and changes to staff practices. Quantitative and qualitative methods, in the form of self-report questionnaires and interviews with staff and family members, will be used to evaluate the effectiveness of the intervention. This study will determine the effectiveness of an intervention that aims to respond to the urgent need for innovative programs to target depression in the palliative care setting. The expected outcome of this study is the validation of an evidence-based training program to improve staff recognition and appropriate referrals for depression, as well as improve psychosocial support for depressed patients and their family members. Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12610000183088.
Priya Darshini Kulkarni
Full Text Available The reason that probably prompted Dame Cicely Saunders to launch the palliative care movement was the need to move away from the impersonal, technocratic approach to death that had become the norm in hospitals after the Second World War. Palliative care focuses on relieving the suffering of patients and families. Not limited to just management of pain, it includes comprehensive management of any symptom, which affects the quality of life. Care is optimized through early initiation and comprehensive implementation throughout the disease trajectory. Effective palliative care at the outset can help accelerate a positive clinical outcome. At the end of life, it can enhance the opportunity for the patient and family to achieve a sense of growth, resolve differences, and find a comfortable closure. It helps to reduce the suffering and fear associated with dying and prepares the family for bereavement.
Sison, Julian; Tran, Hung; Margol, Ashley; Tiwari, Nishant; Garcia, Karla M; Cotter, Jennifer; Kiehna, Erin; Olch, Arthur J; Wong, Kenneth
Diffuse intrinsic pontine gliomas (DIPGs) are rare but devastating brain tumors that occur primarily in children. These gliomas have poor prognoses and present options focus on palliation of symptoms and prolongation of life. Here, we present a case of a 16-year-old female diagnosed with a DIPG whose age group has been mostly left out of discussions regarding psychosocial support options. This report is meant to start a conversation about the different support options available at our institution that have shown promising results in the literature for palliative care applications. These options can include camps for patients with brain tumors, psychological counseling, the Ronald McDonald House, and other psychosocial programs. Many of these programs can be tailored to meet the specific needs of adolescent and young adult (AYA) patients and will hopefully be integrated into a comprehensive palliative care regimen in future studies.
Swart, S.J.; Rietjens, J.A.C.; van Zuylen, L.; Zuurmond, W.W.A.; Perez, R.S.G.M.; van der Maas, P.J.; van Delden, J.J.M.; van der Heide, A.
Context: Palliative care is often focused on cancer patients. Palliative sedation at the end of life is an intervention to address severe suffering in the last stage of life. Objectives: To study the practice of continuous palliative sedation for both cancer and noncancer patients. Methods: In 2008,
Schmalz, Oliver; Strapatsas, Tobias; Alefelder, Christof; Grebe, Scott Oliver
Methicillin-resistant Staphylococcus aureus is a common organism in hospitals worldwide and is associated with morbidity and mortality. However, little is known about the prevalence in palliative care patients. Furthermore, there is no standardized screening protocol or treatment for patients for whom therapy concentrates on symptom control. Examining the prevalence of methicillin-resistant Staphylococcus aureus in palliative care patients as well as the level of morbidity and mortality. We performed a prospective study where methicillin-resistant Staphylococcus aureus screening was undertaken in 296 consecutive patients within 48 h after admission to our palliative care unit. Medical history was taken, clinical examination was performed, and the Karnofsky Performance Scale and Palliative Prognostic Score were determined. Prevalence of Methicillin-resistant Staphylococcus aureus was compared to data of general hospital patients. In total, 281 patients were included in the study having a mean age of 69.7 years (standard deviation = 12.9 years) and an average Karnofsky Performance Scale between 30% and 40%. The mean length of stay was 9.7 days (standard deviation = 7.6 days). A total of 24 patients were methicillin-resistant Staphylococcus aureus positive on the first swab. Median number of swabs was 2. All patients with a negative methicillin-resistant Staphylococcus aureus swab upon admission remained Methicillin-resistant Staphylococcus aureus negative in all subsequent swabs. Our study suggests that the prevalence of Methicillin-resistant Staphylococcus aureus among patients in an in-hospital palliative care unit is much higher than in other patient populations. © The Author(s) 2016.
Astvad, Karen; Johansen, Helle Krogh; Høiby, Niels
BACKGROUND: Oropharyngeal candidiasis (OPC) is a significant cause of morbidity, especially among patients with advanced cancer. The incidence and significance of yeast carriage and OPC in the palliative care setting in Denmark is unknown. The best diagnostic strategy and treatment regimen has...... positive and negative predictive value (∼50%). Candida albicans accounted for half of the isolates cultured. No C. albicans isolate displayed acquired fluconazole resistance; however, 3 out of 12 isolates of normally fluconazole-susceptible species were fluconazole resistant. These were all from patients...... recently treated with azoles. CONCLUSIONS: In total, 52% of culture-positive patients harbored at least one isolate with innately or acquired decreased fluconazole susceptibility. Therefore, susceptibility testing appears recommendable for patients with clinical signs of OPC....
Cerana, Maria Agustina; Park, Minjeong; Hess, Kenneth; Bruera, Eduardo
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 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
Pype, Peter; Teuwen, Inge; Mertens, Fien; Sercu, Marij; De Sutter, An
Palliative sedation is a therapeutic option to control refractory symptoms in terminal palliative patients. This study aims at describing the occurrence and characteristics of suboptimal palliative sedations in primary care and at exploring the way general practitioners (GPs) experience suboptimal palliative sedation in their practice. We conducted a mixed methods study with a quantitative prospective survey in primary care and qualitative semi-structured interviews with GPs. The research team defined suboptimal palliative sedation as a time interval until deep sleep >1.5 h and/ or >2 awakenings after the start of the unconsciousness. Descriptive statistics were calculated on the quantitative data. Thematic analysis was used to analyse interview transcripts. We registered 63 palliative sedations in 1181 home deaths, 27 forms were completed. Eleven palliative sedations were suboptimal: eight due to the long time span until deep sleep; three due the number of unintended awakenings. GPs' interview analysis revealed two major themes: the shifting perception of failure and the burden of responsibility. Suboptimal palliative sedation occurs frequently in primary palliative care. Efficient communication towards family members is needed to prevent them from having unrealistic expectations and to prevent putting pressure on the GP to hasten the procedure. Sharing the burden of decision-making during the procedure with other health care professionals might diminish the heavy responsibility as perceived by GPs.
Warth, Marco; Keßler, Jens; Hillecke, Thomas K; Bardenheuer, Hubert J
Music therapy has been used successfully for over 30 years as part of palliative care programs for severely ill patients. There is nonetheless a lack of high-quality studies that would enable an evidence-based evaluation of its psychological and physiological effects. In a randomized controlled trial, 84 hospitalized patients in palliative care were assigned to one of two treatment arms--music therapy and control. The music therapy intervention consisted of two sessions of live music-based relaxation exercises; the patients in the control group listened to a verbal relaxation exercise. The primary endpoints were self-ratings of relaxation, well-being, and acute pain, assessed using visual analog scales. Heart rate variability and health-related quality of life were considered as secondary outcomes. The primary data analysis was performed according to the intention-to-treat principle. Analyses of covariance revealed that music therapy was more effective than the control treatment at promoting relaxation (F = 13.7; p Music therapy did not differ from control treatment with respect to pain reduction (F = 0.4; p = 0.53), but it led to a significantly greater reduction in the fatigue score on the quality-of-life scale (F = 4.74; p = 0.03). Music therapy is an effective treatment with a low dropout rate for the promotion of relaxation and well-being in terminally ill persons undergoing palliative care.
Whittall, Dawn; Lee, Susan; O'Connor, Margaret
To review factors shaping volunteering in palliative care in Australian rural communities using Australian and International literature. Identify gaps in the palliative care literature and make recommendations for future research. A comprehensive literature search was conducted using Proquest, Scopus, Sage Premier, Wiley online, Ovid, Cochran, Google Scholar, CINAHL and Informit Health Collection. The literature was synthesised and presented in an integrated thematic narrative. Australian Rural communities. While Australia, Canada, the United States (US) and the United Kingdom (UK) are leaders in palliative care volunteer research, limited research specifically focuses on volunteers in rural communities with the least occurring in Australia. Several interrelated factors influence rural palliative care provision, in particular an increasingly ageing population which includes an ageing volunteer and health professional workforce. Also current and models of palliative care practice fail to recognise the innumerable variables between and within rural communities such as distance, isolation, lack of privacy, limited health care services and infrastructure, and workforce shortages. These issues impact palliative care provision and are significant for health professionals, volunteers, patients and caregivers. The three key themes of this integrated review include: (i) Geography, ageing rural populations in palliative care practice, (ii) Psychosocial impact of end-end-of life care in rural communities and (iii) Palliative care models of practice and volunteering in rural communities. The invisibility of volunteers in rural palliative care research is a concern in understanding the issues affecting the sustainability of quality palliative care provision in rural communities. Recommendations for future Australian research includes examination of the suitability of current models of palliative care practice in addressing the needs of rural communities; the recruitment
Full Text Available Palliative care is nowadays essential in nursing care, due to the increasing number of patients who require attention in final stages of their life. Nurses need to acquire specific knowledge and abilities to provide quality palliative care. Palliative Care Quiz for Nurses is a questionnaire that evaluates their basic knowledge about palliative care. The Palliative Care Quiz for Nurses (PCQN is useful to evaluate basic knowledge about palliative care, but its adaptation into the Spanish language and the analysis of its effectiveness and utility for Spanish culture is lacking.To report the adaptation into the Spanish language and the psychometric analysis of the Palliative Care Quiz for Nurses.The Palliative Care Quiz for Nurses-Spanish Version (PCQN-SV was obtained from a process including translation, back-translation, comparison with versions in other languages, revision by experts, and pilot study. Content validity and reliability of questionnaire were analyzed. Difficulty and discrimination indexes of each item were also calculated according to Item Response Theory (IRT.Adequate internal consistency was found (S-CVI = 0.83; Cronbach's alpha coefficient of 0.67 and KR-20 test result of 0,72 reflected the reliability of PCQN-SV. The questionnaire had a global difficulty index of 0,55, with six items which could be considered as difficult or very difficult, and five items with could be considered easy or very easy. The discrimination indexes of the 20 items, show us that eight items are good or very good while six items are bad to discriminate between good and bad respondents.Although in shows internal consistency, reliability and difficulty indexes similar to those obtained by versions of PCQN in other languages, a reformulation of the items with lowest content validity or discrimination indexes and those showing difficulties with their comprehension is an aspect to take into account in order to improve the PCQN-SV.The PCQN-SV is a useful
Ingersoll, Luke T; Saeed, Fahad; Ladwig, Susan; Norton, Sally A; Anderson, Wendy; Alexander, Stewart C; Gramling, Robert
Maximizing value in palliative care requires continued development and standardization of communication quality indicators. To describe the basic epidemiology of a newly-adopted patient-centered communication quality indicator for hospitalized palliative care patie9nts with advanced cancer. Cross-sectional analysis of 207 advanced cancer patients who received palliative care consultation at two medical centers in the United States. Participants completed the Heard & Understood quality indicator immediately before and the day following the initial palliative care consultation: "Over the past two days ["24 hours" for the post-consultation version], how much have you felt heard and understood by the doctors, nurses and hospital staff? Completely/Quite a Bit/Moderately/Slightly/Not at All". We categorized "Completely" as indicating ideal quality. Approximately one-third indicated ideal Heard & Understood quality before palliative care consultation. Age, financial security, emotional distress, preferences for comfort-longevity tradeoffs at end-of-life, and prognosis expectations were associated with pre-consultation quality. Among those with less-than-ideal quality at baseline, 56% rated feeling more Heard & Understood the day following palliative care consultation. The greatest pre-post improvement was among people who had unformed end-of-life treatment preferences or who reported having "no idea" about their prognosis at baseline. Most patients felt incompletely heard and understood at the time of referral to palliative care consultation and more than half improved following consultation. Feeling heard and understood is an important quality indicator sensitive to interventions to improve care and key variations in the patient experience. Copyright © 2018. Published by Elsevier Inc.
DiMartino, Lisa D; Weiner, Bryan J; Mayer, Deborah K; Jackson, George L; Biddle, Andrea K
Frequent emergency department (ED) visits are an indicator of poor quality of cancer care. Coordination of care through the use of palliative care teams may limit aggressive care and improve outcomes for patients with cancer at the end of life. To systematically review the literature to determine whether palliative care interventions implemented in the hospital, home, or outpatient clinic are more effective than usual care in reducing ED visits among patients with cancer at the end of life. PubMed, EMBASE, and CINAHL databases were searched from database inception to May 7, 2014. Only randomized/non-randomized controlled trials (RCTs) and observational studies examining the effect of palliative care interventions on ED visits among adult patients with cancer with advanced disease were considered. Data were abstracted from the articles that met all the inclusion criteria. A second reviewer independently abstracted data from 2 articles and discrepancies were resolved. From 464 abstracts, 2 RCTs, 10 observational studies, and 1 non-RCT/quasi-experimental study were included. Overall there is limited evidence to support the use of palliative care interventions to reduce ED visits, although studies examining effect of hospice care and those conducted outside of the United States reported a statistically significant reduction in ED visits. Evidence regarding whether palliative care interventions implemented in the hospital, home or outpatient clinic are more effective than usual care at reducing ED visits is not strongly substantiated based on the literature reviewed. Improvements in the quality of reporting for studies examining the effect of palliative care interventions on ED use are needed.
Podymow, Tiina; Turnbull, Jeffrey; Coyle, Doug
The homeless have high rates of mortality, but live in environments not conducive to terminal care. Traditional palliative care hospitals may be reluctant to accept such patients, due to behavior or lifestyle concerns. The Ottawa Inner City Health Project (OICHP) is a pilot study to improve health care delivery to homeless adults. This is a retrospective analysis of a cohort of terminally ill homeless individuals and the effectiveness of shelter-based palliative care. As proof of principle, a cost comparison was performed. 28 consecutive homeless terminally ill patients were admitted and died at a shelter-based palliative care hospice. Demographics, diagnoses at admission and course were recorded. Burden of illness was assessed by medical and psychiatric diagnoses, addictions, Karnofsky scale and symptom management. An expert panel was convened to identify alternate care locations. Using standard costing scales, direct versus alternate care costs were compared. 28 patients had a mean age 49 years; average length of stay 120 days. DIAGNOSES: liver disease 43%, HIV/AIDS 25%, malignancy 25% and other 8%. Addiction to drugs or alcohol and mental illness in 82% of patients. Karnofsky performance score mean 40 +/- 16.8. Pain management with continuous opiates in 71%. The majority reunited with family. Compared to alternate care locations, the hospice projected 1.39 million dollars savings for the patients described. The homeless terminally ill have a heavy burden of disease including physical illness, psychiatric conditions and addictions. Shelter-based palliative care can provide effective end-of-life care to terminally ill homeless individuals at potentially substantial cost savings.
Cain, Cindy L; Surbone, Antonella; Elk, Ronit; Kagawa-Singer, Marjorie
Palliative care is gaining acceptance across the world. However, even when palliative care resources exist, both the delivery and distribution of services too often are neither equitably nor acceptably provided to diverse population groups. The goal of this study was to illustrate tensions in the delivery of palliative care for diverse patient populations to help clinicians to improve care for all. We begin by defining and differentiating culture, race, and ethnicity, so that these terms-often used interchangeably-are not conflated and are more effectively used in caring for diverse populations. We then present examples from an integrative literature review of recent research on culture and palliative care to illustrate both how and why varied responses to pain and suffering occur in different patterns, focusing on four areas of palliative care: the formation of care preferences, communication patterns, different meanings of suffering, and decision-making processes about care. For each area, we provide international and multiethnic examples of variations that emphasize the need for personalization of care and the avoidance of stereotyping beliefs and practices without considering individual circumstances and life histories. We conclude with recommendations for improving palliative care research and practice with cultural perspectives, emphasizing the need to work in partnerships with patients, their family members, and communities to identify and negotiate culturally meaningful care, promote quality of life, and ensure the highest quality palliative care for all, both domestically and internationally. Copyright © 2018 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
Séfora Gomez Portela
Full Text Available This research aimed at understanding and reflecting on the perceptions of occupational therapists regarding the implementation of palliative care in home care. This is an exploratory, qualitative study, through semi-structured interviews, conducted in the second semester of 2012 with eight occupational therapists with experience in palliative care in the city of São Paulo. Content analysis identified four themes: characterization and professional trajectory in the field, understanding the concepts of palliative care, home care and palliative care, and occupational therapy and palliative care in home care. The results suggest that the role of the occupational therapist in this field has taken place at different levels of health care, being addressed to people with varying needs. The use of the concept of palliative care by the interviewees exceeds the notion of end of life, following the changes in the epidemiological transition. They understand that professional services follow the trend of national palliative care services with focus on specialized levels, but manifest the importance of its implementation in primary and home care. Among the barriers to practice, they identified the complexity of “being at home “, peculiarities of palliative care with high cost demands, lack of infrastructure and implementation of the current policy. Professional training and scientific roduction in the area were viewed as inadequate, although they identified a call for change. The interviewees recognized palliative care in home care as a strong professional field, but one still requiring study and discussions regarding its limits and conditions of implementation, especially in the Unified Health System.
Kim, Sook-Nam; Choi, Soon-Ock; Shin, Seong Hoon; Ryu, Ji-Sun; Baik, Jeong-Won
A feasible palliative care model for advance cancer patients is needed in Korea with its rapidly aging population and corresponding increase in cancer prevalence. This study describes the process involved in the development of a community-based palliative care (CBPC) model implemented originally in a Busan pilot project. The model development included steps I and II of the pilot project, identification of the service types, a survey exploring the community demand for palliative care, construction of an operational infrastructure, and the establishment of a service delivery system. Public health centers (including Busan regional cancer centers, palliative care centers, and social welfare centers) served as the regional hubs in the development of a palliative care model. The palliative care project included the provision of palliative care, establishment of a support system for the operations, improvement of personnel capacity, development of an educational and promotional program, and the establishment of an assessment system to improve quality. The operational infrastructure included a service management team, provision teams, and a support team. The Busan Metropolitan City CBPC model was based on the principles of palliative care as well as the characteristics of public health centers that implemented the community health projects. The potential use of the Busan CBPC model in Korea should be explored further through service evaluations.
Smith, Alexander K; Thai, Julie N; Bakitas, Marie A; Meier, Diane E; Spragens, Lynn H; Temel, Jennifer S; Weissman, David E; Rabow, Michael W
Many health care organizations are interested in instituting a palliative care clinic. However, there are insufficient published data regarding existing practices to inform the development of new programs. Our objective was to obtain in-depth information about palliative care clinics. We conducted a cross-sectional survey of 20 outpatient palliative care practices in diverse care settings. The survey included both closed- and open-ended questions regarding practice size, utilization of services, staffing, referrals, services offered, funding, impetus for starting, and challenges. Twenty of 21 (95%) practices responded. Practices self-identified as: hospital-based (n=7), within an oncology division/cancer center (n=5), part of an integrated health system (n=6), and hospice-based (n=2). The majority of referred patients had a cancer diagnosis. Additional common diagnoses included chronic obstructive pulmonary disease, neurologic disorders, and congestive heart failure. All practices ranked "pain management" and "determining goals of care" as the most common reasons for referrals. Twelve practices staffed fewer than 5 half-days of clinic per week, with 7 operating only one half-day per week. Practices were staffed by a mixture of physicians, advanced practice nurses or nurse practitioners, nurses, or social workers. Eighteen practices expected their practice to grow within the next year. Eleven practices noted a staffing shortage and 8 had a wait time of a week or more for a new patient appointment. Only 12 practices provide 24/7 coverage. Billing and institutional support were the most common funding sources. Most practices described starting because inpatient palliative providers perceived poor quality outpatient care in the outpatient setting. The most common challenges included: funding for staffing (11) and being overwhelmed with referrals (8). Once established, outpatient palliative care practices anticipate rapid growth. In this context, outpatient practices
Spineli, Vívian Marina Calixto Damasceno; Kurashima, Andrea Yamaguchi; De Gutiérrez, Maria Gaby Rivero
Our aim was to describe the process of palliative sedation from the point of view of physicians and nurses working in palliative care in Brazil. Ours was a descriptive study conducted between May and December of 2011, with purposeful snowball sampling of 32 physicians and 29 nurses working in facilities in Brazil that have adopted the practice of palliative care. The symptoms prioritized for an indication of palliative sedation were dyspnea, delirium, and pain. Some 65.6% of respondents believed that the survival time of a patient in the final phase was not a determining factor for the indication of this measure, and that the patient, family, and healthcare team should participate in the decision-making process. For 42.6% of these professionals, the opinion of the family was the main barrier to an indication of this therapy. The opinion of the physicians and nurses who participated in this study converged with the principal national and international guidelines on palliative sedation. However, even though it is a therapy that has been adopted in palliative care, it remains a controversial practice.
Byock, Ira; Twohig, Jeanne Sheils; Merriman, Melanie; Collins, Karyn
Promoting Excellence in End-of Life Care, a national program of The Robert Wood Johnson Foundation, funded 22 demonstration projects representing a wide range of health care settings and patient populations to develop innovative models for delivering palliative care that addressed documented deficiencies in the care of patients and families facing the final stage of life. To determine the practicality (feasibility of development and operation as well as acceptance by stakeholders) of new models of care and to determine the impact of the models on access to, quality of and financing for palliative care. The program cannot report scientifically rigorous outcomes, but the grant-funded projects used a variety of methods and measures to assess acceptance of new models and their impact from the perspectives of various stakeholders, including patients and their families, clinicians, administrators and payers. While it is not possible to aggregate data across projects, the data reported to the Promoting Excellence national program office were used to describe program impact with respect to the practicality of palliative care service integration into existing clinical care settings (feasibility and acceptance by stakeholders), the availability and use of palliative care services (access), quality of care (conformance to patient expectations and accepted clinical standards) and costs of care. The 22 projects provided services in urban as well as rural settings, in integrated health systems, hospitals, outpatient clinics, cancer centers, nursing homes, renal dialysis clinics, inner city public health and safety net systems and prisons. Populations served included prison inmates, military veterans, renal dialysis patients, Native Americans, Native Alaskans, and African American patients, inner-city medically underserved patients, pediatric patients, and persons with serious mental illness patients. Hosting or adopting institutions sustained or expanded twenty of the 22 models
Viney, Linda L.; And Others
Compared quality of life of terminal cancer patients (n=182) in two palliative care units with that of those in general hospital. Patients in specialized palliative care units were found to differ from those dying in hospital, showing less indirectly expressed anger but more positive feelings. They also reported more anxiety about death but less…
Nguyen, Ly Thuy; Yates, Patsy; Osborne, Yvonne
To explore palliative care knowledge, attitudes and perceived self-competence of nurses working in oncology settings in Hanoi, Vietnam. The study employed a cross-sectional descriptive survey design. The self-administered questionnaires consisted of three validated instruments: the Expertise and Insight Test for Palliative Care, the Attitude Toward Care of the Dying Scale B and the Palliative Care Nursing Self Competence Scale. The sample consisted of 251 nurses caring for cancer patients in three oncology hospitals in Vietnam. The responses identified low scores in nurses' palliative care knowledge related to pain and other symptom management and psychological and spiritual aspects. Nurses' responses reflected discomfort in communicating about death and establishing therapeutic relationship with oncology patients who require palliative care. Additionally, nurses reported low scores in perceived self-competence when providing pain management and addressing social and spiritual domains of palliative care. The findings also revealed that nurses who had higher palliative care knowledge scores demonstrated attitudes which were more positive and expressed greater perceived self-competence. Nurses working in oncology wards need more education to develop their knowledge and skills of palliative care, especially in the areas of pain management, psychological and spiritual care, and communication.
Full Text Available This article is a case reflection of a personal encounter on the palliative care treatment required after the removal of a complicated case of a primary extra-gonadal retro-peritoneal endodermal sinus tumor (yolk sac tumor. This reflection is from the perspective of a recently graduated MD student who spent one month with an Indian pain management and palliative care team at the Institute Rotary Cancer Hospital (IRCH, All India Institute of Medical Sciences (AIIMS, New Delhi
Nyirő, Judit; Hauser, Péter; Zörgő, Szilvia; Hegedűs, Katalin
Adequate communication by medical personnel is especially important at certain points during the treatment of childhood cancer patients. To investigate the timing and manner of communication with parents concerning the introduction of palliative care in pediatric oncology. Structured interviews, containing 14 questions, were carried out with physicians working in pediatric oncology (n = 22). Codes were generated inductively with the aid of Atlas.ti 6.0 software. Interviews show a tendency of a one-step transition to palliative care following curative therapy. Another expert is usually involved in communication, most likely a psychologist. Regarding communication, there are expressions utilized or avoided, such as expressing clarity, self-defense and empathy. The communication of death and dying was the most contradictory. This was the first investigation regarding communication in pediatric palliative care in Hungary. Our results show that a modern perspective of palliative communication is present, but necessitates more time to become entrenched. Orv Hetil. 2017; 158(30): 1175-1181.
Anderson, Wendy G; Puntillo, Kathleen; Boyle, Deborah; Barbour, Susan; Turner, Kathleen; Cimino, Jenica; Moore, Eric; Noort, Janice; MacMillan, John; Pearson, Diana; Grywalski, Michelle; Liao, Solomon; Ferrell, Bruce; Meyer, Jeannette; O'Neil-Page, Edith; Cain, Julia; Herman, Heather; Mitchell, William; Pantilat, Steven
Successful and sustained integration of palliative care into the intensive care unit (ICU) requires the active engagement of bedside nurses. To describe the perspectives of ICU bedside nurses on their involvement in palliative care communication. A survey was designed, based on prior work, to assess nurses' perspectives on palliative care communication, including the importance and frequency of their involvement, confidence, and barriers. The 46-item survey was distributed via e-mail in 2013 to bedside nurses working in ICUs across the five academic medical centers of the University of California, U.S. The survey was sent to 1791 nurses; 598 (33%) responded. Most participants (88%) reported that their engagement in discussions of prognosis, goals of care, and palliative care was very important to the quality of patient care. A minority reported often discussing palliative care consultations with physicians (31%) or families (33%); 45% reported rarely or never participating in family meeting discussions. Participating nurses most frequently cited the following barriers to their involvement in palliative care communication: need for more training (66%), physicians not asking their perspective (60%), and the emotional toll of discussions (43%). ICU bedside nurses see their involvement in discussions of prognosis, goals of care, and palliative care as a key element of overall quality of patient care. Based on the barriers participants identified regarding their engagement, interventions are needed to ensure that nurses have the education, opportunities, and support to actively participate in these discussions. Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
Şenel, Gülcin; Uysal, Neşe; Oguz, Gonca; Kaya, Mensure; Kadioullari, Nihal; Koçak, Nesteren; Karaca, Serife
Introductıon: Delirium is a complex but common disorder in palliative care with a prevalence between 13% and 88% but a particular frequency at the end of life yet often remains insufficiently diagnosed and managed. The aim of our study is to determine the frequency of delirium and identify factors associated with delirium at palliative care unit. Two hundred thirteen consecutive inpatients from October 1, 2012, to March 31, 2013, were studied prospectively. Age, gender, Palliative Performance Scale (PPS), Palliative Prognostic Index (PPI), length of stay in hospital, and delirium etiology and subtype were recorded. Delirium was diagnosed with using Delirium Rating Scale (DRS) and Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revision ( DSM-IV TR) criteria. The incidence of delirium among the patients with cancer was 49.8%. Mean age was 60.3 ± 14.8 (female 41%, male 59%, PPS 39.8%, PPI 5.9 ± 3.0, length of stay in hospital 8.6 ± 6.9 days). Univariate logistic regression analysis indicated that use of opioids, anticonvulsants, benzodiazepines, steroids, polypharmacy, infection, malnutrition, immobilization, sleep disturbance, constipation, hyperbilirubinemia, liver/renal failure, pulmonary failure/hypoxia, electrolyte imbalance, brain cancer/metastases, decreased PPS, and increased PPI were risk factors. Subtypes of delirium included hypoactive 49%, mixed 41%, and hyperactive 10%. The communicative impediments associated with delirium generate distress for the patient, their family, and health care practitioners who might have to contend with agitation and difficulty in assessing pain and other symptoms. To manage delirium in patients with cancer, clinicians must be able to diagnose it accurately and undertake appropriate assessment of underlying causes.
Piedrafita-Susín, A B; Yoldi-Arzoz, E; Sánchez-Fernández, M; Zuazua-Ros, E; Vázquez-Calatayud, M
Adequate provision of palliative care by nursing in intensive care units is essential to facilitate a "good death" to critically ill patients. To determine the perceptions, experiences and knowledge of intensive care nurses in caring for terminal patients. A literature review was conducted on the bases of Pubmed, Cinahl and PsicINFO data using as search terms: cuidados paliativos, UCI, percepciones, experiencias, conocimientos y enfermería and their alternatives in English (palliative care, ICU, perceptions, experiences, knowledge and nursing), and combined with AND and OR Boolean. Also, 3 journals in intensive care were reviewed. Twenty seven articles for review were selected, most of them qualitative studies (n=16). After analysis of the literature it has been identified that even though nurses perceive the need to respect the dignity of the patient, to provide care aimed to comfort and to encourage the inclusion of the family in patient care, there is a lack of knowledge of the end of life care in intensive care units' nurses. This review reveals that to achieve quality care at the end of life, is necessary to encourage the training of nurses in palliative care and foster their emotional support, to conduct an effective multidisciplinary work and the inclusion of nurses in decision making. Copyright © 2014 Elsevier España, S.L.U. y SEEIUC. All rights reserved.
Palliative care is treatment of the discomfort, symptoms, and stress of serious illness. It provides relief from distressing symptoms ... of the medical treatments you're receiving. Hospice care, care at the end of life, always includes ...
Schmidt-Wolf, G; Elsner, F; Lindena, G; Hilgers, R-D; Heussen, N; Rolke, R; Ostgathe, C; Radbruch, L
With a priority programme the German Cancer Aid supported the development of quality-assured outpatient palliative care to cover the whole country. The 12 regional pilot projects funded with the aim to improve outpatient palliative care in different models and different frameworks were concurrently monitored and evaluated. The supported projects, starting and ending individually, documented all patients who were cared for using HOPE (Hospice and palliative care evaluation) and MIDOS (Minimal documentation system for palliative patients). Total data were analyzed for 3239 patients decriptively. In addition to the quantitative data the experiences of the projects were recorded in a number of workshops (2008, 2009, 2010, and 2012). In particular, the experiences reported in the final meeting in July 2012 were considered for this article as well as the final reports for the German Cancer Aid. In the quantitative evaluation 85.6% of 3239 palliative care patients had a cancer diagnosis. In all model projects the goal of a network with close cooperation of primary providers, social support, and outpatient and inpatient specialist services has been achieved. For all projects, the initial financing of the German Cancer Aid was extremely important, because contracts with health insurance funds were negotiated slowly, and could then be built on the experiences with the projects. The participants of the project-completion meeting emphasized the need to carry out a market analysis before starting palliative care organizations considering the different regional structures and target groups of patients. Education, training and continuing education programs contribute significantly to the network. A reliably funded coordination center/case management across all institutions is extremely important. © Georg Thieme Verlag KG Stuttgart · New York.
Beng, Tan Seng; Chin, Loh Ee; Guan, Ng Chong; Ann, Yee Hway; Wu, Cathie; Kuan, Wong Sook; Jane, Lim Ee; Khee, Saw Shier; Meng, Christopher Boey Chiong
A qualitative study was conducted with semistructured interviews to explore the experiences of well-being in 15 adult palliative care inpatients of University Malaya Medical Center, Kuala Lumpur, Malaysia. The results were thematically analyzed. Six basic themes were generated (1) positive attitude, (2) positive cognitions, (3) positive emotions, (4) positive engagement, (5) positive relationships, and (6) positive circumstances. The Seeds Model was conceptualized from the analysis. This model may inform the development of interventions in the enhancement of well-being of palliative care patients. © The Author(s) 2014.
FEATURES OF PALLIATIVE CARE. IN AIDS ... rent infection e.g. IV ampho- tericin B on an in-patient ... nurses for case management, to communicate ... evaluation — an ongoing process of assessment, to .... Rectal, subcutaneous, intravenous.
Kestenbaum, Allison; Shields, Michele; James, Jennifer; Hocker, Will; Morgan, Stefana; Karve, Shweta; Rabow, Michael W; Dunn, Laura B
Spiritual care is integral to quality palliative care. Although chaplains are uniquely trained to provide spiritual care, studies evaluating chaplains' work in palliative care are scarce. The goals of this pre-post study, conducted among patients with advanced cancer receiving outpatient palliative care, were to evaluate the feasibility and acceptability of chaplain-delivered spiritual care, utilizing the Spiritual Assessment and Intervention Model ("Spiritual AIM"), and to gather pilot data on Spiritual AIM's effects on spiritual well-being, religious and cancer-specific coping, and physical and psychological symptoms. Patients with advanced cancer (N = 31) who were receiving outpatient palliative care were assigned based on chaplains' and patients' outpatient schedules, to one of three professional chaplains for three individual Spiritual AIM sessions, conducted over the course of approximately six to eight weeks. Patients completed the following measures at baseline and post-intervention: Edmonton Symptom Assessment Scale, Steinhauser Spirituality, Brief RCOPE, Functional Assessment of Chronic Illness Therapy-Spiritual (FACIT-Sp-12), Mini-Mental Adjustment to Cancer (Mini-MAC), Patient Dignity Inventory, Center for Epidemiological Studies-Depression (10 items), and Spielberger State Anxiety Inventory. From baseline to post-Spiritual AIM, significant increases were found on the FACIT-Sp-12 Faith subscale, the Mini-MAC Fighting Spirit subscale, and Mini-MAC Adaptive Coping factor. Two trends were observed, i.e., an increase in Positive religious coping on the Brief RCOPE and an increase in Fatalism (a subscale of the Mini-MAC). Spiritual AIM, a brief chaplain-led intervention, holds potential to address spiritual needs and religious and general coping in patients with serious illnesses. Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
Howell, Doris M.; Abernathy, Tom; Cockerill, Rhonda; Brazil, Kevin; Wagner, Frank; Librach, Larry
Purpose: Empirical understanding of predictors for home care service use and death at home is important for healthcare planning. Few studies have examined these predictors in the context of the publicly funded Canadian home care system. This study examined predictors for home care use and home death in the context of a “gold standard” comprehensive palliative home care program pilot in Ontario where patients had equal access to home care services. Methods: Secondary clinical and administrative data sources were linked using a unique identifier to examine multivariate factors (predisposing, enabling, need) on total home care expenditures and home death for a cohort of cancer patients enrolled in the HPCNet pilot. Results: Subjects with gastrointestinal symptoms (OR: 1.64; p=0.03) and those with higher income had increased odds of dying at home (OR: 1.14; phome care expenditures. Conclusions: Predictors of home death found in earlier studies appeared less important in this comprehensive palliative home care pilot. An income effect for home death observed in this study requires examination in future controlled studies. Relevance: Access to palliative home care that is adequately resourced and organized to address the multiple domains of issues that patients/families experience at the end of life has the potential to enable home death and shift care appropriately from limited acute care resources. PMID:22294993
Kao, Yee-Hsin; Liu, Yao-Ting; Koo, Malcolm; Chiang, Jui-Kun
For patients receiving palliative home care, the need to visit the emergency department is considered to be an indicator of poor quality care. The situation can be particularly distressing when it occurs outside of normal hours of palliative home care service. The aim of this study was to investigate the factors for emergency department use during out-of-hours periods of palliative home care service among advanced cancer patients in Taiwan. This case-control study was based on a retrospective medical chart review (January 2010 to December 2012) of advanced cancer patients who were receiving palliative home care in a community hospital in south Taiwan. The use of emergency medical services by these patients was dichotomized into either normal hours (8 a.m. to midnight, Monday to Friday, excluding public holidays) of palliative home care or outside normal hours. Logistic regression analyses were performed to evaluate factors associated with emergency services use during out-of-hours period of palliative home care. Of the 94 patients receiving palliative home care, 65 had used emergency services at least once during the 3-year study period. Of these 65 patients, 40% used emergency services during out-of-hours of palliative home care. Patients with distressing conditions (defined as the occurrence of any two conditions of dyspnea, change of consciousness, or gastrointestinal bleeding) were significantly more likely to use emergency services during out-of-hours of palliative home care. Patients at risk of developing dyspnea, change of consciousness, or gastrointestinal bleeding should be provided with relevant information regarding these symptoms and signs.
Bede, Peter; Oliver, David; Stodart, James; van den Berg, Leonard; Simmons, Zachary; O Brannagáin, Doiminic; Borasio, Gian Domenico; Hardiman, Orla
Amyotrophic lateral sclerosis (ALS) is a relentlessly progressive neurodegenerative condition. Optimal management requires a palliative approach from diagnosis with emphasis on patient autonomy, dignity and quality of life. To conduct a systematic analysis of the type, level and timing of specialist palliative care intervention in ALS. Despite an international consensus that ALS management should adopt a multidisciplinary approach, integration of palliative care into ALS management varies considerably across health care systems. Late referral to palliative services in ALS is not uncommon and may impact negatively on the quality of life of ALS patients and their caregivers. However, common themes and principles of engagement can be identified across different jurisdictions, and measurement systems have been established that can assess the impact of palliative care intervention. There is considerable evidence that palliative care intervention improves quality of life in patients and carers. International consensus guidelines would assist in the development of a framework for active palliative care engagement in ALS and other neurodegenerative diseases.
Ajjarapu, Aparna Sai; Broderick, Ann
An estimated 1.5 billion people across the globe live with chronic pain, and an estimated 61 million people worldwide experience unrelieved serious health-related suffering. One-sixth of the global population lives in India, where approximately 10 million people endure unrelieved serious health-related suffering. The state of Kerala is home to Pallium India, one of the most sophisticated palliative care programs in the country. This private organization in Trivandrum provides palliative and hospice care to underresourced populations and emphasizes holistic pain treatment. The current project features the pain stories of six patients who received treatment from Pallium India. Basic patient demographic information was collected, and a Pallium India staff member who was fluent in Malayalam and English asked questions about each patient's pain experience. Pain narratives illustrate the substantial impact of Pallium India's home visit program and the role of total pain assessment in delivering high-quality palliative care.
Duenk, R.G.; Verhagen, C.A.; Bronkhorst, E.M.; Mierlo, P. van; Broeders, M.E.A.C.; Collard, S.M.; Dekhuijzen, P.N.R.; Vissers, K.C.P.; Heijdra, Y.F.; Engels, Y.
BACKGROUND AND AIM: Patients with advanced chronic obstructive pulmonary disease (COPD) have poor quality of life. The aim of this study was to assess the effects of proactive palliative care on the well-being of these patients. TRIAL REGISTRATION: This trial is registered with the Netherlands Trial
Engelman, Suzanne R
A growing body of research and clinical reports support the benefits of utilizing animal-assisted therapy (AAT) as a complementary, transdisciplinary treatment intervention in medical settings. However, fewer articles are found demonstrating AAT's use in palliative care settings. This article is a study of the effects of AAT in palliative care situations, presenting one anecdotal clinical vignette. In this way, the efficacy of this technique in decreasing patient pain, thereby increasing patient quality of life, and lowering staff stress levels may be illustrated.
Wiener, Lori; Weaver, Meaghann Shaw; Bell, Cynthia J; Sansom-Daly, Ursula M
Medical providers are trained to investigate, diagnose, and treat cancer. Their primary goal is to maximize the chances of curing the patient, with less training provided on palliative care concepts and the unique developmental needs inherent in this population. Early, systematic integration of palliative care into standard oncology practice represents a valuable, imperative approach to improving the overall cancer experience for adolescents and young adults (AYAs). The importance of competent, confident, and compassionate providers for AYAs warrants the development of effective educational strategies for teaching AYA palliative care. Just as palliative care should be integrated early in the disease trajectory of AYA patients, palliative care training should be integrated early in professional development of trainees. As the AYA age spectrum represents sequential transitions through developmental stages, trainees experience changes in their learning needs during their progression through sequential phases of training. This article reviews unique epidemiologic, developmental, and psychosocial factors that make the provision of palliative care especially challenging in AYAs. A conceptual framework is provided for AYA palliative care education. Critical instructional strategies including experiential learning, group didactic opportunity, shared learning among care disciplines, bereaved family members as educators, and online learning are reviewed. Educational issues for provider training are addressed from the perspective of the trainer, trainee, and AYA. Goals and objectives for an AYA palliative care cancer rotation are presented. Guidance is also provided on ways to support an AYA's quality of life as end of life nears.
Chong, LeeAi; Abdullah, Adina
The aim of this study was to explore the experience of community palliative care nurses providing home care to children. A qualitative study was conducted at the 3 community palliative care provider organizations in greater Kuala Lumpur from August to October 2014. Data were collected with semistructured interviews with 16 nurses who have provided care to children and was analyzed using thematic analysis. Two categories were identified: (1) challenges nurses faced and (2) coping strategies. The themes identified from the categories are (1) communication challenges, (2) inadequate training and knowledge, (3) personal suffering, (4) challenges of the system, (5) intrapersonal coping skills, (6) interpersonal coping strategies, and (7) systemic supports. These results reinforces the need for integration of pediatric palliative care teaching and communication skills training into all undergraduate health care programs. Provider organizational support to meet the specific needs of the nurses in the community can help retain them in their role. It will also be important to develop standards for current and new palliative care services to ensure delivery of quality pediatric palliative care.
Kjørstad, Odd Jarle; Haugen, Dagny Faksvåg
The criteria for refraining from cardiopulmonary resuscitation in palliative care cancer patients are based on patients' right to refuse treatment and the duty of the treating personnel not to exacerbate their suffering and not to administer futile treatment. When is cardiopulmonary resuscitation futile in these patients? Systematic literature searches were conducted in PubMed for the period 1989-2010 on the results of in-hospital cardiopulmonary resuscitation in advanced cancer patients and on factors that affected the results of CPR when special mention was made of cancer. The searches yielded 333 hits and 18 included articles: four meta-analyses, eight retrospective clinical studies, and six review articles. Cancer patients had a poorer post-CPR survival than non-cancer patients. Survival declined with increasing extent of the cancer disease. Widespread and therapy-resistant cancer disease coupled with a performance status lower than WHO 2 or a PAM score (Pre-Arrest Morbidity Index) of above 8 was regarded as inconsistent with survival after cardiopulmonary resuscitation. Cardiopulmonary resuscitation is futile for in-hospital cancer patients with widespread incurable disease and poor performance status.
Amano, Koji; Morita, Tatsuya; Baba, Mika; Kawasaki, Muneyoshi; Nakajima, Shinichiro; Uemura, Minako; Kobayashi, Yuka; Hori, Moeko; Wakayama, Hiroshi
The role of nutritional support on terminally ill patients with cancer in a palliative care unit has not been clarified. A total of 63 patients were retrospectively investigated; the patients receiving individualized nutritional support (intervention group [n = 22]) were compared to the others (control group [n = 41]). The intervention group received individualized nutritional support. There were no significant differences in the characteristics of patients between the groups. The prevalence of bedsores was significantly lower in the intervention group (14% vs 46%, P = .012). The prevalence of edema and the use of antibiotic therapies tended to be lower in the intervention group than in the control group (36% vs 54%, P = .19; 14% vs 27%, P = .34, respectively). Some terminally ill patients with cancer in a palliative care unit might benefit from nutritional support.
Knight, Carl; Albertsen, Andreas
Palliative care serves both as an integrated part of treatment and as a last effort to care for those we cannot cure. The extent to which palliative care should be provided and our reasons for doing so have been curiously overlooked in the debate about distributive justice in health and healthcar...... to provide pain relief to those who need it as a supplement to treatment and, without justice-based reasons to provide palliative care to those whose opportunities cannot be restored. We conclude that this makes Daniels' framework much less attractive.......Palliative care serves both as an integrated part of treatment and as a last effort to care for those we cannot cure. The extent to which palliative care should be provided and our reasons for doing so have been curiously overlooked in the debate about distributive justice in health and healthcare....... We argue that one prominent approach, the Rawlsian approach developed by Norman Daniels, is unable to provide such reasons and such care. This is because of a central feature in Daniels' account, namely that care should be provided to restore people's opportunities. Daniels' view is both unable...
Namasivayam, Pathma; O Connor, Margaret; Barnett, Tony; Lee, Susan; Peters, Louise
Palliative care in Malaysia developed in the 1990s to improve the quality of life of people with advanced cancer. Like many other countries, Malaysia faces its own challenges in providing palliative care to patients and their families. In Malaysian culture, families play a significant part in providing care to the dying. Connecting with families in patient care is therefore important. This paper reports a focused literature review evaluating studies on the care of the families of terminally ill people in palliative care environments in Malaysia. The search engines CINAHL, Medline, PsycINFO, and Google Scholar were searched for literature published from January 2000 to April 2010 relating to family care in palliative care environments. Due to a paucity of research on family care in Malaysia, the search was broadened to include relevant studies on family care internationally. Four themes were identified: delivering palliative care in Malaysia, communicating with families, crossing cultural boundaries, and the caring experience of nurses. The studies indicate the importance of the nurse-family interaction in providing optimal and culturally appropriate palliative care. This paper emphasizes the need for research into the nurse's role in family care and for developing a theory appropriate to the Malaysian culture and other countries with cultural diversity.
Artico, Marco; Dante, Angelo; D'Angelo, Daniela; Lamarca, Luciano; Mastroianni, Chiara; Petitti, Tommasangelo; Piredda, Michela; De Marinis, Maria Grazia
Terminally ill patients are at high risk of pressure ulcers, which have a negative impact on quality of life. Data about pressure ulcers' prevalence, incidence and associated factors are largely insufficient. To document the point prevalence at admission and the cumulative incidence of pressure ulcers in terminally ill patients admitted to an Italian home palliative care unit, and to analyse the patients' and caregivers' characteristics associated with their occurrence. Retrospective chart review. Patients ( n = 574) with a life expectancy ⩽6 months admitted to a palliative home care service were included in this study. The prevalence and incidence rates were 13.1% and 13.0%, respectively. The logistic regression models showed body mass index ( p 70 and >1 caregiver at home as the dichotomous variables predictors of presenting with a pressure ulcer at time of admission and during home palliative care. The notable pressure ulcers' incidence and prevalence rates suggest the need to include this issue among the main outcomes to pursue during home palliative care. The accuracy of body mass index, Braden Scale and Karnofsky Performance Scale in predicting the pressure ulcers risk is confirmed. Therefore, they appear as essential tools, in combination with nurses' clinical judgment, for a structured approach to pressure ulcers prevention. Further research is needed to explore the home caregivers' characteristics and attitudes associated with the occurrence of pressure ulcers and the relations between their strategies for pressure ulcer prevention and gender-related patient's needs.
Kawaguchi, S; Mirza, R; Nissim, R; Ridley, J
Internal medicine residents are frequently called upon to provide palliative care to hospitalized patients, but report feeling unprepared to do so effectively. Curricular development to enhance residents' palliative care skills and competencies requires an understanding of current beliefs, attitudes and learning priorities. We conducted a qualitative study consisting of semi-structured interviews with ten internal medicine residents to explore their understanding of and experiences with palliative care. All of the residents interviewed had a sound theoretical understanding of palliative care, but faced many challenges in being able to provide care in practice. The challenges described by residents were system-related, patient-related and provider-related. They identified several priority areas for further learning, and discussed ways in which their current education in palliative care could be enhanced. Our findings provide important insights to guide curricular development for internal medicine trainees. The top five learning priorities in palliative care that residents identified in our study were: 1) knowing how and when to initiate a palliative approach, 2) improving communication skills, 3) improving symptom management skills, 4) identifying available resources, and 5) understanding the importance of palliative care. Residents felt that their education in palliative care could be improved by having a mandatory rotation in palliative care, more frequent didactic teaching sessions, more case-based teaching from palliative care providers, opportunities to be directly observed, and increased support from palliative care providers after-hours.
Full Text Available Patients and families increasingly use mobile apps as a relaxation and distraction intervention for children with complex, chronic medical conditions in the waiting room setting or during inpatient hospitalizations; and yet, there is limited data on app quality assessment or review of these apps for level of engagement, functionality, aesthetics, or applicability for palliative pediatric patients. The pediatric palliative care study team searched smartphone application platforms for apps relevant to calming, relaxation, and mindfulness for pediatric and adolescent patients. Apps were reviewed using a systematic data extraction tool. Validated Mobile Application Rating Scale (MARS scores were determined by two blinded reviewers. Apps were then characterized by infant, child, adolescent, and adult caregiver group categories. Reviewer discussion resulted in consensus. Sixteen of the 22 apps identified were included in the final analysis. The apps operated on either iOS or Android platforms. All were available in English with four available in Spanish. Apps featured a relaxation approach (12/16, soothing images (8/16, and breathing techniques (8/16. Mood and sleep patterns were the main symptoms targeted by apps. Provision of mobile apps resource summary has the potential to foster pediatric palliative care providers’ knowledge of app functionality and applicability as part of ongoing patient care.
Full Text Available ... a patient's and family's experience with illness. Category Science & Technology License Standard YouTube License ... 4:24 LIFE Before Death Pediatric Palliative Care - Duration: 5:27. ...
Bakitas, Marie A; Elk, Ronit; Astin, Meka; Ceronsky, Lyn; Clifford, Kathleen N; Dionne-Odom, J Nicholas; Emanuel, Linda L; Fink, Regina M; Kvale, Elizabeth; Levkoff, Sue; Ritchie, Christine; Smith, Thomas
Many of the world's population live in rural areas. However, access and dissemination of the advances taking place in the field of palliative care to patients living in rural areas have been limited. We searched 2 large databases of the medical literature and found 248 relevant articles; we also identified another 59 articles through networking and a hand search of reference lists. Of those 307 articles, 39 met the inclusion criteria and were grouped into the following subcategories: intervention (n = 4), needs assessment (n = 2), program planning (n = 3), program evaluation (n = 4), education (n = 7), financial (n = 8), and comprehensive/systematic literature reviews (n = 11). We synthesized the current state of rural palliative care research and practice to identify important gaps for future research. Studies were conducted in the United States, Australia, Canada, Africa, Sweden, and India. Two randomized control trials were identified, both of which used telehealth approaches and had positive survival outcomes. One study demonstrated positive patient quality of life and depression outcomes. Research to guide rural palliative care practice is sparse. Approaches to telehealth, community- academic partnerships, and training rural health care professionals show promise, but more research is needed to determine best practices for providing palliative care to patients living in rural settings.
Palliative care concentrates on supporting and helping people with an incurable disease and aims to improve patient’s quality of life by reducing or eliminating pain and other physical symptoms. Palliative care is a new phenomenon in Romania . PhD student Luminita Dumitrescu describes the
Claessens, Patricia; Menten, Johan; Schotsmans, Paul; Broeckaert, Bert
Palliative sedation remains a much debated and controversial issue. The limited literature on the topic often fails to answer ethical questions concerning this practice. The aim of this study was to describe the characteristics of patients who are being sedated for refractory symptoms in palliative care units (PCUs) from the time of admission until the day of death. A prospective, longitudinal, descriptive design was used to assess data in eight PCUs. The total sample consisted of 266 patients. Information on demographics, medication, food and fluid intake, decision making, level of consciousness, and symptom experience were gathered by nurses and researchers three times a week. If patients received palliative sedation, extra information was gathered. Of all included patients (n=266), 7.5% received palliative sedation. Sedation started, on average, 2.5 days before death and for half of these patients, the form of sedation changed over time. At the start of sedation, patients were in the end stage of their illness and needed total care. Patients were fully conscious and had very limited oral food or fluid intake. Only three patients received artificial fluids at the start of sedation. Patients reported, on average, two refractory symptoms, the most important ones being pain, fatigue, depression, drowsiness, and loss of feeling of well-being. In all cases, the patient gave consent to start palliative sedation because of increased suffering. This study revealed that palliative sedation is only administered in exceptional cases where refractory suffering is evident and for those patients who are close to the ends of their lives. Moreover, this study supports the argument that palliative sedation has no life-shortening effect. Copyright © 2011 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
Gülçin Senel Özalp
Full Text Available Objective: Cancer patients often experience a large number of symptoms together. The aim of this study is to determine the symptom clusters in cancer patients at palliative care clinic. Methods: Hundred and seventy consecutive patients were enrolled in the study. Memorial Symptom Assessment Scale was used for symptom assessment of the patients. Results: The most experienced symptoms by the patients during the past week before hospitalization in palliative care clinic were lack of energy (95.4%, weight loss (91.2%, lack of appetite (89.4%, pain (88.2%, dry mouth (87.6%, feeling sad (87.6%, feeling nervous (82.9%, worrying (81.2%, and feeling irritable (80.6%. Five symptom clusters were defined. First cluster: pain, feeling nervous, dry mouth, worrying, feeling irritable, weight loss; second cluster: feeling drowsy, numbness/tingling in hands/feet, difficulty in sleeping, dizziness, constipation, I do not look like myself; third cluster: nausea, vomiting; fourth cluster: shortness of breath, difficulty in swallowing, cough, change in the way food tastes; and fifth cluster: feeling bloated, problems with urination, diarrhea, itching, mouth sores, hair loss, swelling of arm or legs, change in the skin. Conclusions: We encountered various symptom clusters in advanced cancer patients. Identification of symptom clusters and knowledge of cluster composition in oncological population may particularly contribute individualization of the treatment.
Franke, Richard J
Palliative care is a quickly growing facet of modern medicine. While scientific advancements have broken new ground for the possibilities of end-of-life care, sensitive treatment of the patient as an individual has lagged behind and has frequently led to an unsatisfactory experience for patients, families, and the medical community at large. This essay argues that centralizing patients during the terminal phases of treatment by using humanistic perspectives has the potential to bring new meaning and improved effectiveness to patients and physicians alike.
Reygan, Finn C G
OBJECTIVE: The international literature points to the specific cancer risks and palliative care needs of lesbian, gay and bisexual (LGB) populations. However, with the exception of a programme in the USA, there is a lack of training internationally for health and social care professionals providing oncological and palliative care to LGB patients. In Ireland, a training project funded by the Irish Cancer Society, the Irish Hospice Foundation and the Health Service Executive developed a training pilot programme for health and social care professionals providing oncological and palliative care to LGB patients. METHODS: Over 200 (N = 201) oncology and palliative care staff participated in 17 brief, 50-min trainings in pilot sites. Evaluation of the training included self-report questionnaires at the end of each training and an evaluation interview with one participant from each of the four sites. RESULTS: The majority of participants reported that they would recommend the training to their colleagues, were interested in further training in the area and found the training useful for their practice. They also reported becoming more familiar with LGB-related language and terminology, became more knowledgeable of LGB health issues and reported becoming more confident in providing care to LGB patients. CONCLUSIONS: Recommendations are that the training be made available across the health services in Ireland and included in postgraduate courses for trainee health and social care professionals. Copyright © 2012 John Wiley & Sons, Ltd.
Vivat, B.; Young, T.; Winstanley, J.; Arraras, J. I.; Bennett, M. I.; Brédart, A.; Costantini, A.; Fisher, S. E.; Greimel, E.; Guo, J.; Irarrazaval, M. E.; Kobayashi, K.; Kruizinga, R.; Navarro, M.; Omidvari, S.; Rohde, G. E.; Serpentini, S.; van Laarhoven, H. W. M.; Yang, G.
Spiritual care and spiritual wellbeing (SWB) are central to palliative care, but no measures of SWB have yet been developed cross-culturally. In 2002 the EORTC Quality of Life (QL) Group began international development of an SWB measure for palliative patients. Three domains of SWB were initially
de Visser, Marianne; Oliver, David J.
Purpose of review Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness. Neuromuscular disorders (NMDs) are characterized by progressive muscle weakness, leading to pronounced and incapacitating
McCabe, Marita R P; Goldhammer, Denisa; Mellor, David; Hallford, David; Davison, Tanya
This study was designed to evaluate the effectiveness of a training program to improve the knowledge, attitudes, and self-efficacy of palliative care staff and thus enable them to better detect and manage depression among palliative care patients and their families. Participants were 90 professional carers who completed a four-session training program. Knowledge, attitudes, self-efficacy, and barriers to working with depressed patients were assessed preintervention, post-intervention, and at a three-month follow-up. The results demonstrated that compared to the control group, the intervention group had improved in all of these areas. Improvements were maintained at the three-month follow-up in all areas except attitudes. The results of this study indicate the importance of training in managing depression among palliative care staff. Booster sessions will likely be needed to ensure that training program gains are maintained.
Green, Emilie; Knight, Selena; Gott, Merryn; Barclay, Stephen; White, Patrick
General practitioners have overall responsibility for community care, including towards end of life. Current policy places generalists at the centre of palliative care provision. However, little is known about how patients and carers understand the general practitioner's role. To explore patient and carer perspectives of (1) the role of the general practitioner in providing palliative care to adult patients and (2) the facilitators and barriers to the general practitioner's capacity to fulfil this perceived role. Systematic literature review and narrative synthesis. Seven electronic databases (MEDLINE, Embase, PsycINFO, BNI, CINAHL, Cochrane and HMIC) were searched from inception to May 2017. Two reviewers independently screened papers at title, abstract and full-text stages. Grey literature, guideline, hand searches of five journals and reference list/citation searches of included papers were undertaken. Data were extracted, tabulated and synthesised using narrative, thematic analysis. A total of 25 studies were included: 14 employed qualitative methods, 8 quantitative survey methods and 3 mixed-methods. Five key themes were identified: continuity of care, communication between primary and secondary care, contact and accessibility, communication between general practitioner and patient, and knowledge and competence. Although the terminology and context of general practice vary internationally, themes relating to the perceived role of general practitioners were consistent. General practitioners are considered well placed to provide palliative care due to their breadth of clinical responsibility, ongoing relationships with patients and families, and duty to visit patients at home and coordinate healthcare resources. These factors, valued by service users, should influence future practice and policy development.
Mosoiu, Daniela; Dumitrescu, Malina; Connor, Stephen R
Palliative care services have been reported to be a less expensive alternative to traditional treatment; however, little is known about how to measure the cost of delivering quality palliative care. The purpose of this project was to develop a standardized method for measuring the cost of palliative care delivery that could potentially be replicated in multiple settings. The project was implemented in three stages. First, an interdisciplinary group of palliative care experts identified standards of quality palliative care delivery in the inpatient and home care services. Surveys were conducted of government agencies and palliative care providers to identify payment practices and budgets for palliative care services. In the second phase, unit costs were defined and a costing framework was designed to measure inpatient and home-based palliative care unit costs. The final phase was advocacy for inclusion of calculated costs into the national funding system. In this project, a reliable framework for determining the cost of inpatient and home-based palliative care services was developed. Inpatient palliative care cost in Romania was calculated at $96.58 per day. Home-based palliative care was calculated at $30.37 per visit, $723.60 per month, and $1367.71 per episode of care, which averaged 45 visits. A standardized methodology and framework for costing palliative care are presented. The framework allows a country or provider of care to substitute their own local costs to generate cost information relevant to the health-care system. In Romania, this allowed the palliative care provider community to advocate for a consistent payment system. Copyright © 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
Levine, Deena R; Baker, Justin N; Wolfe, Joanne; Lehmann, Leslie E; Ullrich, Christina
In the intense, cure-oriented setting of hematopoietic stem-cell transplantation (HSCT), delivery of high-quality palliative and end-of-life care is a unique challenge. Although HSCT affords patients a chance for cure, it carries a significant risk of morbidity and mortality. During HSCT, patients usually experience high symptom burden and a significant decrease in quality of life that can persist for long periods. When morbidity is high and the chance of cure remote, the tendency after HSCT is to continue intensive medical interventions with curative intent. The nature of the complications and overall condition of some patients may render survival an unrealistic goal and, as such, continuation of artificial life-sustaining measures in these patients may prolong suffering and preclude patient and family preparation for end of life. Palliative care focuses on the well-being of patients with life-threatening conditions and their families, irrespective of the goals of care or anticipated outcome. Although not inherently at odds with HSCT, palliative care historically has been rarely offered to HSCT recipients. Recent evidence suggests that HSCT recipients would benefit from collaborative efforts between HSCT and palliative care services, particularly when initiated early in the transplantation course. We review palliative and end-of-life care in HSCT and present models for integrating palliative care into HSCT care. With open communication, respect for roles, and a spirit of collaboration, HSCT and palliative care can effectively join forces to provide high-quality, multidisciplinary care for these highly vulnerable patients and their families.
Johnsen, Anna Thit; Petersen, Morten Aagaard; Gluud, Christian
BACKGROUND: Advanced cancer patients experience considerable symptoms, problems, and needs. Early referral of these patients to specialized palliative care (SPC) could offer improvements. The Danish Palliative Care Trial (DanPaCT) investigates whether patients with metastatic cancer will benefit...
Nokwanda E. Bam
Objectives: This study explored the respondents’ understanding of the concepts ‘caring’ and ‘terminal patient’ and described the experiences of nurses caring for terminally-ill patients with HIV and how these experiences influence the nature of care rendered. Methods: Qualitative research using Husserl’s approach of phenomenology design underpinned the study and Giorgi’s steps of analysis were used to make meaning of the data. Results: The concept ‘caring’ was experienced by the nurses as transforming the patients’ quality of life through supportive care and hope for life. Palliative care made the nurses conscious of their own mortality, enabling them to be more sensitive, compassionate and dedicated to caring for their patients. The findings described the social networking that enabled nurses to collaborate with colleagues in the interdisciplinary teams and shared knowledge, skills and support within the palliative care team in order to optimise patient outcomes. Conclusion: Nurses with prolonged involvement in caring for terminally-ill patients with HIV experienced helplessness and emotional stress. Recommendations based on the results are that training in psychological and holistic care of the patient, professional counselling and stress management services are needed to support the nurse in this context.
Full Text Available ... a patient's and family's experience with illness. Category Science & Technology License Standard YouTube License ... 5:21 Portraits of Life, Love and Legacy through Pediatric Palliative Care - Duration: ...
Full Text Available Abstract Background The dissemination of palliative care for patients presenting complex chronic diseases at various stages has become an important matter of public health. A death census in Swiss long-term care facilities (LTC was set up with the aim of monitoring the frequency of selected indicators of palliative care. Methods The survey covered 150 LTC facilities (105 nursing homes and 45 home health services, each of which was asked to complete a questionnaire for every non-accidental death over a period of six months. The frequency of 4 selected indicators of palliative care (resort to a specialized palliative care service, the administration of opiates, use of any pain measurement scale or other symptom measurement scale was monitored in respect of the stages of care and analysed based on gender, age, medical condition and place of residence. Results Overall, 1200 deaths were reported, 29.1% of which were related to cancer. The frequencies of each indicator varied according to the type of LTC, mostly regarding the administration of opiate. It appeared that the access to palliative care remained associated with cancer, terminal care and partly with age, whereas gender and the presence of mental disorders had no effect on the indicators. In addition, the use of drugs was much more frequent than the other indicators. Conclusion The profile of patients with access to palliative care must become more diversified. Among other recommendations, equal access to opiates in nursing homes and in home health services, palliative care at an earlier stage and the systematic use of symptom management scales when resorting to opiates have to become of prime concern.
Freeman, Rachel; Luyirika, Emmanuel Bk; Namisango, Eve; Kiyange, Fatia
The high burden of non-communicable diseases and communicable diseases in Africa characterised by late presentation and diagnosis makes the need for palliative care a priority from the point of diagnosis to death and through bereavement. Palliative care is an intervention that requires a multidisciplinary team to address the multifaceted needs of the patient and family. Thus, its development takes a broad approach that involves engaging all key stakeholders ranging from policy makers, care providers, educators, the public, patients, and families. The main focus of stakeholder engagement should address some core interventions geared towards improving knowledge and awareness, strengthening skills and attitudes about palliative care. These interventions include educating health and allied healthcare professionals on the palliative care-related problems of patients and best practices for care, explaining palliative care as a clinical and holistic discipline and demonstrating its effectiveness, the need to include palliative care into national policies, strategic plans, training curriculums of healthcare professionals and the engagement of patients, families, and communities. Interventions from a five-year programme that was aimed at strengthening the health system of Namibia through the integration of palliative care for people living with HIV and AIDS and cancer in Namibia are shared. This article illustrates how a country can implement the World Health Organisation's public health strategy for developing palliative care services, which recommends four pillars: government policy, education, drug availability, and implementation.
van der Plas, Annicka G M; Vissers, Kris C; Francke, Anneke L; Donker, Gé A; Jansen, Wim J J; Deliens, Luc; Onwuteaka-Philipsen, Bregje D
Case managers have been introduced in primary palliative care in the Netherlands; these are nurses with expertise in palliative care who offer support to patients and informal carers in addition to the care provided by the general practitioner (GP) and home-care nurse. To compare cancer patients with and without additional support from a case manager on: 1) the patients' general characteristics, 2) characteristics of care and support given by the GP, 3) palliative care outcomes. This article is based on questionnaire data provided by GPs participating in two different studies: the Sentimelc study (280 cancer patients) and the Capalca study (167 cancer patients). The Sentimelc study is a mortality follow-back study amongst a representative sample of GPs that monitors the care provided via GPs to a general population of end-of-life patients. Data from 2011 and 2012 were analysed. The Capalca study is a prospective study investigating the implementation and outcome of the support provided by case managers in primary palliative care. Data were gathered between March 2011 and December 2013. The GP is more likely to know the preferred place of death (OR 7.06; CI 3.47-14.36), the place of death is more likely to be at the home (OR 2.16; CI 1.33-3.51) and less likely to be the hospital (OR 0.26; CI 0.13-0.52), and there are fewer hospitalisations in the last 30 days of life (none: OR 1.99; CI 1.12-3.56 and one: OR 0.54; CI 0.30-0.96), when cancer patients receive additional support from a case manager compared with patients receiving the standard GP care. Involvement of a case manager has added value in addition to palliative care provided by the GP, even though the role of the case manager is 'only' advisory and he or she does not provide hands-on care or prescribe medication.
Chai, Huamin; Guerriere, Denise N; Zagorski, Brandon; Coyte, Peter C
With increasing emphasis on the provision of home-based palliative care in Canada, economic evaluation is warranted, given its tremendous demands on family caregivers. Despite this, very little is known about the economic outcomes associated with home-based unpaid care-giving at the end of life. The aims of this study were to (i) assess the magnitude and share of unpaid care costs in total healthcare costs for home-based palliative care patients, from a societal perspective and (ii) examine the sociodemographic and clinical factors that account for variations in this share. One hundred and sixty-nine caregivers of patients with a malignant neoplasm were interviewed from time of referral to a home-based palliative care programme provided by the Temmy Latner Centre for Palliative Care at Mount Sinai Hospital, Toronto, Canada, until death. Information regarding palliative care resource utilisation and costs, time devoted to care-giving and sociodemographic and clinical characteristics was collected between July 2005 and September 2007. Over the last 12 months of life, the average monthly cost was $14 924 (2011 CDN$) per patient. Unpaid care-giving costs were the largest component - $11 334, accounting for 77% of total palliative care expenses, followed by public costs ($3211; 21%) and out-of-pocket expenditures ($379; 2%). In all cost categories, monthly costs increased exponentially with proximity to death. Seemingly unrelated regression estimation suggested that the share of unpaid care costs of total costs was driven by patients' and caregivers' sociodemographic characteristics. Results suggest that overwhelming the proportion of palliative care costs is unpaid care-giving. This share of costs requires urgent attention to identify interventions aimed at alleviating the heavy financial burden and to ultimately ensure the viability of home-based palliative care in future. © 2013 John Wiley & Sons Ltd.
Mulder, S. F.; Bleijenberg, G.; Verhagen, S. C.; Stuyt, P. M. J.; Schijven, M. P.; Tack, C. J.
Residents report that they received inadequate teaching in palliative care and low levels of comfort and skills when taking care of dying patients. This study describes the effects of a problem-based palliative care course on perceived competence and knowledge in a representative Dutch cohort of
Adsersen, Mathilde; Thygesen, Lau Caspar; Jensen, Anders Bonde
BACKGROUND: Specialised palliative care (SPC) takes place in specialised services for patients with complex symptoms and problems. Little is known about what determines the admission of patients to SPC and whether there are differences in relation to institution type. The aims of the study were t...
Full Text Available Abstract Background Disseminating palliative care is a critical task throughout the world. Several outcome studies explored the effects of regional palliative care programs on a variety of end-points, and some qualitative studies investigated the process of developing community palliative care networks. These studies provide important insights into the potential benefits of regional palliative care programs, but the clinical implications are still limited, because: 1 many interventions included fundamental changes in the structure of the health care system, and, thus, the results would not be applicable for many regions where structural changes are difficult or unfeasible; 2 patient-oriented outcomes were not measured or explored only in a small number of populations, and interpretation of the results from a patient's view is difficult; and 3 no studies adopted a mixed-method approach using both quantitative and qualitative methodologies to interpret the complex phenomenon from multidimensional perspectives. Methods/designs This is a mixed-method regional intervention trial, consisting of a pre-post outcome study and qualitative process studies. The primary aim of the pre-post outcome study is to evaluate the change in the number of home deaths, use of specialized palliative care services, patient-reported quality of palliative care, and family-reported quality of palliative care after regional palliative care intervention. The secondary aim is to explore the changes in a variety of outcomes, including patients' quality of life, pain intensity, family care burden, and physicians' and nurses' knowledge, difficulties, and self-perceived practice. Outcome measurements used in this study include the Care Evaluation Scale, Good Death Inventory, Brief pain Inventory, Caregiving Consequence Inventory, Sense of Security Scale, Palliative Care Knowledge test, Palliative Care Difficulties Scale, and Palliative Care Self-reported Practice Scale. Study
Warth, Marco; Kessler, Jens; Hillecke, Thomas K; Bardenheuer, Hubert J
Relaxation interventions are frequently used to promote symptom relief in palliative care settings, but little is known about the underlying mechanisms. The present analysis aimed at examining the psychophysiological pathways of terminally ill patients' cardiovascular response to a live music therapy vs. prerecorded mindfulness exercise. Eighty-four patients of a palliative care unit were randomly assigned to either of the two interventions. Multilevel modeling was used to analyze trajectories of physiological change. Vagally mediated heart rate variability (VM-HRV) and blood volume pulse amplitude (BVP-A) served as indices of autonomic nervous system response. Participants' gender, age, baseline scores, self-rated pain, and assignment to treatment were entered to the models as predictors. Both VM-HRV and BVP-A showed significant linear and quadratic trends over time, as well as substantial heterogeneity among individuals' trajectories. Baseline scores, pain, and treatment significantly accounted for random variation in VM-HRV intercepts. BVP-A levels were significantly higher in women than in men. Moreover, assignment to treatment significantly accounted for differences in the linear slopes of peripheral blood flow. Higher levels of VM-HRV in the music therapy group highlight the importance of a therapeutic relationship for the effectiveness of relaxation interventions in end-of-life care settings. Music therapy caused significantly stronger reductions of vascular sympathetic tone and, therefore, may be indicated in the treatment of pain and stress-related symptoms in palliative care. Initial self-ratings of pain moderated patients' physiological response and need to be taken into account in clinical practice and future theory building. Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
Erichsén, E; Milberg, A; Jaarsma, T; Friedrichsen, M
For patients in palliative care, constipation is primarily a result of opioid treatment. Impacts from other factors related to constipation in palliative care are rarely studied. The aim was to identify factors related to constipation in patients in palliative care, and then to compare these factors between patients with different types of constipation and patients without constipation. Cross-sectional data on constipation was collected with a 26-item questionnaire from 485 patients in 38 specialist palliative care units in Sweden. Three different constipation groups were used; MC ONLY, PC ONLY, and MC & PC. Logistic regression analyses were used to calculate odds ratios. Patients with hospitalized, bed-restricted, in need of personal assistance for toilet visits, and of having a poor fluid intake. Patients with the perception of being constipated, PC ONLY, (n = 93) had higher odds of having poor appetite, hemorrhoids, hard stool, more opioid treatment, less laxative treatment and of being more dissatisfied with constipation information. Patients with both constipated, MC & PC, (n = 78) had higher odds of having cancer- disease. There were several significant factors related to constipation with higher odds than opioid- treatment, for patients in palliative care, such as; hard stool, cancer diagnosis, dissatisfaction with information, low fluid intake, hemorrhoids, bed restriction, hospitalization, and need of personal assistance for toilet visits.
Full Text Available ... of Rachel—a pediatric neuroblastoma patient—and her family. The story demonstrates how palliative care can positively influence a patient's and family's experience with illness. Category Science & Technology License Standard ...
Lux, Michael R; Protus, Bridget McCrate; Kimbrel, Jason; Grauer, Phyllis
Patients nearing the end of life may experience symptoms that are refractory to standard therapeutic options. Physicians may consider palliative sedation to relieve intolerable suffering. There is limited clinical literature regarding preferred medications for palliative sedation. To determine the preferred medications physicians use when implementing palliative sedation. An Internet-based, cross-sectional survey of hospice and palliative care physicians in the United States. A link to the survey was e-mailed to 3130 physician members of the American Academy of Hospice and Palliative Medicine, of which 381 physicians completed the survey. Physicians were not required to answer all questions. Nearly all (n = 335, 99%) respondents indicated that palliative sedation may be used (acceptable by 73% [n = 248] for refractory symptoms and acceptable by 26% [n = 87] only for imminently dying patients). Seventy-nine percent (n = 252) believed that opioids should not be used to induce palliative sedation but should be continued to provide pain control. Midazolam was the most commonly selected first-line choice for palliative sedation (n = 155, 42%). The most commonly reported second-line agents for the induction of palliative sedation were lorazepam, midazolam (for those who did not select midazolam as first-line agent), and phenobarbital with a reported preference of 20% (n = 49), 19% (n = 46), and 17% (n = 40), respectively. Of the physicians surveyed, 99% (n = 335) felt that palliative sedation is a reasonable treatment modality. Midazolam was considered a drug of choice for inducing and maintaining sedation, and opioids were continued for pain control.
Shen, Hui-Shan; Chen, Szu-Yin; Cheung, Denise Shuk Ting; Wang, Shu-Yi; Lee, Jung Jae; Lin, Chia-Chin
No study has examined the varying family experience of palliative sedation therapy (PST) for terminally ill patients in different settings. To examine and compare family concerns about PST use and its effect on the grief suffered by terminally ill patients' families in palliative care units (PCUs) or intensive care units (ICUs). A total of 154 family members of such patients were recruited in Taiwan, of whom 143 completed the study, with 81 from the PCU and 62 from the ICU. Data were collected on their concerns regarding PST during recruitment. Grief levels were assessed at three days and one month after the patient's death with the Texas Revised Inventory of Grief. Families' major concern about sedated patients in the PCU was that "there might be other ways to relieve symptoms" (90.2%), whereas families of ICU sedated patients gave the highest ratings to "feeling they still had something more to do" (93.55%), and "the patient's sleeping condition was not dignified" (93.55%). Family members recruited from the ICU tended to experience more grief than those from the PCU (P = 0.005 at Day 3 and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
Groeneveld, E Iris; Cassel, J Brian; Bausewein, Claudia; Csikós, Ágnes; Krajnik, Malgorzata; Ryan, Karen; Haugen, Dagny Faksvåg; Eychmueller, Steffen; Gudat Keller, Heike; Allan, Simon; Hasselaar, Jeroen; García-Baquero Merino, Teresa; Swetenham, Kate; Piper, Kym; Fürst, Carl Johan; Murtagh, Fliss EM
Background: Funding models influence provision and development of palliative care services. As palliative care integrates into mainstream health care provision, opportunities to develop funding mechanisms arise. However, little has been reported on what funding models exist or how we can learn from them. Aim: To assess national models and methods for financing and reimbursing palliative care. Design: Initial literature scoping yielded limited evidence on the subject as national policy documents are difficult to identify, access and interpret. We undertook expert consultations to appraise national models of palliative care financing in England, Germany, Hungary, Republic of Ireland, New Zealand, The Netherlands, Norway, Poland, Spain, Sweden, Switzerland, the United States and Wales. These represent different levels of service development and a variety of funding mechanisms. Results: Funding mechanisms reflect country-specific context and local variations in care provision. Patterns emerging include the following: Provider payment is rarely linked to population need and often perpetuates existing inequitable patterns in service provision. Funding is frequently characterised as a mixed system of charitable, public and private payers. The basis on which providers are paid for services rarely reflects individual care input or patient needs. Conclusion: Funding mechanisms need to be well understood and used with caution to ensure best practice and minimise perverse incentives. Before we can conduct cross-national comparisons of costs and impact of palliative care, we need to understand the funding and policy context for palliative care in each country of interest. PMID:28156188
Groeneveld, E Iris; Cassel, J Brian; Bausewein, Claudia; Csikós, Ágnes; Krajnik, Malgorzata; Ryan, Karen; Haugen, Dagny Faksvåg; Eychmueller, Steffen; Gudat Keller, Heike; Allan, Simon; Hasselaar, Jeroen; García-Baquero Merino, Teresa; Swetenham, Kate; Piper, Kym; Fürst, Carl Johan; Murtagh, Fliss Em
Funding models influence provision and development of palliative care services. As palliative care integrates into mainstream health care provision, opportunities to develop funding mechanisms arise. However, little has been reported on what funding models exist or how we can learn from them. To assess national models and methods for financing and reimbursing palliative care. Initial literature scoping yielded limited evidence on the subject as national policy documents are difficult to identify, access and interpret. We undertook expert consultations to appraise national models of palliative care financing in England, Germany, Hungary, Republic of Ireland, New Zealand, The Netherlands, Norway, Poland, Spain, Sweden, Switzerland, the United States and Wales. These represent different levels of service development and a variety of funding mechanisms. Funding mechanisms reflect country-specific context and local variations in care provision. Patterns emerging include the following: Provider payment is rarely linked to population need and often perpetuates existing inequitable patterns in service provision. Funding is frequently characterised as a mixed system of charitable, public and private payers. The basis on which providers are paid for services rarely reflects individual care input or patient needs. Funding mechanisms need to be well understood and used with caution to ensure best practice and minimise perverse incentives. Before we can conduct cross-national comparisons of costs and impact of palliative care, we need to understand the funding and policy context for palliative care in each country of interest.
Naylor, Wayne A
Wound management in palliative patients is often a very challenging area of care. There are many unique issues that can combine to produce complicated wound management scenarios, including the types of wounds and wound symptoms most commonly affecting palliative care patients, as well as the presence of concurrent disease and associated treatment. Problems exist with the availability of suitable dressings and balancing life expectancy with the goals of wound care. A significant, and possibly under-recognized, issue is the emotional and social distress experienced by these patients, which can be directly attributed to their wound. These problems must all be recognized and addressed in order to manage wounds effectively in this patient population. This article aims to explore these issues and offer advice on the management of wound-related symptoms, with the ultimate goal of improving patients' quality of life.
Masel, Eva K; Unseld, Matthias; Adamidis, Feroniki; Roider-Schur, Sophie; Watzke, Herbert H
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.
Full Text Available ... shares the story of Rachel—a pediatric neuroblastoma patient—and her family. The story demonstrates how palliative care can positively influence a patient's and family's experience with illness. Category Science & Technology ...
Calvo-Espinos, Claudio; Ruiz de Gaona, Estefania; Gonzalez, Cristina; Ruiz de Galarreta, Lucia; Lopez, Cristina
Palliative sedation is a common treatment in palliative care. The home is a difficult environment for research, and there are few studies about sedation at home. Our aim was to analyze this practice in a home setting. We conducted a retrospective cross-sectional descriptive study in a home cohort during 2011. The inclusion criteria were as follows: 18 years or older and enrolled in the Palliative Home Care Program (PHCP) with advanced cancer. The variables employed were: sex, age, primary tumor location, and place of death. We also registered indication, type, drug and dose, awareness of diagnosis and prognosis, consent, survival, presence or absence of rales, painful mouth, and ulcers in patients sedated at home. We also collected the opinions of family members and professionals about the suffering of sedated patients. A total of 446 patients (56% at home) of the 617 admitted to the PHCP between January and December of 2011 passed away. The typical patient in our population was a 70-year-old man with a lung tumor. Some 35 (14%) home patients required sedation, compared to 93 (49%) at the hospital. The most frequent indication was delirium (70%), with midazolam the most common drug (mean dose, 40 mg). Survival was around three days. Rales were frequent (57%) as well as awareness of diagnosis and prognosis (77 and 71%, respectively). Perception of suffering after sedation was rare among relatives (17%) and professionals (8%). In most cases, the decision was made jointly by professionals and family members. Our study confirmed the role of palliative sedation as an appropriate therapeutic tool in the home environment.
Stiel, Stephanie; Heckel, Maria; Seifert, Andreas; Frauendorf, Tobias; Hanke, Roland Martin; Ostgathe, Christoph
Palliative care (PC) is no longer offered with preference to cancer patients (CA), but also to patients with non-malignant, progressive diseases. Taking current death statistics into account, PC in Europe will face a growing number of patients dying from non-cancer diseases (NCA). More insights into specialized palliative home care (SPHC) in NCAs are needed. Retrospective analysis and group comparisons between CAs and NCAs of anonymous data of all patients cared for between December 2009 and June 2012 by one SPHC team in Germany. Patient-, disease- and care-related data are documented in clinical routine by specialized PC physicians and nurses in the Information System Palliative Care 3.0 ® (ISPC®). Overall, 502 patients were cared for by the SPHC team; from 387 patients comprehensive data sets were documented. These 387 data sets (CA: N = 300, 77.5 % and NCA: N = 87, 22.5 %) are used for further analysis here. NCAs were significantly older (81 vs. 73 years; p home care (12 vs. 5 %; p home care (6 vs. 20 %; p homes (50 vs. 20 %; p services seems to takes place late in the disease trajectory, as demonstrated by the lower survival rate for NCAs. Nevertheless, the results show, that NCAs PC needs are as complex and intense as in CAs.
Sanderson, Christine R; Cahill, Philippa J; Phillips, Jane L; Johnson, Anne; Lobb, Elizabeth A
Family meetings in palliative care can enhance communication with family members and identify unmet needs. However, the patient's voice may not be heard. This pre and post-test quality improvement project was conducted from 2013-2014 and investigated a patient-centered family meeting, which is a different approach to palliative care family meetings, to determine its feasibility and acceptability for patients, family and the palliative care team. Newly admitted patients to an Australian in-patient specialist palliative care unit were invited to ask anyone they wished to join them in a meeting with the palliative care team and to identify issues they wished to discuss. Consenting inpatients were interviewed shortly after admission; participated in a family meeting and re-interviewed 2-3 days after the meeting. Family members provided feedback at the end of the meeting. A focus group was held with staff for feedback on this new approach for family meetings. Meetings were observed, documented and thematically analyzed. Thirty-one newly admitted patients were approached to participate in a family meeting. Eighty-four percent had family meetings and the majority (96%) was attended by the patient. Thematic analysis revealed 69% of patient-centered meetings raised end-of-life concerns and 54% were "family-focused". Patient-centered family meetings in palliative care were shown to be feasible and acceptable for staff, patients and family members. Many patients and families spontaneously shared end-of-life concerns. A patient-centered approach to family meetings that includes active patient involvement may provide additional and valued opportunities for patients and families to: express mutual concerns, deliver messages of comfort and appreciation, and prepare for death. Further investigation of this approach, including families' bereavement outcomes, is warranted.
Boulanger, Augustin; Chabal, Théo; Fichaux, Marie; Destandau, Mireille; La Piana, Jean Marc; Auquier, Pascal; Baumstarck, Karine; Salas, Sébastien
In February 2nd 2016, the French government enacted the Claeys-Leonetti law that forbade euthanasia and established the right to deep and continuous sedation for end-of-life patients. Moreover, the law also obliges clinicians to abide by any advance directives regarding treatment and investigation, except in cases where they are "obviously inappropriate" in a given medical situation, or in cases of emergency, in order to allow medical staff to take time to assess the patient's situation. Artificial feeding and hydration are considered as treatment. The aim of this report is to investigate individuals receiving palliative care about their opinion about euthanasia, about advance directives, about the right to deep and continuous sedation, and the right to stopping artificial feeding and hydration. The study was an opinion survey conducted among patients treated in two different palliative care institutions: a palliative care unit at the University Hospital (Timone, Marseille, France) and a non-profit association palliative care home ("La Maison", Gardanne, France). Face-to-face interviews were performed by two investigators. The survey included sociodemographics, clinical data, and opinions about euthanasia, deep and continuous sedation, stopping artificial feeding and hydration, and advance directives. Forty patients were interviewed. The mean age was 59.8 years (standard deviation 12). Fifty three percent reported opposition to legalized euthanasia. Eighty three percent were in favour of the right to deep and continuous sedation in patients with refractory pain, 75% when it concerns a patient unable to express their wishes, and 68% when the patient decides to stop vital treatment. Fifty eight percent reported that artificial nutrition and hydration should be considered as care. Fifty eight percent of the patients interviewed would like to see doctors follow the express wishes contained in advance care directives and 53% that advance directives should be subject to
Senthil P Kumar
Conclusions: The overall reporting rate for pediatric palliative care articles in palliative care journals was very low and there were no randomized clinical trials and systematic reviews found. The study findings indicate a lack of adequate evidence base for pediatric palliative care.
Kurita, Geana Paula; Benthien, Kirstine Skov; Sjøgren, Per; Kaasa, Stein; Hjermstad, Marianne Jensen
Studies with neuropsychological assessments in patients with cancer are sparse, and the evidence is very limited regarding their status of cognitive function over time. This study aimed at assessing the prevalence and predictors of cognitive impairment in patients with cancer in palliative care. Prospective longitudinal investigation derived from the European Palliative Care Cancer Symptom study (2011-2013) including patients with cancer in palliative care, ≥18 years, and with at least one assessment post-inclusion. For cognitive assessment, a 4-item version of the Mini Mental State Examination was applied at inclusion and after 4 to 16 weeks. Logistic regression model with multiple imputations was applied. The sample consisted of 1568 patients (50% male, mean age 65.5, 42% with 10-12 years schooling, mean Karnofsky Performance Status-KPS 68%). Longitudinal analysis of the patients with complete MMSE at both assessments (n = 801) showed that 64.5% were not impaired, 12.5% remained cognitively impaired, 11.4% developed impairment, and 11.6% improved. Those who improved cognitively also reported reduced pain intensity and increased appetite. The predictive model (n = 1351) showed that those with low KPS (OR = 1.6, 95% CI 1.0-2.5) most often developed cognitive impairment, while patients with breast cancer (OR = 0.4, 95% CI 0.2-0.7) had lower odds for impairment. During palliative care, a substantial number of patients remained cognitively impaired or developed cognitive impairment; however, it is noteworthy that improvement was also observed. Physical performance and cancer type may predict cognitive impairment.
As the spiritual care needs of patients and their loved ones have become an essential component of palliative care, clinicians are being challenged to develop new ways of addressing the spiritual issues that often arise in the palliative care setting. Recent research has given attention to the communication strategies that are effective with patients or their loved ones who report that they are seeking a miraculous physical healing. However, these strategies often assume a unilateral rather than collaborative view of divine intervention. Communication strategies that are effective with unilateral understandings of divine intervention may be contraindicated with those who hold to a collaborative view of divine intervention. Greater attention to language of human-divine interaction along with approaching faith healing as a third modality of treatment are explored as additional interventions.
Gwyther, Liz; Brennan, Frank; Harding, Richard
The international palliative care community has articulated a simple but challenging proposition that palliative care is an international human right. International human rights covenants and the discipline of palliative care have, as common themes, the inherent dignity of the individual and the principles of universality and nondiscrimination. However, when we consider the evidence for the effectiveness of palliative care, the lack of palliative care provision for those who may benefit from it is of grave concern. Three disciplines (palliative care, public health, and human rights) are now interacting with a growing resonance. The maturing of palliative care as a clinical specialty and academic discipline has coincided with the development of a public health approach to global and community-wide health problems. The care of the dying is a public health issue. Given that death is both inevitable and universal, the care of people with life-limiting illness stands equal to all other public health issues. The International Covenant on Economic, Social and Cultural Rights (ICESCR) includes the right to health care and General Comment 14 (paragraph 34) CESCR stipulates that "States are under the obligation to respect the right to health by, inter alia, refraining from denying or limiting equal access for all persons, ... to preventive, curative and palliative health services." However, these rights are seen to be aspirational-rights to be achieved progressively over time by each signatory nation to the maximum capacity of their available resources. Although a government may use insufficient resources as a justification for inadequacies of its response to palliative care and pain management, General Comment 14 set out "core obligations" and "obligations of comparable priority" in the provision of health care and placed the burden on governments to justify "that every effort has nevertheless been made to use all available resources at its disposal in order to satisfy, as
M R Rajagopal
Full Text Available Background: It is important to ensure that minimum standards for palliative care based on available resources are clearly defined and achieved. Aims: (1 Creation of minimum National Standards for Palliative Care for India. (2 Development of a tool for self-evaluation of palliative care organizations. (3 Evaluation of the tool in India. In 2006, Pallium India assembled a working group at the national level to develop minimum standards. The standards were to be evaluated by palliative care services in the country. Materials and Methods: The working group prepared a "standards" document, which had two parts - the first composed of eight "essential" components and the second, 22 "desirable" components. The working group sent the document to 86 hospice and palliative care providers nationwide, requesting them to self-evaluate their palliative care services based on the standards document, on a modified Likert scale. Results: Forty-nine (57% palliative care organizations responded, and their self-evaluation of services based on the standards tool was analyzed. The majority of the palliative care providers met most of the standards identified as essential by the working group. A variable percentage of organizations had satisfied the desirable components of the standards. Conclusions: We demonstrated that the "standards tool" could be applied effectively in practice for self-evaluation of quality of palliative care services.
... a pediatric neuroblastoma patient—and her family. The story demonstrates how palliative care can positively influence a patient's and family's experience with illness. Category Science & Technology License Standard YouTube License Show more Show less ...
Murray-Brown, Fay; Dorman, Saskie
Nausea and vomiting are common symptoms in patients with terminal, incurable illnesses. Both nausea and vomiting can be distressing. Haloperidol is commonly prescribed to relieve these symptoms. This is an updated version of the original Cochrane review published in Issue 2, 2009, of Haloperidol for the treatment of nausea and vomiting in palliative care patients. To evaluate the efficacy and adverse events associated with the use of haloperidol for the treatment of nausea and vomiting in palliative care patients. For this updated review, we performed updated searches of CENTRAL, EMBASE and MEDLINE in November 2013 and in November 2014. We searched controlled trials registers in March 2015 to identify any ongoing or unpublished trials. We imposed no language restrictions. For the original review, we performed database searching in August 2007, including CENTRAL, MEDLINE, EMBASE, CINAHL and AMED, using relevant search terms and synonyms. Handsearching complemented the electronic searches (using reference lists of included studies, relevant chapters and review articles) for the original review. We considered randomised controlled trials (RCTs) of haloperidol for the treatment of nausea or vomiting, or both, in any setting, for inclusion. The studies had to be conducted with adults receiving palliative care or suffering from an incurable progressive medical condition. We excluded studies where nausea or vomiting, or both, were thought to be secondary to pregnancy or surgery. We imported records from each of the electronic databases into a bibliographic package and merged them into a core database where we inspected titles, keywords and abstracts for relevance. If it was not possible to accept or reject an abstract with certainty, we obtained the full text of the article for further evaluation. The two review authors independently assessed studies in accordance with the inclusion criteria. There were no differences in opinion between the authors with regard to the
Wright, David Kenneth; Vanderspank-Wright, Brandi; Holmes, Dave; Skinner, Elise
A movement is underway to promote a palliative approach to care in all contexts where people age and live with life-limiting conditions, including psychiatric settings. Forensic psychiatry nursing-a subfield of mental health nursing- focuses on individuals who are in conflict with the criminal justice system. We know little about the values of nurses working in forensic psychiatry, and how these values might influence a palliative approach to care for frail and aging patients. Interviews with four nurses working on one of two forensic units of a university-affiliated mental health hospital in an urban area of eastern Canada. Three specific values were found to guide forensic nurses in their care of aging patients that are commensurate with a palliative approach: hope, inclusivity, and quality of life. When we started this project, we wondered whether the culture of forensic nursing practice was antithetical to the values of a palliative approach. Instead, we found several parallels between forensic nurses' moral identities and palliative philosophy. These findings have implications for how we think about the palliative approach in contexts not typically associated with palliative care, but in which patients will increasingly age and die.
Specialist palliative care day care (SPDC) units provide an array of services to patients and their families and can increase continuity of care between inpatient and homecare settings. A multidisciplinary teamwork approach is emphasized, and different models of day care exist. Depending on the emphasis of care, the models can be social, medical, therapeutic, or mixed. We describe our experience of introducing an enhanced therapeutic specialist day care model and using both patient- and carer-rated tools to monitor patient outcomes.
Georges, Jean-Jacques; Onwuteaka-Philipsen, Bregje D; van der Heide, Agnes; van der Wal, Gerrit; van der Maas, Paul J
In recent decades significant developments in end-of-life care have taken place in The Netherlands. There has been more attention for palliative care and alongside the practice of euthanasia has been regulated. The aim of this paper is to describe the opinions of physicians with regard to the relationship between palliative care and euthanasia, and determinants of these opinions. Cross-sectional. Representative samples of physicians (n = 410), relatives of patients who died after euthanasia and physician-assisted suicide (EAS; n = 87), and members of the Euthanasia Review Committees (ERCs; n = 35). Structured interviews with physicians and relatives of patients, and a written questionnaire for the members of the ERCs. Approximately half of the physicians disagreed and one third agreed with statements describing the quality of palliative care in The Netherlands as suboptimal and describing the expertise of physicians with regard to palliative care as insufficient. Almost two thirds of the physicians disagreed with the suggestion that adequate treatment of pain and terminal care make euthanasia redundant. Having a religious belief, being a nursing home physician or a clinical specialist, never having performed euthanasia, and not wanting to perform euthanasia were related to the belief that adequate treatment of pain and terminal care could make euthanasia redundant. The study results indicate that most physicians in The Netherlands are not convinced that palliative care can always alleviate all suffering at the end of life and believe that euthanasia could be appropriate in some cases.
Schaefer, Kristen G.; Chittenden, Eva H.; Sullivan, Amy M.; Periyakoil, Vyjeyanth S.; Morrison, Laura J.; Carey, Elise C.; Sanchez-Reilly, Sandra; Block, Susan D.
Purpose Given the shortage of palliative care specialists in the U.S., to ensure quality of care for patients with serious, life-threatening illness, generalist-level palliative care competencies need to be defined and taught. The purpose of this study was to define essential competencies for medical students and internal medicine and family medicine (IM/FM) residents through a national survey of palliative care experts. Method Proposed competencies were derived from existing Hospice and Palliative Medicine fellowship competencies, and revised to be developmentally appropriate for students and residents. In spring 2012, the authors administered a web-based, national cross-sectional survey of palliative care educational experts to assess ratings and rankings of proposed competencies and competency domains. Results The authors identified 18 comprehensive palliative care competencies for medical students and IM/FM residents, respectively. Over 95% of survey respondents judged the competencies as comprehensive and developmentally appropriate (survey response rate=72%, 71/98). Using predefined cut-off criteria, experts identified 7 medical student and 13 IM/FM resident competencies as essential. Communication and pain/symptom management were rated as the most critical domains. Conclusions This national survey of palliative care experts defines comprehensive and essential palliative care competencies for medical students and IM/FM residents that are specific, measurable, and can be used to report educational outcomes; provide a sequence for palliative care curricula in undergraduate and graduate medical education; and highlight the importance of educating medical trainees in communication and pain management. Next steps include seeking input and endorsement from stakeholders in the broader medical education community. PMID:24979171
Schaefer, Kristen G; Chittenden, Eva H; Sullivan, Amy M; Periyakoil, Vyjeyanth S; Morrison, Laura J; Carey, Elise C; Sanchez-Reilly, Sandra; Block, Susan D
Given the shortage of palliative care specialists in the United States, to ensure quality of care for patients with serious, life-threatening illness, generalist-level palliative care competencies need to be defined and taught. The purpose of this study was to define essential competencies for medical students and internal medicine and family medicine (IM/FM) residents through a national survey of palliative care experts. Proposed competencies were derived from existing hospice and palliative medicine fellowship competencies and revised to be developmentally appropriate for students and residents. In spring 2012, the authors administered a Web-based, national cross-sectional survey of palliative care educational experts to assess ratings and rankings of proposed competencies and competency domains. The authors identified 18 comprehensive palliative care competencies for medical students and IM/FM residents, respectively. Over 95% of survey respondents judged the competencies as comprehensive and developmentally appropriate (survey response rate = 72%, 71/98). Using predefined cutoff criteria, experts identified 7 medical student and 13 IM/FM resident competencies as essential. Communication and pain/symptom management were rated as the most critical domains. This national survey of palliative care experts defines comprehensive and essential palliative care competencies for medical students and IM/FM residents that are specific, measurable, and can be used to report educational outcomes; provide a sequence for palliative care curricula in undergraduate and graduate medical education; and highlight the importance of educating medical trainees in communication and pain management. Next steps include seeking input and endorsement from stakeholders in the broader medical education community.
Full Text Available BackgroundPalliative care is recognized as an important component of care for children with cancer and other life-limiting conditions. In resource limited settings, palliative care is a key component of care for children with cancer and other life-limiting conditions. Globally, 98% of children who need palliative care live in low- or middle-income countries, where there are very few palliative care services available. There is limited evidence describing the practical considerations for the development and implementation of sustainable and cost-effective palliative care services in developing countries.ObjectivesOur aim is to describe the key considerations and initiatives that were successful in planning and implementing a hospital-based pediatric palliative care service specifically designed for a resource-limited setting.SettingBangabandu Sheikh Mujib Medical University (BSMMU is a tertiary referral hospital in Bangladesh. Local palliative care services are very limited and focused on adult patients. In partnership with World Child Cancer, a project establishing a pediatric palliative care service was developed for children with cancer at BSMMU.ResultsWe describe four key elements which were crucial for the success of this program: (1 raising awareness and sensitizing hospital administrators and clinical staff about pediatric palliative care; (2 providing education and training on pediatric palliative care for clinical staff; (3 forming a pediatric palliative care team; and (4 collecting data to characterize the need for pediatric palliative care.ConclusionThis model of a hospital-based pediatric palliative care service can be replicated in other resource-limited settings and can be expanded to include children with other life-limiting conditions. The development of pilot programs can generate interest among local physicians to become trained in pediatric palliative care and can be used to advocate for the palliative care needs of children.
Quillin, John M; Emidio, Oluwabunmi; Ma, Brittany; Bailey, Lauryn; Smith, Thomas J; Kang, In Guk; Yu, Brandon J; Owodunni, Oluwafemi Patrick; Abusamaan, Mohammed; Razzak, Rab; Bodurtha, Joann N
Even at the end of life, testing cancer patients for inherited susceptibility may provide life-saving information to their relatives. Prior research suggests palliative care inpatients have suboptimal understanding of genetic importance, and testing may be underutilized in this clinical setting. These conclusions are based on limited research. This study aimed to estimate genetic testing prevalence among high-risk palliative care patients in a National Cancer Institute-designated comprehensive cancer center. We also aimed to understand these patients' understanding of, and attitudes toward, hereditary cancer testing and DNA banking. Palliative care in-patients with cancer completed structured interviews, and their medical records were reviewed. Among patients at high risk for hereditary cancer, we assessed history of genetic testing/DNA banking; and related knowledge and attitudes. Among 24 high-risk patients, 14 (58.3%) said they/their relatives had genetic testing or they had been referred for a genetics consultation. Of the remaining 10 patients, seven (70%) said they would "probably" or "definitely" get tested. Patients who had not had testing were least concerned about the impact of future testing on their family relationships; two (20%) said they were "extremely concerned" about privacy related to genetic testing. Of patients without prior testing, five (50%) said they had heard or read "a fair amount" about genetic testing. No high-risk patients had banked DNA. Overall, 23 (95.8%) said they had heard or read "almost nothing" or "relatively little" about DNA banking. Written materials and clinician discussion were most preferred ways to learn about genetic testing and DNA banking. Overall, this study demonstrates underutilization of genetics services at the end of life continues to be problematic, despite high patient interest.
Benthien, K.S; Nordly, M.; Videbæk, K.
PURPOSE: The purposes of the present study were to classify the palliative care population (PCP) in a comprehensive cancer centre by using information on antineoplastic treatment options and to analyse associations between socio-demographic factors, cancer diagnoses, treatment characteristics...... and receiving specialist palliative care (SPC). METHODS: This is a cross-sectional screening study of patients with cancer in the Department of Oncology, Rigshospitalet, Copenhagen University Hospital for 6 months. Patients were assessed to be included in the DOMUS study: a randomised controlled trial...... of accelerated transition to SPC at home (NCT01885637). The PCP was classified as patients with incurable cancer and limited or no antineoplastic treatment options. Patients with performance status 2-4 were further classified as the essential palliative care population (EPCP). RESULTS: During the study period...
Spickermann, Maximilian; Lenz, Philipp
At the end of life patients with a life-limiting disease are often admitted to emergency departments (ED). Mostly, in the setting of an ED there may not be enough time to meet the needs for palliative care (PC) of these patients. Therefore, integration of PC into the ED offers a solution to improve their treatment. In the outpatient setting a cooperation between prehospital emergency services, the patient's general practitioner and specialized outpatient PC teams may allow the patient to die at home - this is what most patients prefer at the end of life. Furthermore, due to the earlier integration of PC after admission the hospital stay is shortened. Also the number of PC consultations may increase. Additionally, a screening of PC hneeds among all patients visiting the ED may be beneficial: to avoid not meeting existing PC needs and to standardize the need of PC consultation. An example for such a screening tool is the "Palliative Care and Rapid Emergency Screening" (P-CaRES). © Georg Thieme Verlag KG Stuttgart · New York.
Full Text Available ... views 11:08 Mia Tatun - Albany Medical Center Children's Hospital - Journeys Palliative Care Story - Duration: 3:32. ... 4:01 Mitochondrial Disease Patient Story - Cleveland Clinic Children's Hospital - Duration: 4:17. Cleveland Clinic 82,065 ...
MacDonald, Julie M; Barrett, David
To evaluate and critique current knowledge regarding the role of animals in palliative care. To explore the impact that animals may have on the well-being of individuals and to identify gaps in the evidence base. There is recognition that having a companion animal will affect patient experience. Similarly, there has been some previous exploration on the use of specific animal assisted therapies for patients with different healthcare needs. A literature review was conducted to identify published and unpublished research about companion animals or animal-assisted therapy in palliative and/or end-of-life care. The primary objective was to explore the impact of animals on well-being at the end of life. A search for literature was carried out using a variety of databases and different combinations of search terms linked to animals in palliative care. Included works were critically appraised and thematically analysed. A limited range of literature was identified. From the small number of studies included in the review (n = 4), it appears that there is some evidence of animals (either companion animals or those used specifically to enhance care) having a positive impact on the patient experience. This study suggests that animals play a large part in the lives of people receiving palliative care. Using animals to support care may also offer some benefits to the patient experience. However, there appears to be a dearth of high-quality literature in this area. More research is therefore required. Nurses providing palliative care need to be aware of the part that a companion animal may play in the life of patients. There may also be the opportunity for nurses in some settings to integrate animal therapy into their provision of palliative care. © 2015 John Wiley & Sons Ltd.
Full Text Available Background: Palliative medicine is an upcoming new specialty aimed at relieving suffering, improving quality of life and comfort care. There are many challenges and barriers in providing palliative care to our patients. The major challenge is lack of knowledge, attitude and skills among health-care providers. Objectives: Evaluate the effectiveness of the certificate course in essentials of palliative care (CCEPC program on the knowledge in palliative care among the participants. Subjects and Methods: All participants (n = 29 of the CCEPC at All India Institute of Medical Sciences, Delhi, giving consent for pretest and posttest were recruited in the study. This educational lecture of 15 h was presented to all the participants following pretest and participants were given same set of questionnaire to be filled as postintervention test. Results: In pretest, 7/29 (24.1% had good knowledge which improved to 24/29 (82.8% after the program. In pretest, 62.1% had average knowledge and only 13.8% had poor knowledge. There was also improvement in communication skills, symptom management, breaking bad news, and pain assessment after completion of the program. Conclusion: The CCEPC is an effective program and improving the knowledge level about palliative care among the participants. The participants should implement this knowledge and the skills in their day-to-day practice to improve the quality of life of patients.
De Blas Gómez, Irene; Rodríguez García, Marta
To care for palliative patients is essential that healthcare professionals develop emotional competencies. This means acquiring the habit of self reflection and be emphatic with other people, in order to be able to identify the personal emotions of patients, family and team. Reflection involves a continuing effort to reason about aspects of professional practice, especially on issues as complex as suffering and death. Both reflective reasoning and emotional management are vital in an Aid Relationship. For nursing healthcare professionals, to care the emotional aspects means becoming aware of their own and others feelings, and get to understand and accept to handle them properly. Nursing actions involves many qualities of social competence, such as empathy, understanding, communication skills, honesty, flexibility and adaptability to the individual needs of people cared. In the context of palliative care patients and their families all these aspects are fundamental and are part of the same philosophy. Emotional education still remains a challenge in our profession both in the initial and continuing training.
Garralda, E.; Hasselaar, J.G.; Carrasco, J.M.; Beek, K.; Siouta, N.; Csikos, A.; Menten, J.; Centeno, C.
BACKGROUND: Integrated palliative care (IPC) involves bringing together administrative, organisational, clinical and service aspects in order to achieve continuity of care between all actors involved in the care network of patients receiving palliative care (PC) services. The purpose of this study
Koekkoek, Johan A F; Chang, Susan; Taphoorn, Martin J B
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.
Full Text Available ... patient's and family's experience with illness. Category Science & Technology License Standard YouTube License Show more Show less ... Pediatric Palliative Care - Duration: 5:39. Northeast Ohio Medical University (NEOMED) 27,094 views 5:39 Faces ...
Full Text Available ... Rachel—a pediatric neuroblastoma patient—and her family. The story demonstrates how palliative care can positively influence a patient's and family's experience with illness. Category Science & Technology License Standard YouTube License Show more Show ...
Full Text Available ... a pediatric neuroblastoma patient—and her family. The story demonstrates how palliative care can positively influence a patient's and family's experience with illness. Category Science & Technology License Standard YouTube License Show more Show less ...
Nikbakht-Van de Sande, C V M Vahedi; van der Rijt, C C D; Visser, A Ph; ten Voorde, M A; Pruyn, J F A
stimulate mutual collaboration, improve accessibility to health care services and increase the quality of these services. The most important achievements obtained by the palliative care networks were: increase in personal contacts between colleagues in a region, improved engagement and collaboration between participating organizations, enhanced insight in the health care provisions, joined initiatives for the development of new care products, and organization of patient-tailored care. Important success factors for the networks were deemed: fruitful mutual contacts, regular funding and the collective development of care products. By logistic regression analyses, the collective development of new care products and the organization of case discussions between caregivers from different health care services turned out to be the most important predictors for success of the palliative care networks. Projects that stimulate the communication between professionals appear to improve the mutual collaboration between individual participants and between the participating organizations, which consequently enhances the quality of palliative care.
Guo, Qiaohong; Cann, Beverley; McClement, Susan; Thompson, Genevieve; Chochinov, Harvey Max
Hospitalized palliative patients need to keep in touch with their loved ones. Regular social contact may be especially difficult for individuals on palliative care in-patient units due to the isolating nature of hospital settings. Technology can help mitigate isolation by facilitating social connection. This study aimed to explore the acceptability of introducing internet-based communication and information technologies for patients on a palliative care in-patient unit. In the first phase of the Keep in Touch (KIT) project, a diverse group of key informants were consulted regarding their perspectives on web-based communication on in-patient palliative care units. Participants included palliative patients, family members, direct care providers, communication and information technology experts, and institutional administrators. Data was collected through focus groups, interviews and drop-in consultations, and was analyzed for themes, consensus, and major differences across participant groups. Hospitalized palliative patients and their family members described the challenges of keeping in touch with family and friends. Participants identified numerous examples of ways that communication and information technologies could benefit patients' quality of life and care. Patients and family members saw few drawbacks associated with the use of such technology. While generally supportive, direct care providers were concerned that patient requests for assistance in using the technology would place increased demands on their time. Administrators and IT experts recognized issues such as privacy and costs related to offering these technologies throughout an organization and in the larger health care system. This study affirmed the acceptability of offering internet-based communication and information technologies on palliative care in-patient units. It provides the foundation for trialing these technologies on a palliative in-patient unit. Further study is needed to confirm the
Sigurdardottir, Katrin Ruth; Oldervoll, Line; Hjermstad, Marianne Jensen; Kaasa, Stein; Knudsen, Anne Kari; Løhre, Erik Torbjørn; Loge, Jon Håvard; Haugen, Dagny Faksvåg
The difficulties in defining a palliative care patient accentuate the need to provide stringent descriptions of the patient population in palliative care research. To conduct a systematic literature review with the aim of identifying which key variables have been used to describe adult palliative care cancer populations in randomized controlled trials (RCTs). The data sources used were MEDLINE (1950 to January 25, 2010) and Embase (1980 to January 25, 2010), limited to RCTs in adult cancer patients with incurable disease. Forty-three variables were systematically extracted from the eligible articles. The review includes 336 articles reporting RCTs in palliative care cancer patients. Age (98%), gender (90%), cancer diagnosis (89%), performance status (45%), and survival (45%) were the most frequently reported variables. A large number of other variables were much less frequently reported. A substantial variation exists in how palliative care cancer populations are described in RCTs. Few variables are consistently registered and reported. There is a clear need to standardize the reporting. The results from this work will serve as the basis for an international Delphi process with the aim of reaching consensus on a minimum set of descriptors to characterize a palliative care cancer population. Copyright © 2014 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
Wittenberg, Elaine; Ferrell, Betty; Goldsmith, Joy; Ragan, Sandra L; Paice, Judith
Despite increased attention to communication skill training in palliative care, few interprofessional training programs are available and little is known about the impact of such training. This study evaluated a communication curriculum offered to interprofessional palliative care teams and examined the longitudinal impact of training. Interprofessional, hospital-based palliative care team members were competitively selected to participate in a two-day training using the COMFORT(TM SM) (Communication, Orientation and options, Mindful communication, Family, Openings, Relating, Team) Communication for Palliative Care Teams curriculum. Course evaluation and goal assessment were tracked at six and nine months postcourse. Interprofessional palliative care team members (n = 58) representing 29 teams attended the course and completed course goals. Participants included 28 nurses, 16 social workers, 8 physicians, 5 chaplains, and one psychologist. Precourse surveys assessed participants' perceptions of institution-wide communication performance across the continuum of care and resources supporting optimum communication. Postcourse evaluations and goal progress monitoring were used to assess training effectiveness. Participants reported moderate communication effectiveness in their institutions, with the weakest areas being during bereavement and survivorship care. Mean response to course evaluation across all participants was greater than 4 (scale of 1 = low to 5 = high). Participants taught an additional 962 providers and initiated institution-wide training for clinical staff, new hires, and volunteers. Team member training improved communication processes and increased attention to communication with family caregivers. Barriers to goal implementation included a lack of institutional support as evidenced in clinical caseloads and an absence of leadership and funding. The COMFORT(TM SM) communication curriculum is effective palliative care communication
Manjiri P Dighe
Full Text Available Recent advances in medical care have improved the survival of newborn babies born with various problems. Despite this death in the neonatal intensive care unit (NICU is an inevitable reality. For babies who are not going to "get better," the health care team still has a duty to alleviate the physical suffering of the baby and to support the family. Palliative care is a multidisciplinary approach to relieve the physical, psycho social, and spiritual suffering of patients and their families. Palliative care provision in the Indian NICU settings is almost nonexistent at present. In this paper we attempt to "build a case" for palliative care in the Indian NICU setting.
Sarabia-Cobo, Carmen María; Alconero-Camarero, Ana Rosa; Lavín-Alconero, Lucía; Ibáñez-Rementería, Isabel
Major deficiencies exist in undergraduate nursing education for Palliative Care. Opportunities to care for dying patients are often unavailable to students in traditional clinical settings. Palliative care simulation is an innovative strategy that may help to prepare undergraduate nursing students to provide quality palliative/end of life care. It is valuable to explore the student nurses' beliefs, feelings and satisfaction regarding the impact that simulation clinic applied to palliative care has and how it influenced their overall experience of caring for a dying patient and the patient's family. This study aimed to evaluate a learning intervention in palliative care using a low-fidelity clinical simulation for undergraduate nursing students from a Spanish university, based on the analytics of their expectations and learning objectives. Sixty-eight students participated in this mixed descriptive design study, they participated in a palliative care simulation scenario and completed three questionnaires which assess the knowledge and expectations before the simulation and the subsequent satisfaction with the performance and learning received. The intervention in question met students' learning expectations, singling out social abilities as important tools in palliative care training, and the students were satisfied with the presented case studies. Our results suggest that low-fidelity clinical simulation intervention training in palliative care is an appropriate and low-cost tool for acquiring competitive skills. Learning in the simulation scenarios provides a mechanism for students to improve student communication skills. Copyright © 2016 Elsevier Ltd. All rights reserved.
Gamondi, Claudia; Borasio, Gian Domenico; Oliver, Pam; Preston, Nancy; Payne, Sheila
Assisted suicide in Switzerland is mainly performed by right-to-die societies. Medical involvement is limited to the prescription of the drug and certification of eligibility. Palliative care has traditionally been perceived as generally opposed to assisted suicide, but little is known about palliative care physicians' involvement in assisted suicide practices. This paper aims to describe their perspectives and involvement in assisted suicide practices. A qualitative interview study was conducted with 23 palliative care physicians across Switzerland. Thematic analysis was used to interpret data. Swiss palliative care physicians regularly receive assisted suicide requests while none reported having received specific training in managing these requests. Participants reported being involved in assisted suicide decision making most were not willing to prescribe the lethal drug. After advising patients of the limits on their involvement in assisted suicide, the majority explored the origins of the patient's request and offered alternatives. Many participants struggled to reconcile their understanding of palliative care principles with patients' wishes to exercise their autonomy. The majority of participants had no direct contact with right-to-die societies, many desired better collaboration. A desire was voiced for a more structured debate on assisted suicide availability in hospitals and clearer legal and institutional frameworks. The Swiss model of assisted suicide gives palliative care physicians opportunities to develop roles which are compatible with each practitioner's values, but may not correspond to patients' expectations. Specific education for all palliative care professionals and more structured ways to manage communication about assisted suicide are warranted. © 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.
Benitez-Rosario, Miguel Angel; Castillo-Padrós, Manuel; Garrido-Bernet, Belén; Ascanio-León, Belen
The European Association for Palliative Care and the U.S. National Hospice and Palliative Care Organization have published statements that recommend an audit of palliative sedation practices. The aim was to assess the feasibility of a quality care project in palliative sedation. We carried out an audit of adherence to a guideline regarding palliative sedation, undertaken as a yearly assessment during two years, of a sample of patient charts. With an audit tool, the charts were evaluated as to the presence of the ethical sedation checklist, information that justified palliative sedation, patient and/or family agreement, and the appropriateness of treatment in concordance with the clinical protocol. An educational program and result feedback meetings were used as the implementation strategy. Roughly 25% of the medical charts of patients who died in the palliative care unit were evaluated, 94 in 2007 and 110 in 2008. In 2007 and 2008, 63% and 57% of the patients, respectively, whose median age was 65 years, were sedated, with a median length of two days. The main reason for sedation was agitation concomitant with respiratory failure in roughly 60% and 75% of the cases in 2007 and 2008, respectively. Agreement of the patient/family about sedation was collected from 100% of the cases. The concordance of procedures with the sedation guideline was 100% in both years. Our quality-of-care strategy was shown to obtain a higher level of compliance with the palliative sedation guideline for at least two years. Copyright © 2012 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
Koper, Ian; van der Heide, Agnes; Janssens, Rien; Swart, Siebe; Perez, Roberto; Rietjens, Judith
Palliative sedation is considered a normal medical practice by the Royal Dutch Medical Association. Therefore, consultation of an expert is not considered mandatory. The European Association of Palliative Care (EAPC) framework for palliative sedation, however, is more stringent: it considers the use of palliative sedation without consulting an expert as injudicious and insists on input from a multi-professional palliative care team. This study investigates the considerations of Dutch physicians concerning consultation about palliative sedation with specialist palliative care services. Fifty-four physicians were interviewed on their most recent case of palliative sedation. Reasons to consult were a lack of expertise and the view that consultation was generally supportive. Reasons not to consult were sufficient expertise, the view that palliative sedation is a normal medical procedure, time pressure, fear of disagreement with the service and regarding consultation as having little added value. Arguments in favour of mandatory consultation were that many physicians lack expertise and that palliative sedation is an exceptional intervention. Arguments against mandatory consultation were practical obstacles that may preclude fulfilling such an obligation (i.e. lack of time), palliative sedation being a standard medical procedure, corroding a physician's responsibility and deterring physicians from applying palliative sedation. Consultation about palliative sedation with specialist palliative care services is regarded as supportive and helpful when physicians lack expertise. However, Dutch physicians have both practical and theoretical objections against mandatory consultation. Based on the findings in this study, there seems to be little support among Dutch physicians for the EAPC recommendations on obligatory consultation.
Gordon, Robert; Eagar, Kathy; Currow, David; Green, Janette
This article overviews current funding and financing issues in the Australian hospice and palliative care sector. Within Australia, the major responsibilities for managing the health care system are shared between two levels of government. Funding arrangements vary according to the type of care. The delivery of palliative care services is a State/Territory responsibility. Recently, almost all States/Territories have developed overarching frameworks to guide the development of palliative care policies, including funding and service delivery structures. Palliative care services in Australia comprise a mix of specialist providers, generalist providers, and support services in the public, nongovernment, and private sectors. The National Palliative Care Strategy is a joint strategy of the Commonwealth and States that commenced in 2002 and includes a number of major issues. Following a national study in 1996, the Australian National Subacute and Nonacute Patient (AN-SNAP) system was endorsed as the national casemix classification for subacute and nonacute care. Funding for palliative care services varies depending on the type of service and the setting in which it is provided. There is no national model for funding inpatient or community services, which is a State/Territory responsibility. A summary of funding arrangements is provided in this article. Palliative care continues to evolve at a rapid rate in Australia. Increasingly flexible evidence-based models of care delivery are emerging. This article argues that it will be critical for equally flexible funding and financing models to be developed. Furthermore, it is critical that palliative care patients can be identified, classified, and costed. Casemix classifications such as AN-SNAP represent an important starting point but further work is required.
Larkin, Philip J; Dierckx de Casterlé, Bernadette; Schotsmans, Paul
This paper is a report of a concept evaluation of transience and its relevance to palliative care. A qualitative study into palliative care patients' experiences of transition revealed a gap between current definitions of transition and their expression of the palliative care experience. Transience appears to offer a better definition but remains conceptually weak, with limited definition in a healthcare context. A qualitative conceptual evaluation of transience was undertaken using two case examples, interview data and the literature. Multiple sources were used to identify the literature (1966-2006), including a search on Cumulative Index to Nursing and Allied Health Literature Medline, and Ovid and Arts and Humanities Index using the keywords 'transience' and 'palliative care'. Thirty-one papers related to transience were retrieved. Analysis and synthesis formulated a theoretical definition of transience relative to palliative care. Transience is a nascent concept. Preconditions and outcomes of transience appear contextually dependent, which may inhibit its conceptual development. Transience depicts a fragile emotional state related to sudden change and uncertainty at end-of-life, exhibited as a feeling of stasis. Defining attributes would seem to include fragility, suddenness, powerlessness, impermanence, time, space, uncertainty, separation and homelessness. Transience is potentially more meaningful for palliative care in understanding the impact of end-of-life experiences for patients than current conceptualizations of transition as a process towards resolution. As a nascent concept, it remains strongly encapsulated within a framework of transition and further conceptual development is needed to enhance its maturity and refinement.
The subject of death denial in the West has been examined extensively in the sociological literature. However, there has not been a similar examination of its "opposite", the acceptance of death. In this study, I use the qualitative method of discourse analysis to examine the use of the term "acceptance" of dying in the palliative care literature from 1970 to 2001. A Medline search was performed by combining the text words "accept or acceptance" with the subject headings "terminal care or palliative care or hospice care", and restricting the search to English language articles in clinical journals discussing acceptance of death in adults. The 40 articles were coded and analysed using a critical discourse analysis method. This paper focuses on the theme of acceptance as integral to palliative care, which had subthemes of acceptance as a goal of care, personal acceptance of healthcare workers, and acceptance as a facilitator of care. For patients and families, death acceptance is a goal that they can be helped to attain; for palliative care staff, acceptance of dying is a personal quality that is a precondition for effective practice. Acceptance not only facilitates the dying process for the patient and family, but also renders care easier. The analysis investigates the intertextuality of these themes with each other and with previous texts. From a Foucauldian perspective, I suggest that the discourse on acceptance of dying represents a productive power, which disciplines patients through apparent psychological and spiritual gratification, and encourages participation in a certain way to die. Copyright © 2012 Elsevier Ltd. All rights reserved.
Azuero, Casey; Allen, Rebecca Sue; Kvale, Elizabeth; Azuero, Andres; Parmelee, Patricia
Research has demonstrated that treating cancer patients' psychological and physical health leads to improved overall health. This may be especially true for palliative care patients facing serious illness. This study examines the proportion and determinants of psychology service utilization in an outpatient palliative care population. Data from an existing clinical database in an outpatient palliative clinic utilizing a collaborative care model to deliver psychology services were explored. This study was framed by Andersen's Behavioral Model of Health Service Use, which incorporates three main components: predisposing, enabling, and need factors to model health service utilization. The sample (N = 149) was majority middle aged, female, and White with a primary diagnosis of cancer. Cross-tabulations were conducted to determine how many patients who met screening criteria for depression or anxiety sought psychology services. Logistic regression analyses were conducted to assess for predisposing, enabling, and need factor determinants of psychology service utilization. Among patients who met criteria for moderate depression or anxiety, 50% did not access readily available psychology services. Enabling factors were the strongest determinant of psychology utilization. Factors associated with need for psychology services (i.e., emotional distress and psychological symptom burden) did not reach significance in determining psychology service use. This study extends current knowledge about psychology utilization to palliative care outpatients receiving care within a collaborative care model. Directions for future research include further investigation of care models that optimize enabling strategies to enhance access to these services, and examination of patient-reported barriers to receiving this care. Copyright © 2013 John Wiley & Sons, Ltd.
On 27th June 2007, Malawi's first dedicated palliative care centre, Ndi Moyo, was officially opened by the Honourable. Marjorie Ngaunje, the then Minister of Health. Over 260 patients have registered since August 2006 when they first started to receive treatment for relief of severe and chronic pain which is frequently related ...
Creutzfeldt, Claire J; Hanna, Marina G; Cheever, C Sherry; Lele, Abhijit V; Spiekerman, Charles; Engelberg, Ruth A; Curtis, J Randall
Examine the association of a daily palliative care needs checklist on outcomes for family members of patients discharged from the neurosciences intensive care unit (neuro-ICU). We conducted a prospective, longitudinal cohort study in a single, thirty-bed neuro-ICU in a regional comprehensive stroke and level 1 trauma center. One of two neuro-ICU services that admit patients to the same ICU on alternating days used a palliative care needs checklist during morning work rounds. Between March and October, 2015, surveys were mailed to family members of patients discharged from the neuro-ICU. Nearly half of surveys (n = 91, 48.1%) were returned at a median of 4.7 months. At the time of survey completion, mean Modified rankin scale score (mRS) of neuro-ICU patients was 3.1 (SD 2). Overall ratings of quality of care were relatively high (82.2 on a 0-100 scale) with 32% of family members meeting screening criteria for depressive syndrome. The primary outcome measuring family satisfaction, consisting of eight items from the Family Satisfaction in the ICU questionnaire, did not differ significantly between families of patients from either ICU service nor did family ratings of depression (PHQ-8) and post-traumatic stress (PCL-17). Among families of patients discharged from the neuro-ICU, the daily use of a palliative care needs checklist had no measurable effect on family satisfaction scores or long-term psychological outcomes. Further research is needed to identify optimal interventions to meet the palliative care needs specific to family members of patients treated in the neuro-ICU.
Löfmark, Rurik; Nilstun, Tore; Bolmsjö, Ingrid Agren
In the transition from curative treatment to palliative care of a general end-of-life patient population, the internal communication of the acute care staff seems to be less than optimal. The communication had reference to the dialogue within the staff both before and after the decision to concentrate on palliative care, and possible transfer of the patient. This survey of Swedish nurses and physicians showed that most of 780 respondents wanted more internal communication, and a more individualized procedure of decision-making. All staff should be informed about the decision made but full agreement was not seen as realistic. The largest difference of opinion between nurses and physicians concerned the involvement of nurses in the decision-making about the transition. A uniform documentation of the decision to transfer care focus was the ideal. Approximately every fourth patient in acute care is transferred to receive palliative care. Only approximately half of the respondents had any training in palliative care and the majority wanted more training. There seems to be a need for more palliative care training, perhaps somewhat different for each specialty. Furthermore, a common language to enable nurses and physicians to communicate more easily may improve the transition process.
Meaghann S. Weaver
Full Text Available Pediatric palliative care studies often rely on proxy-reported instead of direct child-reported quality of life metrics. The purpose of this study was to longitudinally evaluate quality of life for pediatric patients receiving palliative care consultations and to compare patient-reported quality of life with parent perception of the child’s quality of life across wellness domains. The 23-item PedsQL™ V4.0 Measurement Model was utilized for ten child and parent dyads at time of initial palliative care consultation, Month 6, and Month 12 to assess for physical, emotional, social, and cognitive dimensions of quality of life as reported independently by the child and by the parent for the child. Findings were analyzed using Bland–Altman plots to compare observed differences to limits of agreement. This study revealed overall consistency between parent- and child-reported quality of life across domains. Physical health was noted to be in closest agreement. At the time of initial palliative care consult, children collectively scored their social quality of life higher than parental perception of the child’s social quality of life; whereas, emotional and cognitive quality of life domains were scored lower by children than by the parental report. At the one year survey time point, the physical, emotional, and social domains trended toward more positive patient perception than proxy perception with congruence between quality of life scores for the cognitive domain. Findings reveal the importance of eliciting a child report in addition to a parent report when measuring and longitudinally trending perceptions on quality of life.
Fan, Sheng-Yu; Lin, Wei-Chun; Lin, I-Mei
The aim of this study was to explore the works of clinical psychologists in palliative care in Taiwan. Clinical psychologists who were working or had experience in palliative care were recruited. A 2-stage qualitative method study was conducted, including semistructured interviews and a focus group. The following 4 main themes were identified: (1) the essential nature of the psychologists' care were caring and company; (2) the dynamic process included psychological assessment, intervention, and evaluation based on psychological knowledge; (3) they needed to modify their care using an integrative framework, by setting practical goals and using techniques with flexibility; and (4) they faced external and internal challenges in this field. Clinical psychologists have beneficial contributions but have to modify psychosocial care based on the patients' needs and clinical situations. © The Author(s) 2014.
Fox, Jennifer; Windsor, Carol; Connell, Shirley; Yates, Patsy
The positioning and meaning of palliative care within the healthcare system lacks clarity which adds a level of complexity to the process of transition to palliative care. This study explores the transition to the palliative care process in the acute care context of metastatic melanoma. A theoretical framework drawing on interpretive and critical traditions informs this research. The pragmatism of symbolic interactionism and the critical theory of Habermas brought a broad orientation to the research. Integration of the theoretical framework and grounded-theory methods facilitated data generation and analysis of 29 interviews with patients, family carers, and healthcare professionals. The key analytical findings depict a scope of palliative care that was uncertain for users of the system and for those working within the system. Becoming "palliative" is not a defined event; nor is there unanimity around referral to a palliative care service. As such, ambiguity and tension contribute to the difficulties involved in negotiating the transition to palliative care. Our findings point to uncertainty around the scopes of practice in the transition to palliative care. The challenge in the transition process lies in achieving greater coherency of care within an increasingly specialized healthcare system. The findings may not only inform those within a metastatic melanoma context but may contribute more broadly to palliative practices within the acute care setting.
Full Text Available ... The Keeney Family discuss pediatric palliative care - Duration: 12:07. Hospice of the Western Reserve 12,073 views 12:07 Perinatal Palliative Care - The Zimmer Family Story - ...
Sakashita, Akihiro; Kishino, Megumi; Nakazawa, Yoko; Yotani, Nobuyuki; Yamaguchi, Takashi; Kizawa, Yoshiyuki
To clarify how highly active hospital palliative care teams can provide efficient and effective care regardless of the lack of full-time palliative care physicians. Semistructured focus group interviews were conducted, and content analysis was performed. A total of 7 physicians and 6 nurses participated. We extracted 209 codes from the transcripts and organized them into 3 themes and 21 categories, which were classified as follows: (1) tips for managing palliative care teams efficiently and effectively (7 categories); (2) ways of acquiring specialist palliative care expertise (9 categories); and (3) ways of treating symptoms that are difficult to alleviate (5 categories). The findings of this study can be used as a nautical chart of hospital-based palliative care team (HPCT) without full-time PC physician. Full-time nurses who have high management and coordination abilities play a central role in resource-limited HPCTs. © The Author(s) 2015.
Full Text Available Terrah L Foster,1,2 Cynthia J Bell,1 Carey F McDonald,2 Joy S Harris,3 Mary Jo Gilmer,1,21Vanderbilt University School of Nursing, Nashville, 2Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, 3Vanderbilt University, Nashville, TN, USAAbstract: Pediatric palliative care aims to enhance life and decrease suffering of children and adolescents living with life-threatening conditions and their loved ones. Oncology nurses are instrumental in providing palliative care to pediatric oncology populations. This paper describes pediatric palliative care and provides an overview of literature related to the physical, psychological, social, and spiritual domains of palliative nursing care for children and adolescents with cancer. Nurses can provide optimal palliative care by accounting for children's understanding of death, encouraging early initiation of palliative care services, and improving utilization of pediatric palliative care in cancer settings. Specific roles of registered nurses and advanced practice nurses in pediatric palliative care will be addressed. Recommendations for future research are made to further advance the science of pediatric palliative care and decrease suffering for children and teens with cancer.Keywords: pediatric palliative care, pediatric cancer, oncology, child, suffering
Hall, Pippa; Weaver, Lynda; Gravelle, Debbie; Thibault, Hélène
Maximizing interprofessional collaborative patient-centred practice holds promise for improving patient care and creating satisfying work roles. In Canada's evolving health care system, there are demands for increased efficiency, cost-effectiveness, and quality improvement. Interprofessional collaboration warrants re-examination because maximizing interprofessional collaboration, especially nurse-physician collaboration, holds promise for improving patient care and creating satisfying work roles. A palliative care team seized the opportunity to pilot a different approach to patient and family care when faced with a reduction in medical staff. Grounded in a collaborative patient-centred practice approach, the Canadian Hospice Palliative Care Association's National Model to Guide Hospice Palliative Care (2002), and outcomes from program retreats and workgroups, a collaborative person-centred model of care was developed for a 12-bed pilot project. Preliminary findings show that the pilot project team perceived some specific benefits in continuity of care and interprofessional collaboration, while the presence of the physician was reduced to an average of 3.82 hours on the pilot wing, compared with 8 hours on the non-pilot wings. This pilot study suggests that a person-centred model, when focused on the physician-nurse dyad, may offer improved efficiency, job satisfaction and continuity of care on a palliative care unit. Incorporating all team members and developing strategies to successfully expand the model across the whole unit are the next challenges. Further research into the impact of these changes on the health care professionals, management and patients and families is essential.
Ho, Andy Hau Yan; Chan, Cecilia Lai Wan; Leung, Pamela Pui Yu; Chochinov, Harvey Max; Neimeyer, Robert A; Pang, Samantha Mei Che; Tse, Doris Man Wah
the empirical Dignity Model has profoundly influenced the provision of palliative care for older terminally ill patients in the West, as it provides practical guidance and intervention strategies for promoting dignity and reducing distress at the end-of-life. to examine the concept of 'living and dying with dignity' in the Chinese context, and explore the generalisability of the Dignity Model to older terminal patients in Hong Kong. using qualitative interviews, the concept of dignity was explored among 16 older Chinese palliative care patients with terminal cancer. Framework analysis with both deductive and inductive methods was employed. the three major categories of themes of the Dignity Model were broadly supported. However, the subtheme of death anxiety was not supported, while two subthemes of generativity/legacy and resilience/fighting spirit manifested differently in the Chinese context. Furthermore, four new emergent themes have been identified. They include enduring pain, moral transcendence, spiritual surrender and transgenerational unity. these findings highlight both a cultural and a familial dimension in the construct of dignity, underline the paramount importance of cultural awareness and competence for working with ethnically diverse groups, and call for a culturally sensitive and family oriented approach to palliative care interventions with older Chinese terminal patients.
Gielen, Joris; Van den Branden, Stef; van Iersel, Trudie; Broeckaert, Bert
Palliative sedation is an option of last resort to control refractory suffering. In order to better understand palliative-care nurses’ attitudes to palliative sedation, an anonymous questionnaire was sent to all nurses (589) employed in palliative care in Flanders (Belgium). In all, 70.5% of the nurses (n=415) responded. A large majority did not agree that euthanasia is preferable to palliative sedation, were against non-voluntary euthanasia in the case of a deeply and continuously sedated pa...
Hongoro, Charles; Dinat, Natalya
Increasing access to palliative care services in low- and middle-income countries is often perceived as unaffordable despite the growing need for such services because of the increasing burden of chronic diseases including HIV and AIDS. The aim of the study was to establish the costs and cost drivers for a hospital outreach palliative care service in a low-resource setting, and to elucidate possible consequential quality-of-life improvements and potential cost savings. The study used a cost accounting procedure to cost the hospital outreach services--using a step-down costing method to measure unit (average) costs. The African Palliative Care Association Palliative Outcome Score (APCA POS) was applied at five intervals to a cohort of 72 consecutive and consenting patients, enrolled in a two-month period. The study found that of the 481 and 1902 patients registered for outreach and in-hospital visits, respectively, 4493 outreach hospital visits and 3412 in-hospital visits were done per year. The costs per hospital outreach visit and in-hospital visit were US$71 and US$80, respectively. The cost per outreach visit was 50% less than the average cost of a patient day equivalent for district hospitals of $142. Some of the POS of a subsample (n=72) showed statistically significant improvements. Hospital outreach services have the potential to avert hospital admissions in generally overcrowded services in low-resource settings and may improve the quality of life of patients in their home environments. Copyright © 2011 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
Full Text Available Aim: To study the epidemiological profile, clinical symptoms and referral patterns of patients with gynecological malignancy. To evaluate pain symptoms, response to treatment and factors affecting management in patients with advanced gynecological malignancies. Methods: A retrospective analysis was performed of the gynecological malignancy cases registered at the Pain and Palliative Care Clinic, Calicut, over a 12-month period between January 2006 and December 2006.Patient characteristics, symptoms and response to treatment were evaluated in detail. Results: A total of 1813 patients registered, of which 64 had gynecological malignancies. Most of the cases were referred from the Oncology Department of the Calicut Medical College. Fifty-five percent of the patients were unaware of their diagnosis. Psychosocial issues and anxiety were observed in 48%. Insomnia was seen in 52% of the cases. Pain was the most common and most distressing symptom. Adequate pain relief was achieved in only 32% of the patients. Conclusions: The number of gynecological malignancy cases attending the Pain and Palliative Care Clinic is small. Pain is the most common and distressing symptom, with only 32% of the patients achieving adequate pain relief. Poor drug compliance, incomplete assessment of pain and the lack of awareness of morphine therapy were identified as the most common causes for poor pain control.
Dellon, E P; Goggin, J; Chen, E; Sabadosa, K; Hempstead, S E; Faro, A; Homa, K
The goal of palliative care is to improve quality of life for people with serious illness. We aimed to create a cystic fibrosis (CF)-specific definition of palliative care. A working group of 36 CF care providers, researchers, palliative care providers, quality improvement experts, individuals with CF, and CF caregivers completed a series of questionnaires to rate the value of each of 22 attributes of palliative care, rank top attributes to construct definitions of palliative care, and then rate proposed definitions. An average of 28 participants completed each of four questionnaires, with consistent distribution of stakeholder roles across questionnaires. Many identified overlaps in routine CF care and palliative care and highlighted the importance of a definition that feels relevant across the lifespan. Modified Delphi methodology was used to define palliative care in CF. The definition will be used as the foundation for development of CF-specific palliative care guidelines. Copyright © 2017 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved.
Cameron, Dee; Johnston, Bridget
Recent worldwide economic events have forced an examination of the nurse's contribution to high-quality, effective, person-centred care. Since the role of specialist nurses is considered one of the least understood or valued developments in nursing, specialist nurses must demonstrate their contribution to quality, person-centred health care. To develop a questionnaire which aims to measure the quality of care provided by palliative care specialist nurses from the patients' perspective and to undertake initial validation. The process of questionnaire development involved six phases including systematic literature reviews, patient advisory groups and expert panel reviews, each of which contributed to the questionnaire face and content validity. Johnston's Expert Palliative Care Nurse Model (2002; 2005) provided an evidence-based framework for the development of the questionnaire, and enabled the identification of the key attributes of the palliative care specialist nurse role, thereby providing the themes on which to base the questionnaire. The Quality Measure for Palliative Nursing, a questionnaire, was developed. The themes identified in the questionnaire--personal characteristics, communication skills, knowledge, relationship with patient and providing comfort--aim to facilitate measurement of the quality of care provided by palliative care specialist nurses. Designed for use by palliative patients the Quality Measure for Palliative Nursing is a one-page questionnaire comprising of 15 questions. The Quality Measure for Palliative Nursing is unique since it aims to measure the quality of care provided by community palliative care specialist nurses, and could also be used to measure patient satisfaction with the quality of care provided. Further testing is recommended to ensure that this questionnaire can provide reliable and valid results.
Tripathy, Swagata; Routray, Pragyan K; Mishra, Jagdish C
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.
Full Text Available ... and Legacy through Pediatric Palliative Care - Duration: 5:39. Northeast Ohio Medical University (NEOMED) 26,045 views 5:39 Little Stars – Paediatric Palliative Care – Charlie's Story - Duration: ...
Full Text Available Barbara A Head,1 Tara J Schapmire,1 Lori Earnshaw,1 John Chenault,2 Mark Pfeifer,1 Susan Sawning,3 Monica A Shaw,3 1Division of General Internal Medicine, Palliative Care and Medical Education, University of Louisville School of Medicine, 2Kornhouser Health Sciences Library, University of Louisville, 3Undergraduate Medical Education Office, University of Louisville School of Medicine, Louisville, KY, USA Abstract: The needs of an aging population and advancements in the treatment of both chronic and life-threatening diseases have resulted in increased demand for quality palliative care. The doctors of the future will need to be well prepared to provide expert symptom management and address the holistic needs (physical, psychosocial, and spiritual of patients dealing with serious illness and the end of life. Such preparation begins with general medical education. It has been recommended that teaching and clinical experiences in palliative care be integrated throughout the medical school curriculum, yet such education has not become the norm in medical schools across the world. This article explores the current status of undergraduate medical education in palliative care as published in the English literature and makes recommendations for educational improvements which will prepare doctors to address the needs of seriously ill and dying patients. Keywords: medical education, palliative care, end-of-life care
Frey, Rosemary; Gott, Merryn; Raphael, Deborah; O'Callaghan, Anne; Robinson, Jackie; Boyd, Michal; Laking, George; Manson, Leigh; Snow, Barry
Central to appropriate palliative care management in hospital settings is ensuring an adequately trained workforce. In order to achieve optimum palliative care delivery, it is first necessary to create a baseline understanding of the level of palliative care education and support needs among all clinical staff (not just palliative care specialists) within the acute hospital setting. The objectives of the study were to explore clinical staff: perceptions concerning the quality of palliative care delivery and support service accessibility, previous experience and education in palliative care delivery, perceptions of their own need for formal palliative care education, confidence in palliative care delivery and the impact of formal palliative care training on perceived confidence. A purposive sample of clinical staff members (598) in a 710-bed hospital were surveyed regarding their experiences of palliative care delivery and their education needs. On average, the clinical staff rated the quality of care provided to people who die in the hospital as 'good' (x̄=4.17, SD=0.91). Respondents also reported that 19.3% of their time was spent caring for end-of-life patients. However, only 19% of the 598 respondents reported having received formal palliative care training. In contrast, 73.7% answered that they would like formal training. Perceived confidence in palliative care delivery was significantly greater for those clinical staff with formal palliative care training. Formal training in palliative care increases clinical staff perceptions of confidence, which evidence suggests impacts on the quality of palliative care provided to patients. The results of the study should be used to shape the design and delivery of palliative care education programmes within the acute hospital setting to successfully meet the needs of all clinical staff. 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.
Reid, Eleanor Anderson; Gudina, Esayas Kebede; Ayers, Nicola; Tigineh, Wondimagegnu; Azmera, Yoseph Mamo
Palliative care aims to reduce physical suffering and the emotional, spiritual, and psychosocial distress of life-limiting illness. Palliative care is a human right, yet there are vast disparities in its provision: of the 40 million people globally in need of palliative care, less than 10% receive it, largely in high-income countries. There is a particular paucity of data on palliative care needs across the spectrum of incurable disease in Ethiopia. The aims of this research were to assess the overall burden of life-limiting illness, the costs associated with life-limiting illness, and barriers to accessing palliative care in Ethiopia. Mixed-methods case-series. One hundred adults (mean age: 43.7 ± 14 years, 64% female) were recruited at three outpatient clinics (oncology, HIV, noncommunicable disease) and hospice patient homes in Ethiopia. Four internationally validated questionnaires were used to assess physical symptoms, psychosocial distress, and disability. In-depth interviews gauged poverty level, costs of care, and end-of-life preferences. Qualitative data were analyzed by thematic content, quantitative data by standard descriptive, frequency and regression analyses. In oncology, 95.5% of the population endorsed moderate or severe pain, while 24% were not prescribed analgesia. Importantly, 80% of the noncommunicable disease population reported moderate or severe pain. The mean psychosocial distress score was 6.4/10. Severe disability was reported in 26% of the population, with mobility most affected. Statistically significant relationships were found between pain and costs, and pain and lack of well-being. Very high costs were reported by oncology patients. Oncology withstanding, the majority of subjects wished to die at home. Oncology patients cited pain control as the top reason they preferred a hospital death. There are extensive unmet palliative care needs in Ethiopia. Untreated pain and high costs of illness are the major contributors to
Tarantola, Arnaud; Crabol, Yoann; Mahendra, Bangalore Jayakrishnappa; In, Sotheary; Barennes, Hubert; Bourhy, Hervé; Peng, Yiksing; Ly, Sowath; Buchy, Philippe
Although limited publications address clinical management of symptomatic patients with rabies in intensive care units, the overwhelming majority of human rabies cases occur in the rural setting of developing countries where healthcare workers are few, lack training and drugs. Based on our experience, we suggest how clinicians in resource-limited settings can make best use of essential drugs to provide assistance to patients with rabies and their families, at no risk to themselves. Comprehensive and compassionate patient management of furious rabies should aim to alleviate thirst, anxiety and epileptic fits using infusions, diazepam or midazolam and antipyretic drugs via intravenous or intrarectal routes. Although the patient is dying, respiratory failure must be avoided especially if the family, after being informed, wish to take the patient home alive for funereal rites to be observed. Healthcare staff should be trained and clinical guidelines should be updated to include palliative care for rabies in endemic countries. © 2016 John Wiley & Sons Ltd.
Duc, Jacqueline K; Herbert, Anthony Robert; Heussler, Helen S
Paediatric palliative care is a nuanced area of practice with additional complexities in the context of intellectual disability. There is currently minimal research to guide clinicians working in this challenging area of care. This study describes the complex care of children with life-limiting conditions and intellectual disability by means of a literature synthesis and commentary with "best-practice" guide. As few articles concerning children with intellectual disability and palliative care needs were identified by formal systematic review, our expert consensus group has drawn from the paediatric palliative, oncology and adult intellectual disability literature to highlight common clinical challenges encountered in the day-to-day care of children with intellectual disability and life-limiting conditions. A longitudinal child- and family-centred approach is key to ensuring best-practice care for families of children with life-limiting conditions and intellectual disability. As highlighted by the great absence of literature addressing this important patient population, further research in this area is urgently required. © 2017 John Wiley & Sons Ltd.
Warmenhoven, F.; Lucassen, P.L.; Vermandere, M.; Aertgeerts, B.; Weel, C. van; Vissers, K.C.; Prins, J.B.
BACKGROUND: Facing a terminal illness can be highly stressful and palliative care patients frequently suffer from mood symptoms. The focus of health care is often on treating symptoms whereas health-promoting factors receive less attention. The aim of this study was to explore the views of
Pelayo, Marta; Cebrián, Diego; Areosa, Almudena; Agra, Yolanda; Izquierdo, Juan Vicente; Buendía, Félix
The Spanish Palliative Care Strategy recommends an intermediate level of training for primary care physicians in order to provide them with knowledge and skills. Most of the training involves face-to-face courses but increasing pressures on physicians have resulted in fewer opportunities for provision of and attendance to this type of training. The effectiveness of on-line continuing medical education in terms of its impact on clinical practice has been scarcely studied. Its effect in relation to palliative care for primary care physicians is currently unknown, in terms of improvement in patient's quality of life and main caregiver's satisfaction. There is uncertainty too in terms of any potential benefits of asynchronous communication and interaction among on-line education participants, as well as of the effect of the learning process.The authors have developed an on-line educational model for palliative care which has been applied to primary care physicians in order to measure its effectiveness regarding knowledge, attitude towards palliative care, and physician's satisfaction in comparison with a control group.The effectiveness evaluation at 18 months and the impact on the quality of life of patients managed by the physicians, and the main caregiver's satisfaction will be addressed in a different paper. Randomized controlled educational trial to compared, on a first stage, the knowledge and attitude of primary care physicians regarding palliative care for advanced cancer patients, as well as satisfaction in those who followed an on-line palliative care training program with tutorship, using a Moodle Platform vs. traditional education. 169 physicians were included, 85 in the intervention group and 84 in the control group, of which five were excluded. Finally 82 participants per group were analyzed. There were significant differences in favor of the intervention group, in terms of knowledge (mean 4.6; CI 95%: 2.8 to 6.5 (p = 0.0001), scale range 0-33), confidence
Full Text Available Abstract Background The Spanish Palliative Care Strategy recommends an intermediate level of training for primary care physicians in order to provide them with knowledge and skills. Most of the training involves face-to-face courses but increasing pressures on physicians have resulted in fewer opportunities for provision of and attendance to this type of training. The effectiveness of on-line continuing medical education in terms of its impact on clinical practice has been scarcely studied. Its effect in relation to palliative care for primary care physicians is currently unknown, in terms of improvement in patient's quality of life and main caregiver's satisfaction. There is uncertainty too in terms of any potential benefits of asynchronous communication and interaction among on-line education participants, as well as of the effect of the learning process. The authors have developed an on-line educational model for palliative care which has been applied to primary care physicians in order to measure its effectiveness regarding knowledge, attitude towards palliative care, and physician's satisfaction in comparison with a control group. The effectiveness evaluation at 18 months and the impact on the quality of life of patients managed by the physicians, and the main caregiver's satisfaction will be addressed in a different paper. Methods Randomized controlled educational trial to compared, on a first stage, the knowledge and attitude of primary care physicians regarding palliative care for advanced cancer patients, as well as satisfaction in those who followed an on-line palliative care training program with tutorship, using a Moodle Platform vs. traditional education. Results 169 physicians were included, 85 in the intervention group and 84 in the control group, of which five were excluded. Finally 82 participants per group were analyzed. There were significant differences in favor of the intervention group, in terms of knowledge (mean 4.6; CI
John Y Rhee
Funding: Arnhold Institute of Global Health at the Icahn School of Medicine at Mount Sinai, the African Palliative Care Association, the International Association for Hospice and Palliative Care, and the Institute for Culture and Society at the University of Navarra.
Vogl, Matthias; Schildmann, Eva; Leidl, Reiner; Hodiamont, Farina; Kalies, Helen; Maier, Bernd Oliver; Schlemmer, Marcus; Roller, Susanne; Bausewein, Claudia
Hospital costs and cost drivers in palliative care are poorly analysed. It remains unknown whether current German Diagnosis-Related Groups, mainly relying on main diagnosis or procedure, reproduce costs adequately. The aim of this study was therefore to analyse costs and reimbursement for inpatient palliative care and to identify relevant cost drivers. Two-center, standardised micro-costing approach with patient-level cost calculations and analysis of the reimbursement situation for patients receiving palliative care at two German hospitals (7/2012-12/2013). Data were analysed for the total group receiving hospital care covering, but not exclusively, palliative care (group A) and the subgroup receiving palliative care only (group B). Patient and care characteristics predictive of inpatient costs of palliative care were derived by generalised linear models and investigated by classification and regression tree analysis. Between 7/2012 and 12/2013, 2151 patients received care in the two hospitals including, but not exclusively, on the PCUs (group A). In 2013, 784 patients received care on the two PCUs only (group B). Mean total costs per case were € 7392 (SD 7897) (group A) and € 5763 (SD 3664) (group B), mean total reimbursement per case € 5155 (SD 6347) (group A) and € 4278 (SD 2194) (group B). For group A/B on the ward, 58%/67% of the overall costs and 48%/53%, 65%/82% and 64%/72% of costs for nursing, physicians and infrastructure were reimbursed, respectively. Main diagnosis did not significantly influence costs. However, duration of palliative care and total length of stay were (related to the cost calculation method) identified as significant cost drivers. Related to the cost calculation method, total length of stay and duration of palliative care were identified as significant cost drivers. In contrast, main diagnosis did not reflect costs. In addition, results show that reimbursement within the German Diagnosis-Related Groups system does not
Maltoni, Marco; Scarpi, Emanuela; Rosati, Marta; Derni, Stefania; Fabbri, Laura; Martini, Francesca; Amadori, Dino; Nanni, Oriana
Palliative sedation is a clinical procedure aimed at relieving refractory symptoms in patients with advanced cancer. It has been suggested that sedative drugs may shorten life, but few studies exist comparing the survival of sedated and nonsedated patients. We present a systematic review of literature on the clinical practice of palliative sedation to assess the effect, if any, on survival. A systematic review of literature published between January 1980 and December 2010 was performed using MEDLINE and EMBASE databases. Search terms included palliative sedation, terminal sedation, refractory symptoms, cancer, neoplasm, palliative care, terminally ill, end-of-life care, and survival. A manual search of the bibliographies of electronically identified articles was also performed. Eleven published articles were identified describing 1,807 consecutive patients in 10 retrospective or prospective nonrandomized studies, 621 (34.4%) of whom were sedated. One case-control study was excluded from prevalence analysis. The most frequent reason for sedation was delirium in the terminal stages of illness (median, 57.1%; range, 13.8% to 91.3%). Benzodiazepines were the most common drug category prescribed. Comparing survival of sedated and nonsedated patients, the sedation approach was not shown to be associated with worse survival. Even if there is no direct evidence from randomized clinical trials, palliative sedation, when appropriately indicated and correctly used to relieve unbearable suffering, does not seem to have any detrimental effect on survival of patients with terminal cancer. In this setting, palliative sedation is a medical intervention that must be considered as part of a continuum of palliative care.
Kato, Koki; Fukuda, Haruhisa
To quantify the difference between adjusted costs for home-based palliative care and hospital-based palliative care in terminally ill cancer patients. We carried out a case-control study of home-care patients (cases) who had died at home between January 2009 and December 2013, and hospital-care patients (controls) who had died at a hospital between April 2008 and December 2013. Data on patient characteristics were obtained from insurance claims data and medical records. We identified the determinants of home care using a multivariate logistic regression analysis. Cox proportional hazards analysis was used to examine treatment duration in both types of care, and a generalized linear model was used to estimate the reduction in treatment costs associated with home care. The case and control groups comprised 48 and 99 patients, respectively. Home care was associated with one or more person(s) living with the patient (adjusted OR 6.54, 95% CI 1.18-36.05), required assistance for activities of daily living (adjusted OR 3.61, 95% CI 1.12-10.51), non-use of oxygen inhalation therapy (adjusted OR 12.75, 95% CI 3.53-46.02), oral or suppository opioid use (adjusted OR 5.74, 95% CI 1.11-29.54) and transdermal patch opioid use (adjusted OR 8.30, 95% CI 1.97-34.93). The adjusted hazard ratio of home care for treatment duration was not significant (adjusted OR 0.95, 95% CI 0.59-1.53). However, home care was significantly associated with a reduction of $7523 (95% CI $7093-7991, P = 0.015) in treatment costs. Despite similar treatment durations between the groups, treatment costs were substantially lower in the home-care group. These findings might inform the policymaking process for improving the home-care support system. Geriatr Gerontol Int 2017; 17: 2247-2254. © 2017 Japan Geriatrics Society.
Alonso-Babarro, Alberto; Varela-Cerdeira, Maria; Torres-Vigil, Isabel; Rodríguez-Barrientos, Ricardo; Bruera, Eduardo
Using a decision-making and treatment checklist developed to facilitate the at-home palliative sedation process, we assessed the incidence and efficacy of palliative sedation for end-of-life cancer patients with intractable symptoms who died at home. We retrospectively reviewed the medical records of 370 patients who were followed by a palliative home care team. Twenty-nine of 245 patients (12%) who died at home had received palliative sedation. The mean age of the patients who received palliative sedation was 58 +/- 17 years, and the mean age of the patients who did not receive palliative sedation was 69 +/- 15 years (p = 0.002). No other differences were detected between patients who did or did not receive palliative sedation. The most common indications for palliative sedation were delirium (62%) and dyspnea (14%). Twenty-seven patients (93%) received midazolam for palliative sedation (final mean dose of 74 mg), and two (7%) received levomepromazine (final mean dose of 125 mg). The mean time between palliative sedation initiation and time of death was 2.6 days. In 13 of the cases (45%), the palliative sedation decision was made with the patient and his or her family members, and in another 13 patients (45%), the palliative sedation decision was made only with the patient's family members. We concluded that palliative sedation may be used safely and efficaciously to treat dying cancer patients with refractory symptoms at home.
Rajesh N Gongal
Full Text Available Introduction: Nepal is beginning to develop palliative care services across the country. Most people live in rural areas, where the Mid-Level Health Workers (MHWs are the major service providers. Their views on providing palliative care are most important in determining how the service is organized and developed.Aim: This study aims to ascertain the perceptions of MHWs about palliative care in their local community, to inform service development.Methods: A> qualitative descriptive design, using focus group discussions, was used to collect data from a rural district of Makwanpur, 1 of the 75 districts of Nepal. Twenty-eight MHWs participated in four focus group discussions. The data were analyzed using content analysis.Result: Four themes emerged from the discussion: (i suffering of patients and families inflicted by life-threatening illness, (ii helplessness and frustration felt when caring for such patients, (iii sociocultural issues at the e | <urn:uuid:cff20e24-ab16-4c34-83a1-17e5a6c343ec> | CC-MAIN-2022-33 | https://worldwidescience.org/topicpages/p/palliative+care+patients.html | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.943188 | 116,205 | 1.59375 | 2 |
Now pre-primary books featuring Disney themes
MBD Group has launched pre-primary for children aged between 3 to 5 years, featuring popular Disney and Pixar stories from Mickey & Friends, Princess, The Lion King, Frozen, Cars, Toy Story franchises and more.
The curriculum areas including Languages, Maths, Environmental Studies and Art have been designed keeping in mind the five domains of development as enlisted in the NCERT pre-school curriculum. The five domains include physical well-being, health and motor development; personal, social and emotional development; creative and aesthetic development; language and cognitive development. (Source: MBD Group) | <urn:uuid:bde046d4-33b9-4e39-b1ba-c358f9a158cd> | CC-MAIN-2022-33 | http://www.allaboutbookpublishing.com/6790/now-pre-primary-books-featuring-disney-themes/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571950.76/warc/CC-MAIN-20220813111851-20220813141851-00672.warc.gz | en | 0.940887 | 127 | 2.0625 | 2 |
How IoT is set to revolutionize the commercial real estate industry.
The Internet of Things is more than a catchy marketing term; it’s coming.
Gartner projects an estimated 8.4 billion connected “things” installed in the business category by 2020. So what does this mean for the building and facility management space? It enables an entirely new generation of devices with a “digital voice” to create and communicate information on their status and surrounding environment generating an unparalleled amount of data to be captured, analyzed, and acted upon.
This paper discusses what’s driving the adoption of the Internet of Things (IoT) in building and facility management, how to create value from the IoT for your organization, and considerations for implementing an IoT strategy for your facility.
Offered Free by: Senseware See All Resources from: Senseware | <urn:uuid:c03c5d13-3a59-4b6a-82fb-7a5acd837837> | CC-MAIN-2022-33 | https://fc-resources.fastcompany.com/free-offer/the-impact-of-internet-of-things-iot-on-facilities-management/w_senc01?sr=hicat&_t=hicat:1088 | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.89641 | 177 | 1.625 | 2 |
Suricata suricatta (Meerkat) is a species of mammals in the family mongooses. They are native to Ethiopia. They are diurnal carnivores. Individuals are known to live for 150 months and can grow to 285.71 mm. They have parental care (female provides care, cooperative breeding, and paternal care). They rely on running to move around.
EOL has data for 69 attributes, including: | <urn:uuid:406e4ede-5506-4ec7-ab45-9c6552c6889c> | CC-MAIN-2022-33 | https://api.eol.org/pages/311580 | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571056.58/warc/CC-MAIN-20220809155137-20220809185137-00672.warc.gz | en | 0.947575 | 88 | 2.359375 | 2 |
Google is expanding its real-time transcription technology and has today announced it for Google Translate. With the tool, users will be able to transcribe live audio. As this is the company’s translation tool, it will transcribe in real-time from another language.
The feature was unveiled at an AI event in San Francisco, although Google says it is currently in prototype. While Google has not confirmed, it seems the tool only works with live audio on Google Translate.
In other words, you won’t be able to transcribe recorded audio or video files. Still, Google points out users can simply play the recorded content through a smartphone mic to activate real-time transcription.
Interestingly, the feature can monitor whole sentences and point out incorrect punctuation and even fix accents.
Google was eager to point out the tool is at an early stage of development. In fact, the company says users should not expect perfect transcriptions. However, because it is AI-based, the model will improve over time and get better.
There is no official launch date for the feature.
Expanding Real-Time Transcription
Last year, Google got the ball rolling on real-time transcription by launching the tool on its Recorder app. When speech has been transcribed, the content can be saved in audio format or as a text file. These saved files can be access by users who can search the contents for words. This means users can directly search for spoke words.
Also this week, Mountain View brought the transcription service to its Google Voice app. Users can have their phone calls transcribed in real-time and receive a text file in their notifications. Like the transcription for Google Translator, no date on the launch of this tool has been given. | <urn:uuid:0eefe288-a14e-493b-892b-103cd9bc5845> | CC-MAIN-2022-33 | https://winbuzzer.com/2020/01/29/google-translate-scores-real-time-transcription-feature-xcxwbn/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571056.58/warc/CC-MAIN-20220809155137-20220809185137-00672.warc.gz | en | 0.94245 | 360 | 1.882813 | 2 |
Suddenly, I heard a huge whoosh to the left of me.
Then I saw a fireball hurtling towards me. As it roared past my head, I was set alight.
Heart thudding in my chest, I frantically tried to pat out the flames.
But each time one went out, another would reignite.
I’m on fire! I panicked.
It was terrifying, I was a human fireball!
Remembering what I’d been taught as a kid, to ‘stop, drop, roll,’ I ran inside to the kitchen for space and dropped to the vinyl floor.
As I rolled around, the flames on my body died out. But the blaze was also on my head and I desperately used my hands to extinguish it.
As it finally went out, I stripped off my clothes, trying to calm down.
‘Eva’s been burnt too,’ someone shouted.
My heart dropped.
Feeling sick to my stomach, I sprinted outside and found my little girl sobbing on the floor.
‘It hurts Mummy!’ she screamed.
The excruciating pain from my burns was kicking in and blisters were appearing on my skin. But all I cared about was helping Eva.
Someone grabbed a bowl of water and I gently poured it down her clothes, which were stuck to her skin.
As Darren and the ambos turned up, I was in agony.
‘You’re going to have to take over now, I’m going to pass out,’ I told a paramedic.
Within seconds, everything went black.
Stirring in Emergency later, I heard my mum Sonja.
‘I’m not going to leave you,’ she said from beside my bed, stroking my head.
It took 10 hazy days of pain until I was finally with it. Fifteen per cent of my body was burned, the worst spanned from my hip all the way down my right leg.
Bandaged up, I listened as surgeons explained how they’d used special ReCell technology on my burns.
The process involved combining my skin cells with an enzyme to create a solution, which is sprayed on the burns to create new skin.
They also harvested new skin by taking it from non-burnt parts of my body.
Thankfully, I was allowed to go and see Eva in the children’s hospital nearby.
Unable to walk, I used a wheelchair to get to her.
I was devastated to see my beautiful daughter bundled up in bandages. The burns were on 20 per cent of her body, covering her left arm and torso.
‘I’ve missed you so much,’ I cried, going to embrace her.
‘Mummy, you can’t hug me because it hurts, but you can hold my fingers,’ she said.
It was so good to hear her little voice, but I couldn’t help tearing up. She was in so much pain and there was nothing I could do.
Eva had needed multiple operations to treat third-degree burns.
We nearly lost her at one point,’ Darren choked. ‘Her body turned septic and her heart rate went.’
Pumping our girl with antibiotics, medics had managed to save her.
After a few hours, I had to return to my own hospital to rest. But two days later, I got to visit Eva again.
‘Mummy, why was I the only child burned?’ she said.
‘We were in the wrong place and accidents happen love,’ I said, trying not to cry. ‘But we’re going to get through this.’
Later, when I went to kiss her goodbye, I saw Eva stop and look at my face.
‘Your burns scare me,’ she told me.
My heart breaking, I was crushed. She wouldn’t let me kiss her face, so I brushed my lips on her fingers and left.
It was blood spots from the burns that were scaring her, so I made sure a nurse covered them up next time.
After another five days in hospital, I was discharged.
Although I love being home, poor Eva is still in hospital. Needing more surgery, it’ll be a few weeks until she can leave.
It’s going to be a long road to recovery for both of us.
Painful to walk, I need regular physio to get my joints working again. And the two of us are going to have to wear compression suits 23 hours a day, for the next 12-18 months.
Luckily, we’ve been told we’ll have minimal scarring.
But it’s the little things now that get me down. All my life I’ve had a fringe, but I lost the whole thing, along with my eyebrows.
Eva and I are incredibly lucky to be alive. Since coming home, I’ve learned more about the accident.
The explosion was caused when my friend refilled the liquid in the burner.
She and another woman at the party were also injured.
Ethanol burners were banned in Australia in 2017 but she didn’t see anything about it in the news.
She’s racked with guilt, but she’ll always remain a close friend of mine. We’d used it heaps of times at her place without any problems.
But I want people to know just how dangerous they are.
Keep your family safe and get rid of them.
If speaking out stops even one more person from going through this pain, then it will be worth it. | <urn:uuid:83236e62-d99c-474e-ac2d-4ec496a5e6c9> | CC-MAIN-2022-33 | https://www.thatslife.com.au/human-fireballs?category=real_life | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571222.74/warc/CC-MAIN-20220810222056-20220811012056-00672.warc.gz | en | 0.98382 | 1,214 | 1.523438 | 2 |
Table of Contents
Into Gold: Jim Carroll's The Basketball Diaries and Forced
||If you want to cite this thesis, here's where you find the bibliographic information.
|Table of Contents
of the thesis.
Shit Into Gold
Through writing, Carroll transforms
his triumphs and his most vile experiences into poems, diaries,
and songs of visionary beauty. As a writer, Carroll is an
alchemist capable of transforming shit into gold.
Writing as a Weapon
The beauty of The Basketball Diaries
is its optimism: more than anything it is about the potential
an individual has to transcend the victimization of a corrupt
system. Carroll shows it is possible to make a difference
both in the way he lives his life and by creating a better
world through art.
Writing as Pennance
Because the writer that he is
grows out of his experiencing and transforming his double
life, Carroll must embrace his past and write about it.
In many ways, Carroll's becoming a Writer depends first
upon accepting the character identity of The Basketball
Diaries then overcoming and transcending that identity
to legitimize himself as an Artist. Also, he must come to
terms with his addiction: he must retain enough personal
control to continue writing while still "hooked."
Writing as Redemption
Because Carroll revises and redefines
his identity and his past with each work, a discussion of
his diaries alone barely scrapes the surface in revealing
his achievement as both an artist and the creator of himself.
Only by appreciating the complex interplay between Carroll's
songwriting, poetry, and his diaries is it possible to see
to what extent, and how, Carroll has been able to revise
and transform his past.
©1990 Cassie Carter. This material may not be reprinted except by permission from the author. | <urn:uuid:66a68d8c-8e75-4f94-a22a-4914dc1b992e> | CC-MAIN-2022-33 | http://www.catholicboy.com/thesis_toc.php | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571056.58/warc/CC-MAIN-20220809155137-20220809185137-00672.warc.gz | en | 0.93107 | 508 | 1.710938 | 2 |
Parliamentary Debate -
THE SLAVERY AND REPARATIONS DEBATE
Following exciting developments on the international scene with regard to dishing out huge sums of money left right and centre, and demanding apologies forthwith from the living for crimes committed by the long dead and buried, it dawned on the stalwarts of the RGiE that they were sadly lagging behind in getting involved in the new pastime.
An emergency debate was called and ministers prompted to search their consciences along with their family trees to see who could conceivably be called upon to compensate financially for their current psychotic behaviour and poverty-stricken existences.
A study group was formed to examine the success of other African governments in this regard and the conclusions have been published in a 3-page report. The main points were read out to the assembled ministers:
a. There are no success stories of any kind to be found in Africa, just lots of people grubbing in the dirt, neglecting to wipe their noses more than once a year and a few sitting on $10 billion worth of gold which they need to get out of the country onto some American's bank account for which they are offering a 10% share by e-mailing them.
[An intermission was called for at this point after the minister at the dais was besieged by clamouring ministers waving bank deposit slips on which their account numbers had been hurriedly scribbled in pencil. Order was restored by the Chief Whip, who took his title literally and produced a sjambok with a dramatic flourish. Several ministers protested furiously, shouting "Are our faces black?"]
b. Since every African country has at one time or another enslaved people from every other African country and none can currently afford to pay a phone bill, the best bet is to get a wealthy western country to do the honours.
Since the RGiE are as poor as church mice this puts us on a par with every other African government and automatically entitles us to claim that some white western government has been oppressing us and should cough up. We have considered the matter at length and feel that the filthy rich Yanks will do nicely.
c. Since valid reasons are never given anyway, it will be sufficient to point out that being white we feel that we are being discriminated against by never being allowed to play the role of victim and given an equal chance to cash in. Blacks always get to play the same role and this is not fair. We demand equal victim time and believe that blacks should play the oppressors for a change, especially on prime time TV and we also want the police chief in future movies to be a white guy, yelling at black cops, like in real life. And we demand that America have a white president again, not one who keeps going to mosques and synagogues and doing interviews with Oprah.
d. At least one of the RGiE members has been taking lessons in droning ghetto doggerel and pointing accusingly at the viewers with splayed fingers and making sweeping hand gestures similar to trying to catch flies in front of their faces in the new tradition of popular music. This course was adopted only after suggestions that an African be recruited for the purpose on the grounds that they have a more intimate acquaintance with flies came to naught. The African candidates under consideration objected that it was not their custom to chase away flies searching for nasal fluids and that the whole idea looked suspiciously like another white man's scheme to spread AIDS.
Their subsequent demands for compensation have been referred to the current Shona regime as Africa's longest practising experts on racism.
e. A second proposal to recruit an African, bleach him white, and send him as a delegate to the Promote Racism Conference in Jamaica was reluctantly abandoned after a letter was received from a lawyer named Cochran pointing out that the patent for bleaching blacks white was held by his client and that he would furthermore sue if any attempt was made to employ a bleached woman since his client was busy patenting that image too. Any indiscriminate use of rubber appendages of any kind would lead to further litigation, as would attempts to scratch any itches in the groin region while singing or imitating a puppet being jerked. The letter pointed out maliciously that, despite being white, his client was black, and would therefore win any case automatically. The letter ended ominously with the admonition "they can get away with murder, you know."
This letter was published on the RGiE website and resulted in a flood of spam offering various rubber implements and appendages for sale. The freebie samples received by the RGiE in the mail have mysteriously disappeared and all efforts to enquire if the female ministers knew where they went were met with dreamy-eyed self-satisfied sighs and shakes of the head. The Sheriff has indicated that if the evidence does not reappear he will have to make an in-depth investigation to get to the root of the matter. This plan was met with a variety of mystifying reactions from the female ministers, ranging from "Start rooting, big boy!" to "Not in my depths, you don't!"
At the end of the debate the ministers voted unanimously to retire to the bar, satisfied that all the great traditions of African parliamentary sessions had been complied with - no big decisions made, everyone else and especially the Yanks blamed for any and all current problems in the world today; whatever it was we didn't do it; and everyone owes us big time for whatever it is they think they did to us in the past and which we know for a fact they did; the cause to end discrimination and racism being taken a step further towards its goal by calling every other race right bastards for not compensating us for the crimes of the fuzzy wuzzies back in whichever century it was. And the begging bowl got a good polish on the off chance that Blair or Bush might drop in.
Report from the Promote Racism Conference in Jamaica
Interview with Al Sharpo, delegate to the Promote Racism Conference in Jamaica.
RGiE journo: "Mr. Sharpo! May we have a few words about the conference please Sir?"
Sharpo: "Yo bro, wassup?"
RGiE journo: "Mr. Sharpo, is it true that you are laying a blanket charge of racism at the door of all whites in the world?"
Sharpo: "Ah din' steal no blankets, de hotel's lyin! Where yo all from, boy, yo don' look black to me???"
RGiE journo: "Well, I'm from Rho... er...Zimbabwe. We're the minority there, but I'm just as African as you are, sir."
Sharpo: "Yo, gotcha, bro. Ain't never heard a da place, but dat ain't no never mind! We Affercuns gotta stick togedder. Slap it right dere! Yo all lookin a bit pale, mind. Yo all big fans of Jacko down dere in dat Zimbummerme, right? Jacko ain't black no mo' neither, know'msaying? Big trendsettuh, ol Jacko am..."
RGiE journo: "Yes, sir, I believe he is. But we'd like to know your views on racist policies towards minorities."
Sharpo: "racist cops? Where dey at? Hide de towels! RUN...!!!"
RGiE journo: "No, no, sir, racist policies, not cops..."
Sharpo: "Oh. Phew! Don' yo all say dem tings like dat, son, speak proper English, know'msaying! Right, racist. Minorrties. Yeah, ah knows all bout dem. Yo all a minorrty, yo say?"
RGiE journo: "Yes sir, and we're being oppressed too. We'd like to know what you think of the white...."
Sharpo: "Gotcha son, yo all bean ohppressed an discriminamated agin, right?"
RGiE journo: "Right."
Sharpo: "Well, dat ain' right son, dat's downright racism. Yo all need to overthrow that ohpressive ruler o' yours an' get a honest man at the top. He killin yo people an stealin yo land too?"
RGiE journo: "Well, yes he is stealing land and farms, and he had about 20,000 people killed just after he came to power..."
Sharpo: "Yessuh, Ah knowed it! A racist devil, no doubt 'bout it. He like all de res, killin an lootin over de backs of de poor ohpressd minorrty! Yo all told the Yewnited Nashuns yet? Where dis here Zimbummerme country o' yours at agin?"
RGiE journo: "Middle of Africa, sir, and yes, we've complained to the UN, but they take no notice."
Sharpo: "Ain dat jes de truth, son, dey all racists, dey leavin de po ohppressd monorrties to suffer while de fat cat get rich over dere backs! Dis here ruler o' Zimbumbley a racist devil, sho nuff. Killin yo people an stealin dere land, he belong up dere in de innernashinal peoples court wot Gennerul Haig set up in Belgium. He gotta go! Jes like dat dere MisterOstrich feller from Yugoslavya. Yessuh, down wit all racist ohpressuhs. What else he doin?"
RGiE journo: "Well, sir, he's letting the people starve, he's planning genocide against one of the tribes, some of his people rape baby girls to cure AIDS and he's having the opposition killed so he can rig the elections, and..."
Sharpo: "Whoa dere son! Enuff! Dis here racist devil man runnin de country an aint no-one doin nuttin bout it? Hell, even our racist persident don do nuttin dat bad! How dis here anoraknamism allowed to get way with it? Racism de evil o de ages, bro, we minorrties gotta stick togethuh, know'msaying? We gotta hep yo all get rid o dis here capillust pig. We all gotta dream and yo all is our bros in Africa, our roots, know'msaying, gotta call Johnny, he da MAN. He can hep yo all!"
[fumbles with cell phone and dials]
Sharpo: "Yo Cock! Wassup! Got a case for yo all. Yo, man, big bucks in it, racist leader in Zimdimbledy ohpressin de minorrty, yo all can't lose, bro! Jes a minute, I'll axe him.... Hey bro, got a Macdonalds an a Texaco an Shell an a Wall Mart an stuff in Zimbuggerme?"
RGiE journo: "Yes, some of them, and some British companies..."
Sharpo: "Yo Cock, bro, like ah said, big bucks out dere, easy pickins, dey all guilty! Yo de man, bro! Wait, I'll axe him agin... Hey bro, who dis racist devil in Zimbumblie?"
RGiE journo: "His name's Mugabe."
Sharpo: "Yo, Cock, de devil named Mugambe... huh?...he din' tell me dat! Yo, bro, sure nuff, gotcha. No deal huh? No big bucks down dere. Reggalar guy an he dun got all de bucks already. OK. Seeya."
RGiE journo: "What did he say?"
Sharpo: "Man, yo all wuz pullin mah leg. Johnny know who dis Zimbley guy am. An yo ain't no fan o Jacko. An Mugumbley cain't be no racist, bro, he black!"
Measure of Success
From our parliamentary reporter.
Some depressed whites in the RGiE have been grumbling about the apparent success of the current Zimbabwean government. Others have been accused of being overly jealous and envious of ZanuPF's glorious success in two short decades, compared with the failures of 90 years of white rule.
"It's just not fair!" a disgruntled Minister of Native Affairs was heard to say as he gloomily pored over the latest news of farm thefts in Zimbabwe and the recent mysterious deaths of opposition members.
"Look at this - no fuel in the country, half the population starving, thousands of deaths from AIDS per week, and no-one allowed to vote for whom they want or say what they want! The U.N. always said that's what we whites were trying to do, and we all know the U.N. never lies. What were we thinking of! We spent 90 years getting nowhere if you ask me! Why couldn't we come up with the idea of chucking 20,000 blacks down old coal mines, hey? Answer me that! Why couldn't we have thought of the idea of pinching all the farms and using them as holiday homes for cabinet ministers? We were so busy trying to be clever that we forgot all the easy methods, that's why! No, we had to go building farms, irrigating the land and growing millions of tons of food, too much for our own good even. No, this Mugabe chap has the right idea. Starve the country and get rid of half the blacks in one go. We never managed a fraction of that!"
"We wasted millions of dollars on political campaigns, elections and economic policies. All the hassles of campaigning on TV, letting the media observe and criticise us, listening to foreign observers, educating people so they'd know how to vote and why. A waste of blooming time and money! Why didn't we just buy a few bullets and shoot the opposition? Spans of cash saved all round and everyone happy! No, course not, WE had to go and ignore a million years of African tradition and culture and be wise guys!"
"And all that money spent on hospitals and health care... and campaigns to get rid of the Tsetse fly. Hell, who cares about malaria when you've got AIDS anyway? Money down the drain, that's what it was. Dipping all those cattle and spraying crops - that's not the way to get rid of all the blacks! Mugabe's got the right idea, I tell you. We were just bloody amateurs."
"It's time we faced the facts. If we were trying to do what the U.N. says we were trying to do, and we all know the U.N. never lies, then we spent 90 years bumbling around and getting nowhere, thinking it was going to take 1,000 years, and Mugabe just keeps his nose clean - well, far as any African can - gets on with the job and does it all in a short 20 years! And that's despite the obstacles we put in his way - we doubled, trebled, the black population, just made it even harder for him to halve it again. But there's no flies on him... well, there are, all Africans love the little buggers... but you know what I mean. He cuts out all the PC crap like elections, economy, education, health, and so on, and gets the job done. Bang! Just like that - bang! bang! bang! No worries."
"Of course, he's got it easier in some ways, have to admit that. WE try a spot of genocide and all those interfering busybodies in the Hague want to know why, then waste more millions of dollars and years and years to get everyone plonked in jail for solving the country's problems. Ridiculous the way we hamstring ourselves! Africa's got the right idea. Get enough genocides going in all corners of the continent and no-one's got the time or the cash to worry about who did which one, or why, and if they try to put all the politicians who did one in jail they wouldn't have room left for any other criminals. And why bother with jails to start with, the whole damn place already is a prison anyway, judging from the way everyone's trying to escape out of the continent into America and Europe, except maybe the Yankee negroes who want to go back and eat the roots there, or something. Leastways, that's what they say they want to do, get away from racist whites and go back to paradise. Don't know why it's taking them so long. I'd go if I was them. Get away from the rat race and back to where the rats lay around in the sun all day. That's the life! Spot of genocide when you get bored, pinch a farm when you need more space, shoot the bugger who votes against you and give the cops a high-five and borrow their spade to bury him. No worries with the neighbours either, they're dying like flies anyway. Now why couldn't WE have made life that simple and uncomplicated? Hey? You tell me that. Why weren't we as smart as this Mugabe chap?"
"WHY DIDN'T WE THINK OF IT FIRST?"
RGiE AT PROMOTE RACISM CONFERENCE IN JAMAICA
Special report by our roving all-ears correspondent
Our reporter overheard the following exchange at the Conference.
The RGiE delegation sauntered forth gaily from the hotel to the conference room where they were accosted by a "Native American" delegate. The conversation, as taped by our reporter, went thus:
"Sorry, you are not allowed in, this is a conference to combat racism. No whites allowed!"
"Listen ouboet, we are Africans from the RGiE."
"No, no, you are not black, so you cannot be Africans. It is obligatory to be black to fight against racism."
"Well, you're not black either, and if you're supposed to be an Indian, how come you're not red?"
"Um, no, no, you do not understand, it is only the whites who are racist. We are protesting against you people treating us badly."
"Get away with you, I've never met you before in my life. Besides, what colour is Michael Jackson then?"
"Yes, well, he may be white, but he used to be black, so he's actually black...inside."
"Just like you look brown, but you're actually red? Well, I look white but I'm actually black."
"Yeah, right, and I'm Jesse Jackson!"
"But he's black and you're brown...? Besides he's stinking rich, who oppressed him, hey? And what about Oprah - richest black woman in the world, hey?"
"The whites, that's who. All whites are racist oppressors and discriminators..."
"Michael Jackson's white."
"...and all the blacks are downtrodden poor victims..."
"Look, bugger off, that's why we don't want whites in the conference - you keep getting our facts mixed up, you don't understand what it's like to be oppressed, not have the vote, thrown in jail or have your land and homes taken away from you..."
"Um, let me introduce myself again, I'm from the RGiE, native of what you might know of as Zimbabwe..."
"See what I mean, whites bring ruin to Africa! Only blacks can run their own countries as they should be run."
"Whites are evil Devil's spawn, they've never done anything to help us poor blacks..."
"Lincoln was white. Besides, you're brown..."
"Look, I'm not white, so that means I'm oppressed and discriminated against, and poor! Even if I happen to be brown instead of black."
"Tiger Woods is brown."
"Now look here you racist pig, my car's waiting and my replacement's arrived. Talk to him, I'm going back to my hotel."
"Hmmm, the white Mercedes over there? And the Chinese guy next to it? Are they both actually black too...?
Readers may on occasion notice vague similarities to living persons, of whom some may not yet be dead and in the public domain hereafter. This
is entirely unintentional, even if you all have a fairly accurate sneaking suspicion of which person was not intended. Should you feel a sudden surge of recognition, please
keep it to yourself or deposit in the nearest public facility.
Letters to the editor will be accepted for publication in future issues. Please sign with your full
name if expressing controversial opinions, and if resident in Zim, include directions for
finding your house, where possible using old street names for the benefit of those older
members of the CIO who have not quite mentally adjusted to the new order yet. A copy of
your letter pasted in a front window, with a large painted arrow pointing at your front door
would be greatly appreciated.
Letters for publication may be sent to THE EDITOR. All letters will be treated with the utmost, impartial, respect for freedom of speech, but we reserve the right to distort them where necessary, change wording at will, and otherwise reverse all opinions expressed in them. Profane letters will not be published, but will be placed in the editor's private collection along with any "artistic" photos of themselves that female readers may wish to contribute.
RGiE's Finnish stripper in action in front of an admiring crowd. See Working document Repatriations...
MEET THE GOVERNMENT!
Join the Rhodesian INDABA!
Come and join the Rhodesian Indaba, an email discussion list set up as part of the Rhodesians Worldwide site. Chat to fellow Rhodesians scattered around the
Excellent humour, serious stuff, Rhodesian history, you name it, no topic is taboo. Indaba is the official watering-hole of the infamous Rhodesian
Government in Exile. The patrons are the roughest, toughest, meanest sonsabitches this side of the Limpopo, and that includes the other side also too. But there
are also genteel ladies on hand to keep us in check as best they can. Lefties, commies and whingers are welcome too, we tend to run out of targets damn quick.
You can join (and leave) online at the
or follow the links to Indaba from Rhodesians Worldwide
To subscribe by email, send a blank email to Indaba Listserver with the word subscribe in the subject line.
Official Disclaimer 2
Rugby Reporter Pissed Off!
A photo of the RGiE's resident rugby reporter, who happens to be CinC of the army as well also too, snapped
in the act of handing over the ball to the RGiE's mascot for commencement of play at the recent
international sponsored by the RGiE. It is rumoured that the CinC, who spent ages in front of the mirror beforehand, is considering legal action against the
Herald photographer. The latter, rather miffed, complained in his defence that the CinC had only said
"Make sure you just get the important people and things in the pic."
RGiE Journo Goes Undercover to "Promote Racism" Conference
The Herald's intrepid roving reporter in his amazingly authentic BAANPOC disguise and clobber. He was very
ably assisted in his choice of raiments and make-up by the Minister of Gastronomy who, despite the lack of Zimmerframe parking facilities, put in hours of research
at the Australian Cultural Art and Talking Movies Archives in order to locate authentic samples of contemporary BAANPOC fashion.
A candid shot of a member of the Rhodesian Armoured Corps after a successful clandestine raid on the SANDF School of Armour to "borrow"
hardware for the new unit. Asked if he had had any problems infiltrating the location, the trooper, a new recruit, shrugged modestly and said "Ag no, man, we had a good map that the
Aussie SAS chap drew for us after he scouted the area - man he was busy there until the crack of dawn, we thought he was never coming back. But he did, and he brung
two local go-go girls along with him. We thought it was going to compromise the op, you know, but he just smiled and said "Itsh for cammiflage thingamajig shtuff, mate, a sheila a day keepsh the copsh away" - he
was pretty hard to understand with that Ozzie accent an all, even without all the hiccoughing and burping, but he got the map done for us, real professional. See, he marked it on the map
right there, inbetween the Irish Pub and the Museum of Armour..."
RECRUITNG DRIVE FOR RGiE
ALL AFRICAN SUPER CANNON FAILS
The much-vaunted All African "super cannon" underwent its first trial shoot in Zambia this week and ran into unexpected problems. Rumoured to be capable of lobbing a 500 kilo payload a distance of 100km with pinpoint accuracy, the cannon was pointed in the general direction of the suspected position of the "racist breakaway state of the RGiE somewhere south of us", as the Artillery General known by his chimpurenga name of "Uncle Joe Stealing" put it. Apparently the gunners, mystified by the disappearance of their one and only test shell, figured that a) it had been stolen or b) it was already loaded, and lowered one of their Shona gunsmithing experts down the 10 metre-long barrel to check, attached to a 5-metre length of rope which no-one remembered to hold onto... According to bystanders the unfortunate gunsmith screamed "It's loaded. Don't Fire!!" but as a somewhat crestfallen General Stealing pointed out "that's not what we heard. It's a long barrel and it echoes a lot..."|
In the main street of nearby Harare, Mugabe was quoted as saying "We are not amused... but of course as everyone knows, it's the whites' fault and... " at which point our reporter left to catch his train, calling out "Don't worry, I've got that speech a hundred times over on tape in the archives. I'll just change the date on one..."
Paid Advertisement for beer, full of gratuitous sex. The other two jugs are filled with beer.|
Neither is gratis... | <urn:uuid:baa4ff37-0949-4613-a8ec-0259c1fe7faa> | CC-MAIN-2022-33 | http://www.rhodesia.nl/Exile/herald5b.htm | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571056.58/warc/CC-MAIN-20220809155137-20220809185137-00672.warc.gz | en | 0.96045 | 5,757 | 1.742188 | 2 |
Mosquito-born disorders have an effect on many folks worldwide each and every year. The Chunk of the mosquito can lead to nearly anything from a skin irritation to contracting malaria. Plainly, mosquitoes are not just a nuisance, but in addition likely dangerous. By using actions which include sporting prolonged trousers in wooded spots or disposing of standing h2o, you are able to lessen the likelihood of attracting mosquitoes. These steps, having said that, tend to be not adequate, and specialty merchandise accustomed to battle mosquitoes are demanded. Each from the goods utilized for mosquito Manage have varying degrees of effectiveness, and it’s important to understand that some might be better than Other people.
There are a variety of mosquito nets available in various measurements,Guest Posting products and styles. Every single kind of net has its pros, and guaranteeing you are using the most fitted one particular will increase your probabilities of eliminating mosquitoes. It is actually critical to find a Web which has a mesh size substantial adequate to permit air to circulate, but sufficiently small to keep the mosquitoes out. Mosquito nets may be used to go over compact and huge areas for example your bed or your porch. Mosquito nets are a powerful method to The natural way fight mosquitoes.
Electric mosquito zapper
An electrical zapper works through the use of ultraviolet light-weight to lure in bugs and afterwards kills them upon contact with its lethal dose of electrical cost. Unfortunately, Though this is the extremely prosperous way of killing bugs, mosquitoes usually are not essentially attracted to ultraviolet mild, and investigation into this technique of mosquito control exhibits that 90% of what the electric zapper kills are literally insects that don’t Chunk. In actual fact, a few of the bugs which might be killed are people who assistance us eliminate mosquitoes by consuming them.
Like the electric mosquito zapper, the mosquito magnet is one of numerous mosquito traps that claim to very best eradicate the pesky insects. The mosquito magnet performs by releasing a carbon dioxide spray, warmth and dampness the mosquito blunders for prey. When the mosquito will get way too near to the magnet, it truly is sucked in and finally dies of dehydration. The mosquito magnet is run by a propane tank and may for that reason be transported wherever. This kind of mosquito Handle is the most expensive of all techniques and there’s no conclusive scientific proof to assist its efficiency.
There are a number of natural and chemical mosquito repellents Impianti nebulizzazione per umidificazione that work to repel mosquitoes. The artificial chemical repellent, DEET, is the best. It is essentially a poison that masks the purely natural odor and carbon monoxide that may be introduced from your human body. DEET must be made use of with warning, Particularly with children. It’s been recognized to induce dizziness and might severely irritate the pores and skin. For these factors, Many of us elect to use a normal mosquito repellent like a citronella spray. Citronella has Energetic substances that repel mosquitoes and for a few, the lemon odor is quite pleasing. | <urn:uuid:a28cc70e-f838-4d37-a77e-70052ebcc1c4> | CC-MAIN-2022-33 | https://waynemayne.in.nf/mosquito-management-the-ideal-solutions-to-properly-combat-mosquitoes/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.942983 | 655 | 2.265625 | 2 |
A biography is a thorough account of a person’s life, that includes more than simply the standard facts. It gives insight right into the life of an individual via his/her very own words. There are many types of biographies, from the most basic to one of the most intricate. The following are some of one of the most prominent bios. You can use them to find out more regarding the lives of several famous people. These bios are typically crafted as part of college projects as well as study papers.
A bio can be in two forms: fiction and non-fiction. Imaginary biographies are commonly fiction, as well as a biography can be a story regarding a person or team of individuals. Some imaginary bios attempt to profit from the individual’s popularity or spread an ideological background. In the USA, one of the most typical kind of bio is a fictional bio. In these jobs, few realities are thrown up with a story. Frequently, the emphasis gets on developing a particular impression, so fiction-style bios do not concern themselves with actual accuracy or factual integrity.
Biographies are among the oldest forms of literature. Writers have actually documented the lives of terrific leaders since old times. Early bios frequently started as historical documents, but they soon took on sensational aspects as well as became cultural impressives. Plato’s Apology records part of the life of Socrates, while the Gospels of the Christian Bible feature four biographies of Jesus Christ. The very first modern-day biography is taken into consideration The Life of Samuel Johnson (1791) by James Boswell. The Life of Samuel Johnson reshaped the definition of biography.
Writers of biography messages typically structure their product chronologically. A biographer will introduce relevant information to the viewers from the biographee’s life in the initial phase. This aids the author conserve time when composing the biography. They additionally can intercut experiences from various stages of the subject’s life. This allows the author to present important information without spending way too much time creating background presentation. If the topic is deceased, ask permission to write the biography.
While the general public’s right to recognize can encourage biographers, the obligation to secure the topic’s privacy must be balanced with the pain and also anguish of the topic. No universal standard of “biographical ethics” has been set. Some authors, such as Manchester as well as Boswell, had eloquent defenders, yet modern biographers face a more difficult time. Furthermore, accessibility to a topic’s records is frequently rejected.
Biographical works are much more academic than most nonfiction texts. As a matter of fact, they are usually written in the first individual. They attempt to unpick secrets or follow hints, typically relying upon witnesses as well as other sources. Biography is not a history lesson; it is a portrait of a person’s life. The bottom line of a bio is that it focuses on a single human, as well as not their whole life.
A biography is an account of a person’s life written by somebody else. Guide includes not simply the fundamental truths of their life, however likewise how they viewed the events that occurred. Normally, a biography covers the life of the topic, in addition to significant moments in that individual’s public as well as personal lives. Frequently, the writer also enters into the person’s psychology, analyzing their psychological, intellectual, as well as spiritual life.
A biography can range from a few sentences to a page. Lots of specialist conference organizers just request a short bio, as well as the bio acts as a recommendation for their target market when you present yourself. Nevertheless, if you’re a member of an expert network, such as LinkedIn, your bio can be a lot more in-depth. So, if you’re preparing a specialist biography, right here are a few pointers to help you create a reliable bio:
Initially, consider what a bio is. A bio is a detailed account of an additional person’s life, consisting of accurate details and stories from that person’s life. It might cover the person’s connection with member of the family, significant events in his or her life, and also success. One of the most popular biographies have to do with famous people, but you can additionally check out a bio about an individual that has a fantastic tale to inform.
An additional biography that can be interesting is one regarding a famous politician. A bio concerning Abraham Lincoln or Charles Darwin will be an interesting read. While biographies concerning political figures are often well-referenced, they can be less than comprehensive. Bios concerning famous people typically have a focus on the personal life of the author. While biographies commonly focus on exactly how people happened where they are today, they are likewise usually helpful. The writer’s history can aid you discover a bio of a crucial political figure.
The term Biography describes the in-depth description of an individual’s life. A bio exceeds the standard realities concerning a person’s life and consists of the person’s experience of different life occasions. For example, a bio concerning Abraham Lincoln can be as described as a story. Bios often feature the life stories of historical figures, such as the founding fathers of the United States. Biographies can also cover the lives of famous individuals from various periods.
A biographer should structure a bio in a manner that will hold the focus of the reader. It must develop a thesis and afterwards create supporting points to show the thesis. Biographies commonly are organized in sequential order, so understanding the centerpieces in an individual’s life will save time and effort when writing a bio. Once you have selected a chronological order, you can carry on to the next action. Relying on the category you’re dealing with, you could intend to structure the major points chronologically, such as in chronological order.
A scholastic biography depends heavily on recorded realities and kept in mind success. While the details of an individual’s life are often vital, the lessons learned by an individual can easily be shed in the minutiae. As an example, an academic chronicler could group realities connected to a person’s success by field. As an example, an aesthetic artist could be organized according to their influence on a particular type of art. Leaders in business, politics, and other fields are often organized chronologically. Extra resources
An additional sort of biography is a cumulative bio. For example, Captain Charles Johnson composed a publication called A General Background of the Pirates in 1724. This work cataloged the life stories of a lot of the globe’s most well-known pirates, and assisted to shape the image of pirates in pop culture. A smaller team could have a collective biography, such as a people club in New york city City. Nonetheless, it’s important to keep in mind that the term biographies usually refer to two types of biographical work. | <urn:uuid:07ad83e9-0bb8-456e-afce-915ad8b7dfe2> | CC-MAIN-2022-33 | https://caviezelcountry.com/2022/08/06/the-ultimate-revelation-of-biography/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571950.76/warc/CC-MAIN-20220813111851-20220813141851-00672.warc.gz | en | 0.958832 | 1,442 | 3.09375 | 3 |
Picpoul is often used in the blend for both red and white wines. It is one of the permitted grapes in Châteauneuf-du-Pape and can be a white single variety in Pinet, Meze, Florenzac, and Castlenau-de-Guers. It is generally green-gold and full bodied. Of late, this grape is being featured in many wines, usually in blends, from Languedoc and southern France.
Picpoul has both light skinned and dark skinned versions, as well as the rarer Gris. It buds late and is sensitive to oidium (powdery mildew). It has declined in popularity due to its susceptibility to fungal diseases and its low yield.
Picpoul means lip stinger, which refers to the high acidity of the grape. It is one of the oldest domesticated grapes and achieved a reputation for quality as early as the 17th century. | <urn:uuid:82bce0ea-dd45-45f5-9b88-81f4e0f93c2b> | CC-MAIN-2022-33 | https://www.kobrandwineandspirits.com/grape_glossary/picpoul/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.977683 | 198 | 2.171875 | 2 |
What It Takes To Be The Official Kansas Riverkeeper
The Friends of The Kaw is celebrating 30 years of conservation and preservation of the Kansas River and it takes a lot of work to do it.
Whether it's cleaning plastic out of sandbanks, educating students about water ecology, or working with cities on shoreline land development; maintaining the Kansas River is a full-time job. The official 'Kansas River Keeper' explains.
- Dawn Buehler, executive director of Friends of the Kaw | <urn:uuid:e079ebe3-8e41-4ec0-b3b1-190e20e7183d> | CC-MAIN-2022-33 | https://www.kcur.org/podcast/up-to-date/2021-07-28/what-it-takes-to-be-the-official-kansas-riverkeeper | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882572833.95/warc/CC-MAIN-20220817032054-20220817062054-00472.warc.gz | en | 0.913165 | 100 | 1.539063 | 2 |
Customized Prefabricated Steel Structure Building Project Mills Agricultural Steel Building
Brief: An extension to the existing building was required to accommodate agricultural plant and machinery and provide shelter for sheep and lambs. The existing building as built by us in December 2014.
A lean-to design was seen to be the most practical and cost-effective building design, this could be attached to the existing building, and use the existing columns and concrete side walls, by putting on a shallower pitched roof, this maximised the roof height.
The ground levels around the existing building where generally higher than the finish floor level of the building, as the levels were reduced to accommodate the first building. This meant that the ground would require to be lowered where the new building is, and a retaining wall to hold back the higher ground
The access into the building was through a sheeted gate/door which had split upper and lower leaves, which on a day to day basis makes it easier to open. When machinery is required in the building the top doors can be opened.
The roof material used was fibre cement which suits this type of building, as there is no condensation and it is non-corrosive. The sides used Yorkshire/hit and miss boarding to allow air movement through the building. Concrete panels were used on the side below the vertical boarding to give an easy to maintain wall that doesn’t get damaged easily, is strong and can be cleaned.
We carried out the complete project; excavating the site, building the retaining wall, setting the footings, erecting the building and providing a concrete floor with a hand trowel finish suitable for sheep and machinery. When complete we fitted portable sheep enclosures that would allow them to pen the sheep and lambs.
1 - High quality and durability: The steel building is safe and reliable, and it can withstand severe environments such as fire, strong winds, and heavy rain.
2 - Faster construction: All the structure parts are prefabricated in the factory, and then installed at the construction site. As a result, it will save up to 50% time period of construction and save costs for building owners.
3 - Minimal maintenance: The exterior of a metal building is essentially maintenance-free and long-lasting. Steel does not support mold growth, resists rust and decay better than other building materials. The bottom line is that low maintenance costs lead to low operating costs - a huge benefit over time.
4 - Economical - Reasonable cost: This building form has lightweight and short construction period, thus it can be put into operation very soon. Its comprehensive economic benefits are better than concrete structure building.
5 - Environmentally friendly: The steel structure can be recycled, and it will cause less environmental pollution when being built or removed.
6 - Wide architectural possibilities: It is applicable to many industries and non-industries, such as manufacturing, agriculture and civil usage.
7- Delicate appearance: The steel building design is with a modern sense. The wall panels are available in multiple colors and the building structure is with high flexibility.
8 - Space flexibility: Larger spans for flexible interior design.
9 - Seismic Resistance: Extensive research confirms that steel structure buildings withstand significant earthquake and wind events. Watch a test building outlast earthquakes simulated at UC San Diego.
10 - Adjustable design: Can cater to future expansions (vertical and horizontal)
|Main steel frame
|Q235&Q345B(Q355), welded/hot rolled H section steel|
|Purlin||Galvanizd Z&C section steel|
|Roof & Wall Panel||EPS, Rockwool, PU sandwich panel or corrugated steel sheet|
|Skylight sheet||Usually V-760, 1.2mm / V-900, 1.0mm / V-780, 1.2mm|
|Window||Aluminum alloy window/Plastic window|
|Door||Sandwich panel door & Steel door or as request|
|Steel material grade||Steel Q345B(Q355)&Q235/Q235B|
|Design software: Auto CAD,PKPM,MTS,3D3S, Tarch, Tekla Structures(Xsteel)V12.0.etc|
|Used||The steel workshop warehouse building is widely used for workshop plant, warehouse, office building, steel shed, aircraft hangar etc.|
|Tel :||+86 15824687445| | <urn:uuid:ba07d790-870c-480a-ab78-af8767e6cd63> | CC-MAIN-2022-33 | https://www.gescosteel.com/china-customised_prefabricated_windproof_steel_structure_building_construction-13945675.html | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.927591 | 982 | 1.726563 | 2 |
NASA astronauts aboard the International Space Station are currently testing a 4K camera to film science experiments. In practical terms, this will mean that the recordings, at a higher frame rate and in higher resolution than normal HD camera, offer up more information to researchers reviewing the recordings.
It also means some very fun and interesting videos.
In the most recent of these, astronaut Scott Kelly, who is part of NASA's crew spending a year in space rather than the standard six months to gauge the effects on the body of a long-term Mars mission, is playing with water.
More specifically, he has a globule of water, to which he is adding things and filming the effects. In microgravity, water floats in the air as quivering blobs, which makes for some experiments the astronauts seem to find really fun, such as popping water balloons, or injecting air bubbles and seeing how the water moves.
In Kelly's experiment, he switches it up a little. First, he creates the water globule, then he adds what looks like blue and yellow food dye to colour the water an algae green. Finally, he adds effervescent tablets, which causes the green globule to bubble and distort as the tablet rapidly breaks down, creating carbon dioxide.
The RED Epic Dragon 4K camera has also been used in the production of films, such as Peter Jackson's "The Hobbit" trilogy.
"This is a huge leap in camera technology for spaceflight," said program manager for NASA's Imagery Experts Program Rodney Grubbs of the camera in July.
"These cameras have large sensors capable of very high-resolution imaging at high frame rates. It is like having a high speed 35MM motion picture film camera, but it is compact, can use lenses we already have up there, and it is digital. No film to return to Earth."
You can watch Kelly perform his experiment in the video below. Turn it up to 2160p for the full 4K experience. | <urn:uuid:d743ed9d-ae69-4c85-b88a-cf1bee121df0> | CC-MAIN-2022-33 | https://www.cnet.com/culture/watch-a-floating-green-ball-of-water-effervesce-in-space-in-glorious-4k/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.948441 | 403 | 3.078125 | 3 |
As technology gets smaller and more powerful, wearables and portable devices are becoming more common in our everyday lives. Makers are looking to make projects portable and with that comes the need for high capacity batteries that are reliable, powerful, and compact. The clear choice for most projects is a Lithium Polymer (also known as Lithium-ion Polymer) battery (LiPo for short).
If you haven’t already checked them out, be sure to take a look at our tutorials on using PowerBoost Modules with LiPo Batteries, and Tips for Using LiPo Batteries. They cover off on same basic safety tips and best practices when using LiPo batteries, but today we’ll be looking at what differentiates different LiPo batteries, and how to choose the best one for your project.
The first step to choosing the right LiPo is understanding the various specifications that are associated with LiPos.
- Cells: A LiPo battery is made up of cells. A cell is a bit like a smaller battery inside the pack. Each cell has a nominal voltage of 3.7V (we’ll look at cell voltage next), and while most batteries are a single cell, some can have multiple cells which is denoted by an ‘S’ which stands for ‘series’ as the cells are wired in series. Bear in mind that not all rechargeable batteries are 3.7V, this is specific to LiPo chemistry, and other types of Lithium batteries such as coin cell batteries can have a different cell voltage. For packs with multiple cells, the nominal voltage is given as 3.7 x the number of cells. So a 3S pack would be rated at 11.1V.
- Voltage: As we discussed above, a LiPo battery cell will have a nominal voltage of 3.7V. The word ‘nominal’ is used as the actual voltage of the cell will change depending on how much charge it has left. A fully charged LiPo cell will have a voltage of 4.2V, and a when it is fully depleted, a voltage of 3.0V. A quality LiPo charger will avoid overcharging your battery, however, you’ll need to monitor the voltage when in use to ensure it doesn’t drop below 3.0V otherwise you WILL damage it.
- Capacity: The capacity of a battery is usually measured in milliamp hours (or mAh for short) or just Amp hours (Ah). This is true for all batteries, not just LiPos, and 1000mAh = 1Ah. What this means is that a 1000mAh battery can deliver 1000mA (or 1 Amp) for 1 hour, before being depleted. Provided you don’t exceed the maximum discharge rating (see below), you can supply any combination of mA consumption over time to the mAh rating. To work out the power you can draw from a LiPo for any given time, use this formula:
60 x (Battery Capacity/Average Current Draw)
- Discharge Rating: All LiPo batteries are rated to provide a certain amount of current from the cell, this rating is called the discharge rating and is provided as a unit called ‘xC’. All LiPo packs will have a rating such as 1C, 2C, 10C, etc... This means that they can provide a maximum current of ‘x’ (the number in front of C), multiplied by the capacity. So a 1000mAh battery with a discharge rating of 2C can provide 2000mA (or 2A). In addition to this rating, some high-performance packs may also have a ‘burst’ discharge rating which means they can deliver a higher current for a short amount of time (we’d recommend no more than 5 seconds to be safe).
Something to take note of though is that just because the LiPo cell is rated for a certain current draw, it doesn’t mean that the connectors are. Some LiPos, particularly 1S packs have thinner leads on them to make them easier to fit into portable projects. These leads may only be rated for a 1A draw, so if you plan on using more than that, you’ll need to upgrade your pack (BE CAREFUL!!!).
- Charge Rating: The charge rating determines how quickly the battery pack can be recharged, and it’s worked out in the same way the discharge rating is. It will have a ‘C’ rating which shouldn’t be exceeded when charging (seriously, don’t do it). Whilst some batteries may feature a charge rating higher than an amp, it’s good practice to limit the charge rate of batteries to 1A to ensure safe charging and long battery life.
- Size: This one might be a little obvious, but the larger the capacity of a battery, the bigger it will be. Most LiPos are fairly thin, but always be sure to pay attention to the dimensions of your battery, lest you accidentally kneecap your project.
Now that you’ve got a handle on all of the distinguishing features of LiPo batteries, let’s compare a few different packs and look at whether they would be suitable for different projects.
All of these packs feature common specifications such as being 1S (single cell, 3.7V packs with JST connectors and 2C discharge ratings (although as mentioned above, the wiring harness is only rated for 1A). The main difference is the capacity and the physical size. So what would you use each of these packs for?
- 120mAh LiPo: These little guys are perfect for low power projects and wearables the use BLE and other low-energy consumption technologies. They pair especially well with a solar charger due to their low capacity which allows them to be quickly recharged.
- 1000mAh LiPo: 1000mAh is the sweet spot of general purpose batteries as it’s got enough juice to keep most projects running for a decent amount of time, but they’re thin enough to fit into most enclosures and cases.
- 2600mAh Cylindrical LiPo: If 1000mAh doesn’t quite cut it, and perhaps you want something less wide, then a cylindrical LiPo could be just what you're after. These guys look like a bit AA battery, but they use the same LiPo chemistry and come in two flavours, with or without solder tabs. For the version without solder tabs, we've also got both single and double battery holders specifically for these 18650 size cells.
- 6000mAh Lipo: Stepping up to the beefiest LiPo we carry, is this monster. 6000mAh is a lot of energy which is contained in a surprisingly compact package. Whilst it does away with the thin form factor of the previous packs, it’s can still fit into most medium sized projects.
So there you have it folks, our recommendations on how to choose a LiPo, some important information about the difference between different batteries, and some of our favourite packs. Bear in mind, we’ve got plenty of other packs in between those sizes, so take a look at the rest of our range, and happy making! | <urn:uuid:08f7ab3b-b178-47ae-919c-031eaeeca0f5> | CC-MAIN-2022-33 | https://core-electronics.com.au/guides/analogue-electronics/choosing-your-next-lipo-battery/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571950.76/warc/CC-MAIN-20220813111851-20220813141851-00672.warc.gz | en | 0.945946 | 1,505 | 2.9375 | 3 |
Lamborghini’s Polo Storico department has been at it again. At this year’s Rétromobile classic car show in Paris, it revealed one of just four original factory-built Miura SVJs ever built, which it’s recently restored to as-new condition. Yes, we know the pictures are awful, sorry. But isn’t it lovely?
The SVJ was the ultimate edition of the Miura, inspired by the extreme one-off Miura ‘Jota’ test mule that was built to FIA ‘Appendix J’ regulations. This SVJ was built in 1973 for German touring-car racer Hubert Hahne, then Lambo’s German importer.
The unit was initially spec’d in black with a white leather interior, then in 1977, Hahne had the exterior repainted silver. The car remained in Germany until the early noughties, when it was exported to Japan. This is the first time it’s been seen in public since then.
Polo Storico’s restoration began “with in-depth analysis of documents held in the archives” and a “search for sources and accounts from the period when it was built,” so the car’s original spec and condition could be matched exactly.
How much is it worth? One sold at auction four years ago for almost $2 million (around P101.5 million), and values of cars like this tend not to decrease...
NOTE: This article first appeared on TopGear.com. Minor edits have been made. | <urn:uuid:9bde4a2f-dd82-4700-b2d1-7675e675b913> | CC-MAIN-2022-33 | https://www.topgear.com.ph/features/feature-articles/lamborghini-miura-svj-retromobile-tguk-a2613-20200209 | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.96665 | 340 | 1.507813 | 2 |
During one of the meetings of the 50th Association of Southeast Asian Nations Regional Forum at Manila, the foreign ministers of the member nations issued a communiqué "emphasizing the importance of non-militarisation and self-restraint," ending an impasse regarding the disputes on the South China Sea.
China's People's Liberation Army Air Force says it has conducted "combat patrols" near the disputed Spratly Islands and Scarborough Shoal in the South China Sea as part of an effort to normalize such drills and respond to security threats. Xian H-6 strategic bombers and Su-30 fighter jets took part in the patrols, according to Xinhua News Agency.
Chinese Vice Foreign Minister Liu Zhenmin says the United States was making political provocations with its patrols in the disputed South China Sea. He also says China is building military facilities on islands and reefs in the South China Sea as part of its national defense policy. Yesterday, U.S. President Barack Obama said, for the sake of regional stability, countries should stop building artificial islands and militarizing their claims in this sea.
Japan's prime minister Shinzō Abe says he is considering sending Japanese Navy warships to the South China Sea to back-up U.S. naval operations, saying, "With regard to activity by the Self-Defense Forces in the South China Sea, I will consider it while focusing on what effect the situation has on Japan’s security." In response, China's Ministry of Foreign Affairs spokesperson, Hong Lei, told Chinese state media that China will remain on “high alert for intervention by Japan in the South China Sea issue”.
Indonesia announces that it is planning to take China to court over the Natuna Islands. [https:--www.forbes.com-sites-timdaiss-2015-11-12-indonesia-ups-the-ante-in-disputed-south-china-sea-oil-and-gas-lurks-in-the-background- ("Forbes")]Territorial disputes in the South China Sea | <urn:uuid:37b0f6e3-ac84-4c8f-b62b-816be42fdc63> | CC-MAIN-2022-33 | https://offstream.news/feed/2015/11/3/japan-vietnam-relations.html | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571222.74/warc/CC-MAIN-20220810222056-20220811012056-00672.warc.gz | en | 0.93982 | 430 | 1.53125 | 2 |
How do you write a perfect judicialep-paper?
A Judicialep-purdue homework article is an academic report presented by students at the end of every semester. The work helps the supervisors to assess the understanding of the particular themes that the course applicants have in mind. As such, every student is supposed to conduct their research and come up with excellent reports.
By now, we must be very conversant with the kinds of disputes that we face when writing these papers. If that is not enough, then you might consider hiring expert sources to help you out. But now, how certain are you that you’ll get accurate results? Besides, is there a step-by-step plan to ensure that you submit an excellent document before the deadline? Whatever the case may be, it is better to hire a reliable service provider and achieve your set objectives within the stipulated time https://grademiners.com/.
Quality of Thesis
When you are through with the research and have gathered all the relevant information from data bases, it becomes easy to create a bibliography or reference section for the document. However, from the descriptions, it seems obvious that you don’t have to include everything that you’ve just checked out. The essential thing that you have to do is:college admission essay writer.
Brainstorm for ideas that can spice up the entire paperwork. Remember, the document is all about summarizing the finding of facts. So, coming up with a killer description is paramount. Don’t be in a rush to draft an annotation simply because it doesn’t have any bearing. Drafting a reference section is also another attribute that makes the literature review section strong. Every referencing instance that arises in a legal document has to be expressed chronologically.
Although the court setupwill do most of the organizing, formatting and citing parts, the supreme court composing the entire document. It would be best if you came up with a citation that captures every aspect of your study field.
Superior essay-Best Way to Outline Your Research
Before you start creating an outline for your supreme court paper, first, you should figure out the scope of your assignment. What do you want the readers to understand? Ascertain that you come up with a preliminary info that they can quickly analyze online paper writing service. Besides, whatever you include in the outline should relate to the topic in a comprehensive but concise manner. Lastly, it needs to be coherent and logical.
Have you ever worked with Jason Burrey? According to his regular customers, Jason is the guy to ask for help when it’s already too late to start working on your assignment. Friendly, cheerful, and attentive to detail, Jason will not rest until work is done 110%. Finding an essay writer who could keep up with Jason’s schedule would be one mission impossible for sure. | <urn:uuid:459089e2-e771-43c3-b484-3e073b7b673d> | CC-MAIN-2022-33 | https://datacenterhub.org/projects/jasonburrey | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571950.76/warc/CC-MAIN-20220813111851-20220813141851-00672.warc.gz | en | 0.945802 | 592 | 1.710938 | 2 |
The day has come: Flash is EOL and dead
The content of this article is from Geeker's Digest.
Today, January 12th 2021, is the day Adobe’s Flash technology has officially entered the realms of zombie software. What once started in the early 2000s with Macromedia Flash and the sudden urge to make every website running Flash, is now nothing less than a dead piece of technology.
This Flash icon is now shown in some browsers.
But Flash did not die all of a sudden on this day. It was declared dead more than 10 years ago when legendary Apple co-founder Steve Jobs wrote “Thoughts on Flash” to Adobe (and the world). Jobs correctly foresaw that the Flash technology would be superseded by not only superior but standardized technology:
New open standards created in the mobile era, such as HTML5, will win on mobile devices (and PCs too).Steve Jobs in April 2010
It took another few years until Adobe themselves announced in 2017 that Flash will definitely be EOL (end of life) at the end of 2020. Google chimed in quickly and announced that Flash will be removed in Chrome toward the end of 2020.
Opening a website requiring the Flash plugin today will result in displaying a large Flash logo with a big blue information sign. A click on it redirects the browser to the official Adobe website where the end of Flash is described:
Adobe website informing about the end of Flash
Depending on the browser used by the end user, the EOL information is shown differently.
Using Microsoft’s Internet Explorer shows the EOL icon:
Google’s Chrome simply shows an empty page. Only the favicon points to a “broken plugin”.
Chrome already removed the Flash plugin
This happens because (most and updated) Chrome installations already removed the Flash plugin by today.
And in Mozilla’s Firefox, an “alternative content” information is shown: | <urn:uuid:c96966b0-3e56-46f8-9cf0-16be62dd1122> | CC-MAIN-2022-33 | https://faizanhussain.com/blog/post/the-day-has-come-flash-is-eol-and-dead/34 | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571950.76/warc/CC-MAIN-20220813111851-20220813141851-00672.warc.gz | en | 0.905237 | 407 | 1.835938 | 2 |
A key part of the process of immigrating into the United States is the successful completion of an immigration medical exam. If you have been advised to complete this exam, you may be wondering what to expect. Here's a look at what you should know as you prepare to complete this exam.
The Purpose Of The Exam
An immigration medical exam is designed to ensure that those permitted to enter the country are free of serious communicable diseases, mental illness, and other medical concerns that could prove problematic.
What type of birth control you get depends on your needs and your body. One of the most effective forms of birth control is the IUD, or intrauterine device. An IUD is a small t-shaped object that actually sits inside your uterus, affecting the uterine environment in a way that prevents pregnancy. There are two different types of IUDs, and there or pros and cons to each. Learn more about the two types before making your choice.
The dangers of urinary tract infections can be high if left untreated. Thankfully, penicillin can manage this problem quite well for most people. However, those with allergies to penicillin may need to try other care options that don't interfere with their health. Thankfully, there are many different choices a person can choose from, each of which provides many high-quality benefits for their health.
Penicillin Allergies Can Be Hard to Tolerate
Ophthalmologists do way more than just offer eye exams. While the work of optometrists and opticians is primarily centered around diagnosing the correct eye prescription of their patients and fitting patients for glasses and contacts, ophthalmologists have a greater depth of practice. Ophthalmology services include but are not limited to the following things:
So many things can go wrong when it comes to vision. The most common vision issues that millions of American experience are myopia or hyperopia.
If you own and operate an offshore recreational boat and provide tours to locals and visitors of the area, relying upon your navigational skills and quick protocol can prevent accidents and serious injuries. Even if you and the others are constantly monitoring the passengers, an incident could occur in which someone falls overboard or is injured on a fishing hook, recreational gear, or a protrusion that is in the water. You can purchase a coast guard–approved lifeboat first aid kit to provide emergency care if needed. | <urn:uuid:9a412f62-f151-4155-8a0d-cb6806ccd3f9> | CC-MAIN-2022-33 | http://flqalf.com/author/marilyn-rodriquez/page/18/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571950.76/warc/CC-MAIN-20220813111851-20220813141851-00672.warc.gz | en | 0.9547 | 507 | 1.890625 | 2 |
Using natural oils for skincare was once reserved for women with a traditional mindset. But now the skincare world seems to be singing praises of oils and their miracles. Amongst these oils, tea tree oil has become the beauty cure-all du jour with the standing of being a godsend for acne woes.
Here we give you a swift trip of the qualities of tea tree oil along with tips on how to pull out its benefits in your daily skincare gig.
Anti-bacterial and Anti-inflammatory
Owing to its anti-bacterial and anti-inflammatory properties, this essential oil is commonly used in skincare products. It can be used to treat acne issues, cleanse the skin thoroughly and heal wounds and inflammation. It comprises the antiseptic compound called terpenin. This does not only kill bacteria, but also fights fungus, virus, reduces scalp dandruff, itching and fungal infections.
Long presaged for its acne controlling properties, tea tree oil is one of those skincare products everyone has been familiar with. It is used in diluted form with other carrier oils to kill acne-based bacteria.
It’s a common ingredient found in anti-acne skincare products. These include face washes, creams, body washes and toners. Besides controlling breakouts, it is also used to combat excessive oil formation on the skin.
It is effective in reducing acne based lesions. All you have to do is mix a few drops of tea tree oil with any other carrier oil. Apply on the spots with a cotton ball. You can also prepare a mask. Just mix in some tea tree oil in fuller’s earth clay and yogurt and apply on your face.
Tea tree oil is a completely organic skincare product. Derived from the tea tree plant, its oil is completely natural with no synthetic ingredients. So if you want to avoid the application of any chemical based skincare products you should opt for tea tree oil.
If synthetic acne treatments like benzoyl peroxide don’t suit your skin and cause dryness and irritation, you can try tea tree oil. It’s gentle to the skin and gets readily absorbed too. You can also dilute it with some water, if your skin is overly sensitive.
Strengthen and Brighten nails
Being a powerful antiseptic, tea tree oil is effective in fighting fungal infections on the nails. It also expels the yellow stain your nail paint has left on top of your nails.
Soothe Irritated Scalp
The antifungal properties of tea tree oil help it soothe itchy scalp and reduce dandruff. It does this by scrubbing off dead skin cells and the dandruff causing yeast. You can massage your hair with tea tree oil combined with another carrier oil of your choice. You can also use a shampoo containing tea tree oil as an ingredient.
It’s very reasonable. It cures your skin issues at a fraction of the cost of other skincare products.
Amplify your Moisturizer
Owing to its purifying effect on the skin, the oil is a great add on to your moisturizer. You can mix a few drops of the oil to your moisturizer and prevent acne breakouts, keeping your face clean and clear. This is a better option than buying a skincare product with tea tree ingredients. You will know that you are using 100 percent organic tea tree oil on your skin with as much amount as you can.
Produce your own Toner
You can also use this oil by mixing it in with your toner. Simply mix two drops of the oil with water and apply on your face using a cotton pad. It’s going to strip away the makeup residue and will leave skin feeling fresh and hydrated.
Invigorate your Eyes
Because of its anti-bacterial and anti-inflammatory properties, you can use these oils as eye wipes. It will be great for refreshing tired eyes and maintaining the hygiene of your eyelids. When used on your eyes, it will provide a zingy uplifting feel and an impeccable way to rejuvenate your eyes.
You can also treat acne prone oily skin with a skincare product containing tea tree oil. Like a tea tree oil based face wash for instance.
When applying on the hair, combine a few drops of tea tree oil with a carrier oil and massage on the scalp.
How Often Should I Use It?
There is no right or wrong answer to that because everyone’s skin reacts differently to it. Though you might like to test it on a patch of your skin to make sure it doesn’t tingle your skin. You can then add it to your skincare regimen accordingly.
Things to Keep in Mind:
Since you now know the numerous benefits of tea tree oil for your skin, there’s no reason why you wouldn’t include it in your skincare routine.
High Profile Skincare Products
- Determining what type of belts to invest in can be a difficult task, especially since there are many types of wholesale womens belts available in the market. There are so many types of attractive belts, from which you can choose what will be suitable for you. | <urn:uuid:362b5d42-4757-4ecf-a1a3-13e3708f3a67> | CC-MAIN-2022-33 | https://www.guest-articles.com/shopping/why-is-tea-tree-oil-worthy-of-being-part-of-your-skincare-regimen-13-12-2021 | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571222.74/warc/CC-MAIN-20220810222056-20220811012056-00672.warc.gz | en | 0.952774 | 1,117 | 1.8125 | 2 |
Coal last generated in the UK before 2pm on last Wednesday 1 May, and smashed through the previous record at around 9am on Sunday 5 May.
The most recent coal-free record was set also on a bank holiday weekend. From 10:30pm Thursday 18 April 2019 until 5:30pm on Monday 22 April 2019, a period of just over 90 hours, the country’s energy demand was met entirely without coal.
However the country’s coal-free record has shown no sign of abating and as of 4pm today (Tuesday 7 May 2019), the UK has gone 146 hours without coal.
Should the UK make it another 22 hours, it will set a new milestone of having gone a week without any coal generation.
And the signs are good, with Duncan Burt, director of operations for National Grid, System Operator, commenting that it looks promising for that feat to be achieved, having lasted today’s morning peak.
Burt also tweeted to commend the work of those at National Grid in making it happen.
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Figures provided by Drax Electric Insights show that for a period on Saturday afternoon, the country’s solar and wind fleet combined to supply more than 53% of the country energy demand, also coinciding with the lowest carbon intensity of the period at 72g CO2/kWh.
The new coal-free run also means that the UK has exceeded 1,000 hours without coal generation this year already, as figures compiled by MyGridGB confirm. | <urn:uuid:7a4966c3-3783-4b80-8d35-820788ef57c0> | CC-MAIN-2022-33 | https://infinitybatterystorage.com/uk-smashes-yet-another-coal-free-record/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.951131 | 326 | 2.46875 | 2 |
To radiate or not to radiate, that should be the question all doctors ask continuously. Unfortunately the explosion of higher-sensitivity diagnostic imaging has some patients asking for them by name, a dangerous scenario as CT (CAT) scans are being implicated in increased cancer risk.
I have had my Los Angeles chiropractic patients ask me (more like passively demand) for an advanced imaging study, despite it being unnecessary. Why? Because doctors have been pushing them in the same manner they’ve been pushing antidepressants, statins and other drugs. When doctors order CT scans and MRIs for every patient coming in with an ache or pain, regardless of how small, the public will start to think advanced imaging is a medical necessity. Often it isn’t. Here’s the skinny:
An article just published in the New England Journal of Medicine, discloses that X-ray computed tomography (CT) is being overused by doctors, and this overuse is leading to increased medical mistakes as well as increased cancer risk. CT scans generate three-dimensional images of the inside of an object from a large series of two-dimensional X-ray images taken around a single axis of rotation. CT scans use far more radiation than traditional x-rays, and their use has increased dramatically over the last two decades–for example, approximately 72 million scans were performed in the United States in 2007. According to the report, 10% of the U.S. population gets CT scans every year, and that number is growing by more than 10% every year.
Increased CT scans is a concern not only because of the heightened cancer risk, but also because one of the main groups getting this type of mega-radiation is children. The lifetime cancer risk for children receiving CT scans in non-negligible. To put this into perspective:
In the United States, of approximately 600,000 abdominal and head CT examinations annually performed in children under the age of 15 years, a rough estimate is that 500 of these individuals might ultimately die from cancer attributable to the CT radiation. (via Wikipedia)
The good news is that the FDA and Congress are considering measures to prevent medical mistakes. However, discretionary use is still in the hands of doctors, and I imagine the overuse of CT scans will continue as long as the fear of liability continues to loom over doctors’ heads.
Although MRIs use no radiation, their overuse is also epidemic. I am of the opinion that this is one reason medical costs are out of control. You can give every American double the health coverage, if doctors don’t stop using these imaging techniques indiscriminately, costs will continue to soar.
The way I handle unnecessary MRI requests is to explain that diagnostics should guide treatment. For the most part, if knowing whether a spinal disk bulge is present radiologically will not change my treatment protocol (and it rarely does), then the study is unnecessary. I simply remind the patient that MRIs are not cheap–they run around a couple thousand dollars–and even with the best insurance, the patient is responsible for the co-payment, which will be several hundred dollars.
You still want it, even though it’s not going to change anything we do here?
Be my guest. Here’s your scrip. Have fun.
Some people just can’t be convinced; but I’m hoping the fear of developing cancer from unnecessary CT scans wises people up. We’ll see. | <urn:uuid:3b961bf0-b134-4ad9-a68b-477d74e2f85f> | CC-MAIN-2022-33 | https://www.nickcampos.com/2010/06/cat-scan-fever/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882570793.14/warc/CC-MAIN-20220808092125-20220808122125-00672.warc.gz | en | 0.9555 | 721 | 2.421875 | 2 |
Many residential property owners add insulation to their roofs to reduce heat loss during the winter months and increase the efficiency of cooling systems during the summer. How can you tell if your Denver roofing needs insulation? Follow these tips:
Check the attic.
Does your home have an attic? Sometimes, you can tell whether your Denver roofing is in need of insulation just by walking through the attic. First, take a look around to see if you notice any moisture during the hot summer months. When a roof is poorly insulated, the heat outside can lead to condensation on the inside. Some homeowners may notice that there is moisture even though they already had insulation installed. This could be a sign of a poor insulation job or damaged materials. If you see any moisture, it’s time to call a roofing professional to add insulation.
Look for ice dams.
Ice dams are areas of thick ice patches that collect at the edge of a roof and block water from draining off of the roof. When water becomes trapped behind an ice dam, it can eventually become so heavy that it begins to leak into your home. Because of this, ice dams should be avoided at all costs, and they can be with proper insulation. During a snowstorm, if heat is escaping through the roof because of poor insulation, the temperature of the rising heat will melt snow. This melted snow travels down the roof, freezing again on the lower ridges of the roof, causing ice dams. If you notice a buildup of ice dams, remove them as quickly as possible and call a Denver roofing professional to add insulation.
Talk to neighbors.
It can be difficult for you to tell whether your heating and cooling bill is abnormally high. After all, you have nothing to compare it to besides previous months’ bills. Talk to your neighbors about their average heating and cooling costs per month and see if yours falls within the same range. If it doesn’t, this is a telltale sign of heat loss, most likely through the roof. In fact, 25% of lost heat in a home escapes through the roof, so this could be a major cause of your skyrocketing energy bills.
Get an energy audit.
Some homeowners opt to get a professional energy audit to determine whether or not their roofs need insulation. The most common type of energy audit, the blower door test, is done to determine whether there are significant air leakages throughout the home, including in the roof. If the professional auditor does find that you are losing massive amounts of energy, adding insulation to your Denver roofing may help you conserve this energy. Learn more about home energy audits
and whether this is a logical first step for you.
Does your Denver roofing need insulation? If you’re in need of a residential or commercial roofing professional, there’s no better place to turn to than K1 Roofing. Contact us
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Harsh conditions, mistreatment, and individual murders led to many deaths.
President Bill Clinton's Cabinet as the Director of the Office of National Drug Control Policy.
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Oregon bill would help transgender residents change vital records to reflect new name, gender
Transgender residents want the Oregon Legislature to make it easier for them to change their names and gender designations on vital records.
In written and oral testimony at a committee hearing Monday, more than a dozen people described their challenges with the state’s current statute, which requires a legal petition that must be publicly posted in a county courthouse.
“I have feared for my safety because I am transgender, so as you can imagine having to go into a government building where my old feminine sounding name would be publicly announced and posted is prohibitive,” North Portland resident J Gibbons said.
The court process also is inconsistent from county to county and can be costly and hard to navigate, according to Basic Rights Oregon, which requested the legislation.
“Considering the harassment and discrimination transgender people continue to experience, this risk is an undue burden for many of us,” said Brook Shelley, co-chair of the group’s board of directors.
House Bill 2673 would create an alternative, streamlined method for transgender residents to change their name or gender marker at the Oregon Health Authority.
It also would eliminate the requirement for courts to publicly post court orders changing their name or gender identity.
Some transgender people may feel more urgency around updating their documents in light of recent actions at the federal level and in other states, House Majority Leader Jennifer Williamson, D-Portland said.
President Donald Trump recently rolled back federally guaranteed protections for transgender students, although Oregon has its own guidelines protecting those students.
“Here in Oregon, we’ve been a leader in ensuring every Oregonian has their basic rights protected, but of course there’s more we can do,” Williamson said.
The committee will consider at least one amendment to the bill.
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Throughout The Rest Of Your Body:
Anyone who has had a severe allergic reaction after getting a mRNA COVID-19 vaccine , should not get another dose of either of the mRNA COVID-19 vaccines. Anyone who has had a severe allergic reaction after receiving Johnson & Johnsons Janssen COVID-19 vaccine, should not receive another dose of that vaccine.
Deltaand Omicroncould Lead To ‘hyperlocal Outbreaks’
If Deltaand now Omicroncontinue to accelerate the pandemic, Dr. Wilson says the biggest questions will be about the heightened transmissibility. The answer could depend, in part, on where you liveand how many people in your location are vaccinated, he says. I call it patchwork vaccination, where you have these pockets that are highly vaccinated that are adjacent to places that have 20% vaccination, Dr. Wilson says. The problem is that this allows the virus to hop, skip, and jump from one poorly vaccinated area to another.
In some cases, a low-vaccination town that is surrounded by high vaccination areas could end up with the virus contained within its borders, and the result could be hyperlocal outbreaks, he says. Then, the pandemic could look different than what weve seen before, where there are real hotspots around the country.
So, instead of a three- or four-year pandemic that peters out once enough people are vaccinated, an uptick in cases would be compressed into a shorter period of time. That sounds almost like a good thing, Dr. Wilson says. Its not. If too many people are infected at once in a particular area, the local health care system will become overwhelmed, and more people will die, he says. Thats something we have to worry about a lot.
Alert Those You Came In Close Contact With
There may be a period of panic after testing positive not just for your own health, but for the health of others you may have been around recently.
As soon as possible, identify anyone with whom you came in close contact while contagious and alert them that you’ve tested positive.
You’re contagious with COVID-19 as early as:
- Two days prior to symptom onset or testing positive
If you have COVID-19, close contact is defined as:
- Being within 6 feet of someone for a combined total of 15 minutes or more over a 24-hour period while contagious
Bottom line: It’s incredibly important to let people know that they have been exposed, so they can take the necessary quarantine precautions and get tested as recommended.
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How Can I Protect Myself While Caring For Someone That May Have Covid
You should take many of the same precautions as you would if you were caring for someone with the flu:
- Stay in another room or be separated from the person as much as possible. Use a separate bedroom and bathroom, if available.
- Make sure that shared spaces in the home have good air flow. If possible, open a window.
- Wash your hands often with soap and water for at least 20 seconds or use an alcohol-based hand sanitizer that contains 60 to 95% alcohol, covering all surfaces of your hands and rubbing them together until they feel dry. Use soap and water if your hands are visibly dirty.
- Avoid touching your eyes, nose, and mouth with unwashed hands.
- Extra precautions:
- You and the person should wear a face mask if you are in the same room.
- Wear a disposable face mask and gloves when you touch or have contact with the person’s blood, stool, or body fluids, such as saliva, sputum, nasal mucus, vomit, urine.
- Throw out disposable face masks and gloves after using them. Do not reuse.
- First remove and throw away gloves. Then, immediately clean your hands with soap and water or alcohol-based hand sanitizer. Next, remove and throw away the face mask, and immediately clean your hands again with soap and water or alcohol-based hand sanitizer.
What Should I Do If Im Fully Vaccinated And Ive Been Exposed To The Coronavirus
If youre fully vaccinated and youve come in contact with someone infected with COVID-19, you dont need to quarantine unless you have possible COVID symptoms.
Even if you dont have any symptoms, the CDC recommends that you:
- Get tested 5-7 days after exposure.
- Wear a mask indoors in public for 14 days after exposure or until your COVID-19 test result is negative.
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What Is Viral Load
Viral load refers to the amount of virus present in someones bodily fluids at a given point in time. Scientists can measure this by looking at your blood, or more commonly in COVID, swabs of your nose and throat.
Generally, higher viral loads are thought to correspond to a more contagious individual.
However, this isnt always clear in reality. For example, some people with COVID who dont have symptoms and have low viral loads transmit more, as they are less likely to follow social distancing, mask wearing, and stay at home.
The evidence on how viral load relates to severity of disease is mixed. Some studies find no relationship between the amount of virus in swabs and poorer outcomes, but others find an increased death rate with increasing viral load.
What Is The Incubation Period For The Omicron Variant
Omicron is now the most dominant strain of coronavirus in the U.S., and its incubation period may be shorter than those of previous variants. Research is just beginning. But some scientists who’ve studied Omicron and doctors who’ve treated patients with it suggest the right number might be around 3 days.
Some early research suggests Omicron may be more contagious than the Delta variant. But health experts are still looking into how sick it can make people and how well vaccines and treatments work against it.
They expect vaccines and booster shots to help protect people from serious illness, hospitalization, and death. If youre fully vaccinated and you get a breakthrough infection of Omicron, youre less likely to become seriously ill than an unvaccinated person.
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What Is The Incubation Period For Covid
Viruses are constantly changing, which sometimes leads to new strains called variants. Different COVID-19 variants can have different incubation periods.
When researchers set out to learn the incubation period for the original strain of the coronavirus, they studied dozens of confirmed cases reported between Jan. 4 and Feb. 24, 2020. These cases included only people who knew that theyd been around someone who was sick.
On average, symptoms showed up in the newly infected person about 5.6 days after contact. Rarely, symptoms appeared as soon as 2 days after exposure. Most people with symptoms had them by day 12. And most of the other ill people were sick by day 14. In rare cases, symptoms can show up after 14 days. Researchers think this happens with about 1 out of every 100 people.
Some people may have the coronavirus and never show symptoms. Others may not know that they have it because their symptoms are very mild. Current studies might not include the mildest cases, and the incubation period could be different for these.
What We Know About Vaccine Breakthrough Infections
- Vaccine breakthrough infections are expected. COVID-19 vaccines are effective at preventing most infections. However, like other vaccines, they are not 100% effective.
- Fully vaccinated people with a vaccine breakthrough infection are less likely to develop serious illness than those who are unvaccinated and get COVID-19.
- Even when fully vaccinated people develop symptoms, they tend to be less severe symptoms than in unvaccinated people. This means they are much less likely to be hospitalized or die than people who are not vaccinated.
- People who get vaccine breakthrough infections can be contagious.
CDC is collecting data on vaccine breakthrough infections and is closely monitoring the safety and effectiveness of all Food and Drug Administration approved and authorized COVID-19 vaccines.
Because vaccines are not 100% effective, as the number of people who are fully vaccinated goes up, the number of vaccine breakthrough infections will also increase. However, the risk of infection remains much higher for unvaccinated than vaccinated people.
The latest data on rates of COVID-19 cases, hospitalizations and deaths by vaccination status are available from the CDC COVID Data Tracker.
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Can You Get Covid After Being Vaccinated
Yes. Breakthrough COVID-19 cases happen in people who are fully vaccinated, and they seem to happen more frequently now that the delta variant is circulating widely and immunity may be waning among those who got the vaccine many months ago. All three available coronavirus vaccines are very good at protecting you against severe forms of COVID-19, but they are not 100% effective in preventing infection. Breakthrough COVID can be caused by the delta variant, which is more contagious than some other coronavirus variants.
What You Need To Know About Covid
Explore top articles, videos, research highlights and more from the AMAyour source for clear, evidence-based news and guidance during the pandemic.
The three COVID-19 vaccines available in the United Statesfrom Moderna, Pfizer-BioNTech and Johnson & Johnsonare doing exactly what they were meant to do: protect against severe illness and hospitalization. But with the more dangerous Delta variant of SARS-CoV-2 spreading rapidly, the U.S. is seeing more COVID-19 vaccine breakthrough infections.
Nevertheless, the fact remains that getting vaccinated is effective in preventing people from getting severely ill or dying from the disease. Even as new COVID-19 variants appear, vaccines continue to hold their ground. But since no vaccine is perfect, it is expected that we will see some COVID-19 breakthrough infections.
More than 161 million people in the U.S. have been fully vaccinated against COVID-19, according to the Centers for Disease Control and Prevention . Meanwhile, the CDC reports that there have been more than 10,000 COVID-19 vaccine breakthrough cases. However, while the CDC initially tracked all breakthrough COVID-19 infections, as of May 1 the agency shifted to only tracking those linked to hospitalization or death. Over 5,100 patients with COVID-19 vaccine breakthrough infections were hospitalized or died.
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If Youre Sick Or Caring For Someone Whos Sick
If youre infected with COVID-19, even if not ill, follow the advice of your local public health authority for isolating at home. Most people with mild symptoms will recover on their own.
Adults and children with mild COVID-19 symptoms can stay at home while recovering. You dont need to go to the hospital.
If youre caring for someone at home who has or may have COVID-19, you should follow the appropriate precautions to prevent the spread of illness.
Learn more about:
The only way to confirm you have COVID-19 is through a laboratory test.
Follow the testing directions provided by your local public health authority if you have:
- been exposed to a person with COVID-19
People who are partially or fully vaccinated may still be asked to get a COVID-19 test.
If youve been tested and are waiting for the results, follow instructions:
- on how to quarantine or isolate and
- from your local public health authority
Learn more about:
How Long Does It Take To Be Fully Vaccinated
If you receive the single-shot Johnson & Johnson vaccine, you are considered fully vaccinated two weeks after you get the shot.
If you get the Pfizer vaccine, there is a 21-day period between the first and second doses. If you get the second dose exactly three weeks after the first one, you will be considered fully vaccinated five weeks after the first dose.
If you receive the Moderna vaccine, there is a 28-day waiting period between the first and second dose, so it will take a week longer to be fully vaccinated.
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Sick And Immunocompromised People
These guidelines do not apply to moderately or severely ill people with COVID-19 or people with weakened immune systems. Immunocompromised people should always isolate for at least 10 days, and up to 20 days for people who were severely sick with COVID-19.
If a person does not have access to repeat COVID-19 testing after five days in isolation, or does not want to retest, the CDC recommends that people take precautions until day 10 by continuing to wear a well-fitted mask around others at home and in public.
Most Breakthrough Infections Are Mild
Because people who are vaccinated have had some immunity, some antibodies, a majority of these breakthrough cases are going to be asymptomatic, said Dr. Sanghavi. According to the data, reported by CDC and other publications, it seems like around 25% to 30% of the patients who have had breakthrough infections are completely asymptomatic.
There are about 50% to 60% of the patients who would have some symptoms, but are mild and still may not need hospitalization, he added. “The severity of the symptoms of these COVID breakthrough infection cases would be milder, but in certain patients you may still need all the aggressive care that we provide to an unimmunized person who gets a COVID infection.
For 90% of the patients, the breakthrough infection would be mild, but for 10% of the patients, they would still require hospitalization, said Dr. Sanghavi. But then 1% to 2% of those hospitalized from breakthrough infections may still die, unfortunately. So, its still a concern.
That is the reason why everybody should get vaccinatedbecause even if you are immunosuppressed and get a breakthrough infection, that infection would be mild as compared to a regular infection, he said.
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What Can I Expect Postcovid
Everyone will have a different experience in their recovery from COVID-19. Some people may recover in days, some in weeks. But for others, it could be months. Although each case is unique, people recovering from more severe symptoms are likely to face a longer recovery period.
Schedule regular appointments with your GP to discuss your symptoms and how best to manage them. Your GP will tell you about any medicines that might suit your needs.
Common symptoms you may experience during your recovery:
- change in sense of taste or smell
- anxiety and/or low mood
If you have any of the following symptoms, call emergency services on 000 immediately and tell the phone operator youve previously been diagnosed with COVID-19.
- severe shortness of breath or difficulty breathing
- severe chest pain or pressure
- a new or returning fever
- worsening ability to concentrate and increased confusion
- difficulty waking up
Can My Child Get A Covid
The Centers for Disease Control and Prevention now recommends a COVID-19 vaccine for children ages 5 and older. Johns Hopkins Medicine encourages all families to have eligible children vaccinated with the COVID-19 vaccine. Currently, Pfizers vaccine is the only approved COVID-19 vaccine for children.
We encourage you to use all available local and state resources, including retail pharmacies, to get the COVID-19 vaccine. You can also review our resources to help find a vaccination site for your child.
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Myth: All Events Reported To The Vaccine Adverse Event Reporting System Are Caused By Vaccination
FACT: Anyone can report events to VAERS, even if it is not clear whether a vaccine caused the problem. Because of this, VAERS data alone cannot determine if the reported adverse event was caused by a COVID-19 vaccination.
Some VAERS reports may contain information that is incomplete, inaccurate, coincidental, or unverifiable. Vaccine safety experts study these adverse events and look for unusually high numbers of health problems, or a pattern of problems, after people receive a particular vaccine.
Recently, the number of deaths reported to VAERS following COVID-19 vaccination has been misinterpreted and misreported as if this number means deaths that were proven to be caused by vaccination. Reports of adverse events to VAERS following vaccination, including deaths, do not necessarily mean that a vaccine caused a health problem.
Learn more about VAERS.
Vaccination For People Who Have Had Covid
For people who have had COVID-19 confirmed by a nucleic acid amplification test , a single dose of the vaccine is required. The infection triggers the immune system’s response the same way a 1st dose of the vaccine does. The dose of vaccine given to someone who has had COVID-19 has a booster effect the same way a 2nd dose of the vaccine does. It would be preferable to wait eight weeks or more after diagnosis before being vaccinated.
For COVID-19 cases confirmed by epidemiological link or who have only received a positive result for a serological or antigenic test, two vaccine doses are necessary. The epidemiological link and serological or antigenic test cannot confirm beyond doubt that a person has had COVID-19. The administration of two doses is necessary to ensure that the person is adequately protected against COVID-19.
A person who has had COVID-19 may choose to receive a 2nd dose of the vaccine. Giving two doses of vaccine to someone who has had COVID-19 is not dangerous.
For people who had COVID-19 when they were given the 1st dose or in the days after they were vaccinated, two doses are required.
For people with a weakened immune system or on dialysis, three doses are necessary, regardless of whether they have had COVID-19. For further information, see the Additional or booster dose of COVID-19 vaccine page.
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Optimizing your web presence is no longer just a “nice to have” option. It’s a necessity.
With millions of active users interacting across the Internet at the same time, getting lost in all the noise is inevitable unless you take steps to stay relevant.
And that’s where search engine pptimization (SEO) comes into play.
SEO refers to the steps you take to ensure that your site or page are the first things to show up when a user enters a certain keyword.
The benefits of this are tremendous. You’ll see a significant boost in engagement, generate more leads, make more sales, and improve your bottom line.
However, competition for the top spots in organic search results is fierce. Because of the low barrier to entry, anyone can create a site and optimize it to rank better on Google or Bing.
What separates the best from everyone else is the smart implementation of certain strategies, as well as using tools to help make optimization much more efficient.
In this article, you’ll learn the best ways to optimize your WordPress site for SEO, including the tools that will make that journey substantially easier.
Pre-Requisites for WordPress SEO
Before diving into the wild and wonderful world of WordPress SEO tools, it’s important to get the basics right first.
SEO plugins are features you add to an already well-thought-out and presented package. These plugins aren’t magic, and they certainly won’t create sensational results if the base they have to stand on isn’t strong.
WordPress is widely regarded as a great site for SEO optimization as it has Content Management Systems (CMS) that make the entire process super easy and intuitive.
Take advantage of this user-friendliness and ensure that the content you post on your site is high quality and value-added.
Just keep in mind that no plug-in can help you if your page doesn’t offer great information. Even if you get people to your site, they probably won’t stay there for very long.
It’s also important for you to use themes/templates that have clean code as that helps with SEO.
Another important thing to mention is that you absolutely don’t need every single plugin from this list. These are just to give you an idea of the different options and what they have to offer.
Choosing just one from each of the categories is more than good enough, especially if you’re new to optimization.
Don’t get caught up in all the technology, since you could potentially reach the point of overwhelm, and experience analysis paralysis (a.k.a., you become so caught up with things that you never make any headway on what you’re trying to achieve).
At the end of the day, always keep the basics in mind, regardless of whatever stage you’re at right now.
WordPress General SEO Plugins
These tools are designed to help you turn your simple WordPress into an SEO machine. They will help you optimize your site, give you suggestions, and perform keyword searches.
1. Yoast SEO
Yoast SEO is an industry favorite with thousands of glowing reviews. It’s a premium plugin that offers an incredible number of powerful features while still being easy to use and understand.
Some of these features include:
- Internal link suggestions.
- Focused keyword reports.
- A page and content analysis tool.
- Built-in Redirect manager (for error 404 URLs).
- XML Sitemaps.
The page analysis tool that Yoast offers is very useful as it provides an all-inclusive snapshot of how your page is doing.
The readability, the length of the content, alt attributes, keyword density, title tags, and meta description among others, are all analyzed to ensure you’re on the right track.
2. All in One SEO Pack
As of the time of this writing, All in One SEO Pack has been downloaded more than 74 million times and has cemented itself as a super feature-rich WordPress plugin that’s perfect for beginners and experts alike.
The plugin offers:
- Google Accelerated Mobile Pages support.
- XML Sitemap support.
- Google Analytics support.
- A built-in API.
- A redirect manager.
- Integration with ecommerce sites like Shopify.
- Automatic blog title optimization.
- Automatic meta tags.
More seasoned users can also create custom headlines, tags, meta descriptions, and keywords depending on their needs.
3. Premium SEO Pack
Premium SEO Pack offers several super useful modules for you to take advantage of in both the free and paid versions. For the regular license, a fairly reasonable $44 gets you:
- Focus Keyword Analysis.
- Custom permalinks.
- Page SEO reports as well as scores.
- Page Analysis and recommendations.
- Keyword suggestions.
- 404 monitoring.
- A W3C validator.
- Mass optimization.
- Local SEO.
- A video sitemap.
The price tag might be higher than other services on this list, but the features and customizability Premium SEO Pack offers more than justify it.
It’s a great choice for seasoned SEO professionals looking to take their WordPress site to the next level.
4. SEOPressor Connect
This plugin takes your most essential SEO data and lays it out in one intuitive dashboard. The dashboard gives you a glance at insights into your site’s search engine visibility amongst other things.
The main selling point of SEOPressor however is their emphasis on contextual content instead of keywords.
A $9 monthly subscription gets you:
- Automatic internal linking.
- Readability scoring.
- Over-optimization checking (irrelevant keywords, overstuffing, etc.).
- XML sitemap generator.
- Dynamic spider control.
The learning curve is steep, but this professional tool is a mainstay in advanced SEO processes.
Semrush is an incredibly popular WordPress plugin that is adored by SEO experts, marketers, bloggers, and businesses of every size.
You can use Semrush to find organic keywords and terms to rank for and the plugin’s competitive research functionality lets you compare your competitor’s rankings and find new terms to gain a leg up on them.
Semrush’s SEO Writing Assistant tool also improves your overall website content by helping you write more search-friendly content. It does this through tight integration with WordPress.
6. Squirrly SEO
Squirrly SEO has over 3 million installs and consistently good reviews. It’s not hard to see why. The WordPress plugin has over 200 features to help you optimize your content with updates keeping things fresh constantly.
Instead of listing down all the things the program offers, here’s an incredibly detailed video that runs through everything from the developers themselves:
The app has subscription tiers starting from $20 for your first month and it goes up from there depending on your use case and requirements.
WordPress Site Speed Plugins
You’ve painstakingly optimized your site for keywords and search trends and now you have a steady stream of visitors flocking to your WordPress site. But your work is far from over. Nothing will put off new readers more than slow load times and unoptimized content.
This data proves that the speed of your site is an incredibly important part of the efficiency puzzle and not paying attention to it could leave a bad taste in your customer’s mouths.
Thankfully though, the following WordPress plugins will help you keep your site snappy and well optimized for years to come.
1. W3 Super Cache
W3 Super Cache is a fantastic tool to help speed up your WordPress site. It’s made by the company responsible for WordPress itself, so you know the quality is going to be exceptional.
The plugin manages your site’s cache files to ensure that performance isn’t affected. This improves site speed and allows the end-user to have a better experience.
Google also uses site speed and cache metrics in its ranking algorithm so this could be the difference between you ranking higher or lower.
Oh right, and this plugin is completely free to use.
2. Media File Renamer
While this plugin might not help your site’s speed, it certainly helps reduce the time it takes to optimize your images and files. Going back through large sites and sifting through file names and attributes is a huge hassle.
Media File Renamer solves this issue by renaming media files based on their image titles. When an image file is updated, the entire site is updated to include these references.
The free version of the plugin is an auto renamer so if you want manual control of your naming then you’ll have to get the pro version which starts at $24 for an annual subscription.
3. WP Smush
This simple plugin allows you to simply and intuitively reduce the image sizes on your site without compressing the integrity or quality of the overall image.
WP Smush supports all the common file formats including JPEG, GIF, and PNG. Besides this, it offers:
- Removal of unused colors from images.
- Compatibility with other plugins.
- Removal of metadata from JPEG images.
- Ability to handle more than 50 images at a time.
- Ability to pinpoint what images are slowing down your site.
This video from the developer does a good job of walking you through the process.
Another simple tool on the list, WP-Optimize lets you optimize and streamline your site’s database. The plugin has over 17 million installs and a high rating so the quality is undeniably good.
Besides cleaning up and optimizing your databases so they run better, WP optimize also offers:
- Scheduled automatic cleanups of revisions, spam comments, trashed content, etc.
- Defragmentation of MySQL tables.
- Database statistics overview.
- Image compression.
- Granular control over specific optimizations.
The vast majority of content produced and consumed in the world is done on mobile devices like smartphones and tablets.
Not optimizing your site for mobile will be a huge deterrent to your long-term success. As previously mentioned, speed is important for sites to remain competitive, and being mobile-friendly is another essential part of the equation.
The following plugins will assist in making your site more mobile-friendly so visitors will have no reason not to stick around.
1. WP Touch Pro
WP Touch Pro is an obvious first choice for this particular category of plugins. With over 13 million downloads, this tool has become a mainstay for almost everyone.
It replaces your site with a user-friendly, mobile-focused theme. This change enhances the site, making it easier and faster to read.
It overlays a mobile-friendly theme on your site without compromising your current theme. Your content and URL remain the same.
The plugin simply optimizes your content for different screen sizes. You can see just some of the customizable options the app offers in the screenshot above.
If you want more validation, WP Touch Pro is actually recommended by Google itself so implementing it could mean that your site performs more favorably in search rankings.
Regardless of whether your site is hosted through companies like GoDaddy or simply through WordPress.com, Autoptimize is a fantastic plug-in that helps improve your site’s overall web upload speeds.
It does this by optimizing your database, deleting your caches, and aggregating scripts. These changes can reduce your site loading times by up to 30%.
This is a huge improvement by any metric and ensures that your visitors don’t leave your site because of slow load times.
The plugin is super easy to use with a myriad of pricing models to choose from.
WordPress Analytics Plugins
Knowledge is power and as a site owner, this statement should be at the forefront of everything that you do. Data never lies and will tell you the cold hard facts on how your site is doing and what improvements you need to be making.
Google Analytics is the best way to make sense of this and if used properly can help you craft effective strategies for your WordPress site experience. Plugins designed to optimize this data are therefore a great idea to use.
Knowing is half the battle and with these plugins, you’ll be in good hands.
1. Monster Insights
No list on Google Analytics plugins could be complete without MonsterInsights. The app has more than 85 million all-time installs and is hugely popular for good reasons.
A big advantage of MonsterInsights is that it is super easy to install and requires absolutely no coding knowledge.
Once you’re up and running, the plugin tells you exactly how visitors came onto your WordPress site. The reasons could be referrals, keyword searches, or a backlink that led to you.
This data can help you pinpoint weaknesses or optimize trends to keep visitors flocking to your site. MonsterInsights also lets you get to know your visitors better. You can find out their age, their country, their gender, and even what browser they use.
This data comes from the MonsterInsights Website Audience Report and can be super useful when planning new campaigns and strategies.
You can also use MonsterInsights to see what kind of content the audiences are searching for and the volume based on their demographic.
These features are just the tip of the iceberg when it comes to the vast array of tools MonsterInsights offers. It’s truly a must-have tool for anyone looking to gain more insight into their site and SEO processes.
2. Google Analytics Dashboard (Exact Metrics)
29 million installs later, Google Analytics Dashboard is a no-brainer choice for a high-quality Google Analytics plugin. The brainchild of Exact Metrics, this powerful tool intuitively displays your data right in your WordPress dashboard.
Installing the plugin is a bit more complicated than other options but the effort is well worth it.
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Image Credits: Paulo Bobita | <urn:uuid:8910012d-2114-4b4d-9780-5fdba7232e58> | CC-MAIN-2022-33 | https://www.searchenginejournal.com/wordpress-seo/best-wordpress-seo-plugins/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.904435 | 3,384 | 1.507813 | 2 |
(September 18, 2017 / JNS) By Adam Abrams/JNS.org
Despite the raging civil war to Israel’s north and east in Syria, the Jewish state’s northern border has remained precariously quiet over the last decade. No stranger to looming threats, Israeli officials are planning and ready for several worst-case scenarios in the north as Iran and its terror proxy Hezbollah continue to forge their stranglehold on the region.
In a possible war scenario with Hezbollah, the Israeli military can launch a “massive and overwhelming” operation that would effectively “neutralize” a significant part of the Lebanese terror organization’s military capability, Lt. Col. Jonathan Conricus, the head of the International Media Branch for the IDF Spokesperson’s Unit, told JNS.org.
The IDF’s operation would be based on “very accurate intelligence” collected “relentlessly” and “would minimize to the greatest extent possible, harm to non-combatants…. by using the most precise guided munitions that strike only at the legitimate military targets,” Conricus said.
Striking only Hezbollah targets without collateral damage will be a challenging military feat because Hezbollah is deliberately “deployed in order to maximize collateral damage” to civilians, he added.
One-third of the homes in southern Lebanon’s 130 villages are known to house military components belonging to Hezbollah.
“Hezbollah’s strategic choice of the battlefield, embedding its military assets in Shiite villages and towns, has put the majority of the Shiite population in Lebanon in harm’s way, using it as human shields….” Brigadier general (Res.) Assaf Orion, a senior research fellow at Israel’s Institute for National Security Studies (INSS), told JNS.org.
Defeating the terror group would likely involve “significant IDF ground incursions into Lebanon as well as taking out Hezbollah rocket positions located in high-density population areas,” in hospitals, schools and apartment buildings, Dr. Jonathan Schanzer, senior vice president of research at the Foundation for Defense of Democracies think tank, told JNS.org.
In a future conflict, one could expect “significant damage to Israel,” Orion said, but simultaneously “a devastating and unprecedented destruction in Lebanon, including a significant victory against Hezbollah’s military forces and destruction of most infrastructure enabling its war fighting capacity.”
Largest drill in decades
Due to Hezbollah’s deep entrenchment within civilian infrastructure, the IDF has narrow windows of opportunity to engage “legitimate military targets,” Conricus said.
However, the IDF is prepared for this scenario and recently completed its largest drill in two decades in Israel’s northern region, simulating cross-border Hezbollah attacks on Israeli towns in which the terror group aims to commit massacres and take hostages.
The exercise was planned over a year and half in advance and tens of thousands of soldiers from all branches of the IDF participated.
During the initial stage of the drill, soldiers simulated rooting out Hezbollah terrorists from Israeli towns and defending the Jewish state’s sovereignty. The drill’s second stage simulated “decisive maneuver warfare” into the depths of Hezbollah’s territory, Conricus said.
The exercise sought to enhance “coordination and synchronization” between the IDF’s ground forces, air force, navy, intelligence and cyber units, and shorten “the intelligence cycle” from when a “target is identified to any type of munition meeting that target,” he added.
Hezbollah’s new capabilities and the coming two-front war
The IDF has acknowledged that since the 2006 Second Lebanon War, Hezbollah has matured from a guerilla organization to a fighting force equipped with heavy artillery, high-precision missiles and drones. The terror group also receives about $800 million a year in funding from Iran.
A third of Hezbollah’s forces are currently entrenched in Syria’s ongoing civil war — becoming battle-hardened, but simultaneously overstretched, losing some 2,000 fighters in the conflict.
Hezbollah and Iran have established weapons factories in Lebanon that can produce powerful missiles and, according to the IDF official, “more than 120,000 rocket launchers and rockets” are positioned in southern Lebanon, “in clear violation of U.N. Security Council Resolution 1701.”
Iran and Hezbollah are also constructing permanent military facilities in southern Syria to establish a land bridge stretching from Tehran to Beirut along Israel’s northern border.
According to Schanzer, this indicates the next war with Hezbollah “would likely be a two-front battle in Lebanon and Syria,” which could also include other Iranian terror proxies in the region.
The IDF official confirmed, “it is definitely possible and plausible” that the Israeli military will be required to fight on more than one front, which the military is prepared for.
Intimate intelligence and advanced technology
Using its “networked intelligence,” the IDF is prepared to implement “a massive precision strike…. on a scale which far exceeds the assessed growth in Hezbollah’s military [capability],” Orion said.
Since 2006, Hezbollah has occasionally been given a glimpse of the “quality, scope and intimacy” of Israeli intelligence collected against it, the IDF official said, which has created a deterrence and quiet for the past 11 years.
A recent purported Israeli airstrike against a Syrian chemical weapons facility Sept. 7, which occurred during the massive IDF exercise, may have served as one such glimpse into Israel’s intelligence capability directed against the terror group and its allies.
Israel is “far better prepared for the next war with Hezbollah” than it was in the 2006, Schanzer said. “We see now the appearance of stealth tank technology, the preparation for ground warfare and the possibility of tunnels into Israel… as well as the preparation for mass volleys of rockets launched by Hezbollah into Israel.”
The Israeli Air Force has also acquired several new state-of-the-art F-35 “Adir” stealth fighter jets, and in recent weeks the military unveiled multiple revolutionary defense technologies that will soon be added to its arsenal.
Jewish News Syndicate
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Yale University Press, 2018
Agent: Sandra Dijkstra
How did a group of charismatic, apocalyptic Jewish missionaries, working to prepare their world for the impending realization of God's promises to Israel, end up inaugurating a movement that would grow into the gentile church? Committed to Jesus’s prophecy—“The Kingdom of God is at hand!”—they were, in their own eyes, history's last generation. But in history's eyes, they became the first Christians.
In this electrifying social and intellectual history, Paula Fredriksen answers this question by reconstructing the life of the earliest Jerusalem community. As her account arcs from this group’s hopeful celebration of Passover with Jesus, through their bitter controversies that fragmented the movement’s midcentury missions, to the city’s fiery end in the Roman destruction of Jerusalem, she brings this vibrant apostolic community to life. Fredriksen offers a vivid portrait both of this temple-centered messianic movement, and of the bedrock convictions that animated and sustained it.
"One comes to see the impetus for Fredriksen’s ceaseless reminders of Jesus’s and Paul’s Jewishness. Gentiles are apt to forget. Gentile Christians are sometimes eager to do so. But remembering, as Fredriksen well knows, makes for good history and even better theology. For jogging our collective memory, and with such erudition and elegant prose, we are all in her debt."
—Los Angeles Review of Books
“A significant contribution . . . When Christians Were Jews is an inviting introduction into this important period that will stimulate and challenge readers of all backgrounds and faith traditions.”
—Malka Z. Simkovich, Christian Century
"...Complex and fascinating discussions... When Christians Were Jews is easy for non-scholars to read, although some knowledge of the Christian scripture is helpful... Anyone interested in Judaism in the first century C.E., or in the early history of Christianity, will find this book a welcome addition to their book shelves.
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To help ensure a problem-free driveway, use the following list for information about proper construction. Placing concrete at the proper thickness. Thickness is the major factor (even more than the strength of the concrete) in determining a driveway's structural capacity. Place concrete at a minimum thickness of 4 inches. Increasing the ...
TS 3.30 – September 2017 Page 4 of 4 Construction Specification for Hot Mix Asphalt Sidewalks, Boulevards and Driveways TS 3.30.07.02 Asphalt Driveway – Residential Residential asphalt driveways shall be constructed according to T-310.050-8 with 150 mm of
Section 5: Pavement Naperville Standard Specifications 500-2 REV 08/01/18 501 GENERAL The standards and requirements found in this article are for materials and construction of roadway pavement, parking lots, driveways, and bicycle/pedestrian pavement within the City of Naperville, Illinois. 501.1 STANDARD DOCUMENTS
• good construction practices; and • timely maintenance. Don Siler, asphalt technology specialist for Marathon Petroleum Company (MPC), concurs. "Good materials, good practices, good workmanship and good site preparation make a good driveway," he says. "Driveways must be properly designed and constructed," he adds.
The ia Department of Transportation (VDOT) specifications, standards, and test methods have been the standard in ia for more than 50 years. During that time VDOT has changed their nomenclature for asphalt mixes several times, typically following a major rewrite of their asphalt specifications and mix design criteria.
Essentially, these specifications specify the end results and also specify certain minimum construction method requirements (e.g., temperatures below which paving is not allowed, descriptions of initial test sections, minimum number of rollers, conditions under which …
TxDOT has established standards and specifications for the construction and maintenance of highways, streets and bridges. Below are links to documents and important information for contractors and professional service providers.
Specification for all materials and labor to construct a concrete sidewalk and associated curbing. 608.01101015. Concrete Driveway Apron: Specification for all materials and labor to construct a concrete driveway apron. 609.10010015. Curbing: Specification for all materials and labor to construct or install curbing. 609.10010415. Asphalt Curbing
Residential Driveway Paving 101 Residential Driveways. A residential driveway must be properly constructed in order to be a good investment. This information is intended to be a general guide for the homeowner on the design and construction of a residential asphalt driveway.
• Section 332: Placement and Construction of Asphalt Emulsion ... • Detail 2250-1: DRIVEWAY ENTRANCE – RESIDENTIAL ATTACHED SIDEWALK • Detail 2255: RESIDENTIAL DRIVEWAYS ... MAG UNIFORM STANDARD SPECIFICATIONS FOR PUBLIC WORKS CONSTRUCTION TABLE OF CONTENTS PART 100 - GENERAL CONDITIONS
Placing an Overlay. Driveways of either asphalt or concrete can be overlaid with Hot Mix Asphalt—with excellent results. Usually for driveways, a surface course of 1-1/2 to 2 inches thick will suffice. Before paving, be sure the contractor patches any serious holes or cracks with Hot Mix and compacts it.
R) "PRIVATE RESIDENTIAL DRIVEWAY" is an individual or shared access way from a public or private road which will serve, now or any time in the future, no more than two residential lots. Construction of the access-way shall conform to the County of San Page 4 of 20
Well, in reality, asphalt driveways can be 2 inches, 4 inches, or even up to 9. So, without further ado, let's take a detailed look into Asphalt Paving Thickness to know what you might need to consider when getting a new driveway. -11 inches thick. The final choice depends on the specific use of the driveway and what you're looking for in ...
Residential Driveway : MC-301.02: Residential Driveway with Mountable Curb : MC-301.03: Residential Driveway - Open Section Road: MC-301.04: Residential Driveway - Limited Width : MC-301.05: Residential Driveway with Curb Radius : MC-302.01: Commercial Driveway : MC-303.01: Methods of Transitioning Driveways : MC-500.01: Driveway Endwall - Open ...
Typically, Richfield Blacktop paves residential driveways with one lift of paving, 3″ thick. That is then compacted to 2 ½" thickness. That, combined with the carefully compacted sub-base, is the ideal thickness to provide maximum life and endurance for a residential driveway. If asphalt is applied too thickly, it won't be properly ...
Standard Construction Specifications Division 40 – Asphalt Surfacing Revised 11/08 SECTION 40.02 SEAL COAT Article 2.1 Description The Work under this Section consists of the performance of all Work required for the construction of a seal coat of asphalt cement and cover aggregate on RAP, strip-paved, and gravel surfaces. Article 2.2 Asphalt
All construction shall conform to either these City of Raleigh specifications or to the latest edition of the NCDOT Standard Specifications for Road and Structures. If a required detail is not included on this web page, the North Carolina Department of Transportation (NCDOT) Roadway Standard Drawings shall apply. Any questions regarding the ...
Construction Specification for Hot Mix Asphalt Sidewalks, Boulevards and Driveways Page 5 of 5 TS 3.30 – September 2018 TS 3.30.10 BASIS OF PAYMENT TS 3.30.10.01 Asphalt Sidewalk – Item Asphalt Driveway – Residential – Item Asphalt Driveway – Commercial – Item Asphalt Boulevard – Item Sidewalk Resurfacing – Item Payment at the Contract Price for the above tender item(s) shall ...
More information on asphalt pavement warranties is available in the Warranty Application Guidelines in the Innovative Contracting Manual published by the Office of Construction Administration, in the Item 880 Asphalt Concrete (7 Year Warranty) specification, and in Supplement 1059 Asphalt Concrete Surface Course Warranty Requirements.
103.1 Intent of Plans and Specifications. It is the intent of plans and specifications submitted to the County for review to describe a complete work to be performed. 103.2 Changes and Alterations. All changes and alterations in the plans and specifications must be prepared by the Engineer and approved by the County Engineer. 104.
Asphalt driveway thickness depends on the soil that's being paved on and the industry standards of the region you live in. What is the soil like in the region you live in? Here in Denver Colorado, we have two types of soils we pave on. The first, on the front range, the soils tend to be expansive soils so most contractors excavate and install 3 ...
Design and Construction Standards Section is responsible for the Infrastructure Design Manual, Standard Construction Specifications, Standard Drawings, and Product Approval. These documents are used on Capital Projects, as well as private development projects. Would you like to receive periodic updates from the City Engineer? Register for our newsletter.
Design & Construction Standards Standard Specifications. We develop, publish, and manage standard construction contract specifications, standard modifications for highways and statewide special provisions for highways and airports, as well as coordinate with and advise others in development and use of specifications for buildings, marine highways, and harbors.
The Specifications of a Driveway. The first part, or layer, of a driveway is called the subbase course. The second layer, made of stone, is called the base …
Driveways and driveway approaches require a Building Permit prior to construction. TO APPLY FOR A DRIVEWAY PERMIT, SUBMIT THE FOLLOWING: ... RIGHT‐OF‐WAY TO BE COMPLETED IN ACCORDANCE WITH AN APPROVED PLAN AND SPECIFICATIONS AND UNDER THE SUPERVISION AND INSPECTION OF THE PUBLIC WORKS DEPARTMENT OF THE CITY OF …
Shire of Waroona – Gravel/ Bitumen/ Asphalt Driveways Specification DRAFT1 Page 5 of 3 6 Layback Construction The finished product shall be true to the drawing dimensions and finish specified. Tolerances for driveway shall be in accordance with the following requirements:
At one time it was thought that a prime coat was an essential element of good pavement construction. However, in recent years some engineers have eliminated the use of a prime, especially when asphalt layer(s) (surface and/or base) is 4 inches or more in thickness.
STANDARD CONSTRUCTION SPECIFICATIONS Michael D. Kadlecik, City Manager David L. Wooden, Public Works Director ... ST16 - Residential Asphalt Driveway to Concrete Street (08/19/99) 718 ST17 - Residential Asphalt Driveway to Asphalt Street (08/19/99) 719
Specifications: Regardless of how you have the asphalt installed, there are a few things to watch for. Make sure that the new asphalt will slope away from the house and carry the rain water to the street or to a catch basin in the drive – not onto a neighbor's property or into the garage; that the asphalt
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Web development showcases a range of procedures and skills inside the maintenance and design of online internet sites. The various specialities of web page design include graphic design web site design softwareFor eachapplications progress and style web server management and design social media marketing supervision as well as networking information management and website advertising and marketing and advertising. Furthermore, it covers innovative techniques active in thegeneration and repair, and business of your internet site. A few of the the areas involve moral design, multimedia system exploration, and content progress.
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Industrial designer Gifford Jackson in 1992, aged 70, reviewing a technical drawing of a 1983 haemoglobin meter project (a medical device to measure the concentration of haemoglobin in blood) for Delphi Industries.
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The FDA announced the approval of an new weight-loss drug on Sept. 11, 2014. The drug name is Contrave. Using two separate drugs to lose weight naturally can be very effective you can find combinations while watching FDA now awaiting approval. When dealing with weight loss and the individuals who go through it you need to err assisting caution and allow FDA do its job and demand some research be done so the public knows the side effects and risks of the medications before we drive them. Keep in mind that drug companies are in business to generate money and that they would say almost anything to keep people on the medications. Researchers found out that participants taking this drug for any year, dropped excess weight within four weeks and have kept the weight off throughout the 56 weeks from the study. Contrave is a combination with the drugs naltrexone and bupropion, which seems to reflect a new trend of weight-loss drugs which are made up of several active ingredient, which may make them more efficient and safer. Combo-pilling will be the newest fad or even better the newest in the future under scrutiny and thus it is just more publicly known in recent months, comb-pilling to lose weight has been around since the eighties. The biggest reason that using a combination of pills is starting to become popular will be the fact that by right now there aren't long term prescription diet pills that have been authorized by the FDA besides orlistat. The truly disturbing part is doctors are prescribing these combinations of medications however some of the combinations are already rejected or have yet to be approved by the FDA. Seizures are a side effect with Contrave and shouldn't be taken in individuals with seizure disorders. The drug also can raise blood pressure and heartrate, and really should not be used in those with a history of cardiac arrest or stroke in the last six months. Blood pressure and pulse should also be measured before beginning the drug and throughout therapy with all the drug. The FDA also warned that Contrave can raise blood pressure levels and pulse rate and must not used in patients with uncontrolled high hypertension, along with by you are not heart-related and cerebrovascular (circulation system dysfunction impacting mental performance) disease. Patients having a history of cardiac arrest or stroke in the last six months, life-threatening arrhythmias, or congestive heart failure were excluded in the clinical trials. Those taking Contrave really should have their heart-rate and pulse monitored regularly. In addition, since compound includes bupropion, Contrave comes with a boxed warning to alert physicians and patients for the increased chance of suicidal thoughts and behaviors linked to antidepressant drugs. The warning also notes that serious neuropsychiatric events are already reported in patients taking bupropion for quitting smoking. The most common unwanted side effects with Contrave include nausea, constipation, headache, vomiting, dizziness, insomnia, dry mouth, and diarrhea. | <urn:uuid:c093d690-b808-4528-b204-60f714331b16> | CC-MAIN-2022-33 | https://fermewallonne.be/node/411 | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.956625 | 633 | 1.648438 | 2 |
Mick Cusimano passed away last weekend, and the first thing I felt was regret.
Among my on-hold Stone Soup history projects, I wanted to reach out to recording artist Tracy Chapman. Why? Because of this written account from Mick on his website on the early days of Fire of Prometheus:
In 1985 we invited many musicians and poets to an all day show on the Boston Common. We found one woman performing next to us in a Harvard Square doorway and invited her. Tracy Chapman was her name and she did several songs to a polite crowd.
Yesterday, I finally asked myself, Why didn't I just ask Mick about it?
Mick and I were poets and creators from two distinct eras of Boston's poetry scene. Like oil and water, we didn't quite mix, though we were frequently together. We were on similar journeys, just very separate lanes.
I found him to be a pain in the ass at times. I'm absolutely sure he felt the same about me. One old codger and a slightly older codger, both set in their ways, keeping out of each other's way. It seems almost charming now.
Because of the late start time, I only rarely made it to the Squawk readings he helped organize. I would see him more occasionally at Stone Soup (including for one feature I've written about elsewhere) and Deb Priestly's Open Bark readings.
I even went to a gathering where he showed some of his films, which I believe took place at his apartment. Watching his Clowns On The Left animated feature with the screen propped on a bed definitely helped helped reinforce the surrealist tone he wanted to convey.
|Mick's s sendup of Highway Poet K. Peddlar Bridges|
As a comics fan, I first knew of Mick in the mid-nineties through his cartooning work in various zines and his own self-published Underground Surrealist magazine.
Mick's comics work was quirky and eccentric enough to stand out among countless other cartoonists emulating the 60's undergrounds and 90's autobiographical cartoonists. His work never shook off its caricature roots, which made it more charming.
Though I ended up liking Mick's comics, I didn't know what to make of them at first, and other poets seemed to know even less.
One time a flustered writer told me that Mick should stop with his drawing to focus on poetry primarily.
As little as I knew of Mick, that didn't seem like a possibility or even a good idea. Looking at what he accomplished with his film work, it's clear I was right.
Mick chased his passions in as many mediums as he could with a fervor that I wish I could replicate now.
I've also tried to branch out in other areas artistically, but I know how little I know in any other field. It gives me pause more and more as I get older.
I think Mick liked not knowing, plunged forward, and he still came out on top. That takes determination.
This week, I'll be pouring over Mick's website, saving what images and words I can. I don't suspect it will remain up for much longer, which is a shame.
His website is a wonder to behold with it's 90's design and its tough to navigate links. In it's own way, it serves an immaculate time capsule to that time in poetry just as slam was taking root, and just before Jack Power's proteges started printing poetry books with real binding.
It's a glimpse of a scene that could have otherwise been lost to time and the internet.
Mick probably never meant to be an archivist, but it's a role I'm grateful he fell into naturally.
I wish I knew of his struggle with brain cancer. I would have pressed harder to have him read again.
I think of everything he uploaded to YouTube over the last decade. How much more was at his apartment, not yet worked on, left to be thrown away by relatives and landlords?
Mick deserves a proper sendoff, with as much absurdism in the face of cynicism as possible. Sadly, the one most qualified to create that sendoff was Mick himself. | <urn:uuid:c3a8d770-daeb-47ac-99a2-0006c5f4647f> | CC-MAIN-2022-33 | https://chadparenteaupoetforhire.blogspot.com/2022/07/rip-mick-cusimano.html | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571950.76/warc/CC-MAIN-20220813111851-20220813141851-00672.warc.gz | en | 0.98969 | 869 | 1.515625 | 2 |
Linking Journalism with the Web of Life
There’s a multi-billion-dollar yearly trade in medicines, foodstuffs and industrial products derived from plants, animals, fungi and bacteria. But many such products have been commercialised without any of the profits returning to the countries and communities whose biodiversity and traditional knowledge made the innovation possible. And in some cases, biological resources have been accessed illegally.
That’s why, in 2010, parties to the UN Convention on Biological Diversity (CBD) reached a new agreement — called the Nagoya Protocol — to ensure legal access and guarantee that any benefits arising from the use of genetic resources are shared fairly and equitably. But what exactly is "access and benefit-sharing?" What are countries doing to meet their CBD commitments and ensure that companies meet their legal obligations? Are benefits flowing where they should? This webinar on 24 February for journalists will explain the complexities of this agreement and explore how it serves as a rich source of untold stories.
Krystyna Swiderska | Principal Researcher, International Institute for Environment and Development
Alejandro Lago | Manager of the UNDP GEF Global ABS Project
Add a Comment | <urn:uuid:9e842457-adce-49ed-abc0-f039df6d9102> | CC-MAIN-2022-33 | http://biodiversitymedia.ning.com/profiles/blogs/webinar-beating-the-biopirates-a-journalist-s-guide-to?xg_source=activity | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.92201 | 250 | 2.53125 | 3 |
Jul 5, 2021
Justine Altman joins us today as we’re digging into how to optimize pregnancy success after miscarriage.
Experiencing a miscarriage opens you up to a tremendous range of emotions, including anger, depression, isolation, and shame.
If you’ve had a miscarriage, it’s vital not to judge yourself or your feelings. Pregnancy loss is physical and emotional trauma, and you should take the time you need to work through it.
Justine is part of my team here at Fab Fertile. She is an integral part of our Couples Coaching program - which uses functional lab testing, diet, and lifestyle changes to dramatically improve conception.
If you are struggling with infertility...your body is desperately trying to tell you something...focusing on your health will either help you get pregnant naturally or if you do need to go to the fertility clinic it will improve your chances of success.
Justine is a Functional Diagnostic Nutrition Practitioner. She was diagnosed with POCS and struggled with infertility but after taking a functional approach was able to have both her children naturally.
In this episode you'll learn:
1) Why looking at this gene variant is important to consider if you’ve experienced miscarriage
2) Why reviewing these blood markers can give us healing opportunities that may be missed by conventional medicine.
3) What role diet/lifestyle plays with miscarriage and how to know which suggestions are right for you
4) Why taking time to allow the body to heal after a miscarriage is essential and how to optimize your chances of a successful pregnancy
Excited that our LIVE Summer Fertility Challenge is launching on
July 19th. You'll receive newly designed chef-prepared recipes
(perfect for summer and curated to optimize fertility). There will
be daily motivation, guidance, and support from the Fab Fertile
Team. Join the Fertility Diet Challenge
05:56- INTRO TO TODAY'S EPISODE AND JUSTINE'S BIO
07:40- MISCARRIAGE THEME: IGNORING THE MALE PARTNER'S HEALTH
10:55- MISCARRIAGE THEME: MTHMR
16:26- MISCARRIAGE THEME: HOMOCYSTEINE
21:09- MISCARRIAGE THEME: THYROID DYSFUNCTION
33:45- MISCARRIAGE THEME: IODINE DEFICIENCY
36:05- MISCARRIAGE THEME: BLOOD CLOTTING DISORDER
37:03- MISCARRIAGE THEME: INFECTIONS
41:51- MISCARRIAGE THEME: PROGESTERONE DEFICIENCY
46:44- FINAL THOUGHTS
Book your Free Supercharge Your Fertility Discovery Call here: https://intakeq.com/booking/cZ7XW6
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Got questions? Join the Fab Fertile Support Group for motivation, support, and education so that you can prepare for pregnancy success.
Connect with Sarah on social media and learn more about functional fertility solutions that will help you have your baby. | <urn:uuid:7c555f51-c1e9-4e1a-8baa-bd8aa465c4f7> | CC-MAIN-2022-33 | https://getpregnant.libsyn.com/website/why-addressing-these-common-miscarriage-themes-can-help-improve-pregnancy-success | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571950.76/warc/CC-MAIN-20220813111851-20220813141851-00672.warc.gz | en | 0.897638 | 744 | 1.59375 | 2 |
At the launch party for my biography of Frances Darlington in November last year a conversation with Sue Dalton (Director of Ripon Museums), resulted in my reuniting my research with my artistic practice. I had first been in touch with Sue to ask permission to photograph a piece of Frances’s work, The World War One Memorial to boys from St. George’s Police Orphanage in Harrogate.
The memorial is an intricate piece of work, and aligns heroism with the knightly ideals of neo-medievalists of the early twentieth century. In the chapter on it in the book I had cited Arthur Machen’s story The Bowmen, published in the Evening News on 29th September 1914, which had been inspired by various reports of visions at the front line. Machen told of a vision of St. George, and although published as a comforting piece of fiction was taken by the desperate and distraught ones left behind to be a true story. I wrote:
Frances’ panel likewise depicts the traditional stuff of crusades: Christians triumphing over Saracens and Turks, and the same imagery that Machen employed in his story. The whole is based upon religious and historical associations which were fluid within the British public mind at the time. The Islamic spiked helmets are also pointedly reminiscent of Bismark’s German spiked helmets. Joan of Arc, dressed in chain mail and with bobbed hair somehow announces a type of female strength, modernised by the war. Joan of Arc had become a popular figure in France since her beatification in 1909. The same year Parisian hairdresser Antoine, first cut womens’ hair (and later that of Coco Chanel and Josephine Baker) into what the French called the “Coupe a la Jeanne D’Arc”; the bob which would find huge popularity in later years. Following the publication of Machen’s story, more visions were reported from the front, some even claiming to have seen Joan of Arc. Allied soldiers took images of Joan of Arc with them into the battlefield. She appeared on French stamps, posters, and on the cover of the October 1918 edition of Red Cross Magazine, she appears alongside St. George and George Washington. …
St. Joan of Arc is the only female in the St. George’s panel and is isolated and inactive amidst all of the fighting, but she is strong and resolute and their spiritual protector. Her steadfast yet passive role is quite an accurate analogy for what most women, mothers, sisters, wives, daughters, were actually able to do in the First World War: to wait behind, to take on male roles in industry etc., and to pray while men were ferried off on trains to fight until almost certain death. In retrospect there is something almost pivotal in her representation after a war which saw women’s contribution to society completely transformed. Frances is combining the visual languages which she had made her own in her earlier works: the medieval figures and costumes are utilised to express a moral ideal with a strong religious, historical and romantic current of ideas propagated at the time.
Aligning all this with my own political and historical appraisals to create an honest piece of contemporary art was a challenge. Perhaps it is something to do with my Scottish education, but part of me shunned the overt Red Cross English patriotism. The man who had unveiled it in 1918 had been a military figure at the Easter Rising. However the knightly analogies were of great interest, not because I concurred with romanticising war like this, but because of my interest in the way mid to late nineteenth and early twentieth century culture looked to medievalism amid drastic modern innovations.
My response to it is woven from three main threads:
1. WAR, the tragic reality of war amid the romanticised images of valour Frances was adhering to.
2 KNIGHTS, the shifts in social change resulting from the war amid reversion to older ideals, romanticised notions of nobility (see 1), the notion of a God given right to fight opposing the true beliefs of religions.
3. WOMEN, shifting social position and identity, (see 1 and 2).
My first thoughts were sketched out as quarterings of a pre-Raphaelite head, with gun sights, helmet, shield, interlocking through animation eventually ending up with modern woman. My end results are pretty close to this initial set of ideas.
The artwork had to be a response, my response as an artist, to the memorial as a whole, and this meant including all I knew about it, who it was made by and the context it was made in. It seems strange to acknowledge women in a response to a war memorial and they are rarely remembered in monuments. Women were not allowed to join the army, they weren’t allowed to vote and they had only just been granted the right to keep their own earnings if they were married! (The Married Women’s Property Act 1882). There was little they could do except volunteer to be nurses. Of the thirty-seven boys mentioned in the St. George’s War memorial, ten were killed. I attempted to pursue a line of research into their regiments through Forces War Records, but came up with too many possibilities, and much as I would have liked to have done this, there was insufficient time to research this properly.
Joan of Arc features strongly in Frances’s piece, a steadfast woman amid the fight, but I wanted her to look as horrified by the prospect of war as all the people I had read about. I wanted her to represent men and women in fear and bravery, and I wanted the mask of the twentieth century to be almost forced upon her, as mechanised war seemed to be forced upon millions of young men. Almost as a resistant human being trapped in their time. I thought of the pacifists shot for not wanting to fight, of those caught up in the war merely because they were of the right age and gender, and this enforced mask delineates and remembers them. The film has two “borders” which show at the beginning, a made up pageant from an old film, juddery and tinted it aims to represent the past ideals, and the way the war was linked to them, and at the end a simple cycle of a spade digging a grave, with a crucifix in the background. It is old footage and seemed to signify the digging of trenches and the digging of graves and the colossal waste of good young lives. Although Joan of Arc died for what she believed to be right and true, the film, The Passion de Jeanne D’Arc represents an important point for this piece. Often spoken of as “sacrifice”, a sacrifice is something willingly given, not forcibly taken. While many joined up in the sense of fighting for a rightful cause, others were forced. It begged the question of autonomy and power – whose sacrifice was it? (And this seemed to collar the shift in social hierarchies as much as the notion of war memorials). In some consolatory sense Germany was the aggressive expansive force in Europe, it was overriding the sovereignty of other countries and to stop it was the right thing to do. So there is a tension between the rights and wrongs of the war, and of the goods and evils of sacrifice. My only real solid conclusion was that I should create an environment which brought these tensions to the fore, but which also provided a healing and redemptive potential.
The memorial was made for an audience which largely consisted of children in the orphanage, but it had some ideas contemporary with the war woven into it which I felt I needed to break with in my response. The idea of valour and war is dealt with through the idea of Christian Crusaders and Muslim Saracens. These quite clearly have their badges of honour, the cross and the crescent, so I deliberated over my translations of the St. George’s flag to the emblem of The Red Cross, and decided to include the emblem of its sister organisation The Red Crescent. Adding these to the army canvas immediately rendered the tent to a place of healing. The religious symbols took on their own meaning, these are not emblems of war, these refer to beliefs, to faith, most importantly to healing and restoration. As the memorial was in the Prison Chapel it seemed fitting to emphasise the healing aspect of religion which is at its true core.
The idea of a knight’s tomb seemed to fit in with the neo-medieval thematic of Frances’s piece and I wanted one knight’s tomb to reference the shift of war memorials, remembering the many and not just the few.
The opposite side of the tent has a companion painting. To accompany the knight’s tomb is his real enemy, evil, caricatured as it has ever been as a serpent. I decided on a serpent bench from Harrogate, looking like one petrified in metal. There are plenty of references to St. George around Harrogate, even the street names “Dragon Parade” evoke something of it. As part of the research I went to visit the site of the Orphanage, now demolished with a new housing estate built on top of it. All that remains is part of the mock-medieval wall. The benches date from the 1880s, so it is possible that the bench which I drew and photographed on Otley Road was contemporary with the orphans remembered in the piece. The Robin was a final remembrance of Frances Darlington, who often included robins and small birds in her work, at times this was representative of resurrection (eg. the panels in St. Wilfrid’s Church, Harrogate) but also as a signature: her nickname was “Dickie” as in “dickie bird”. | <urn:uuid:208a3308-1838-46c3-a3a1-1bca0d0cdbc7> | CC-MAIN-2022-33 | https://louisiem.wordpress.com/2014/10/01/noble-bloods-at-ripon-prison-and-police-museum/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882573744.90/warc/CC-MAIN-20220819161440-20220819191440-00472.warc.gz | en | 0.980218 | 2,031 | 2.40625 | 2 |
It has been detected, is almost null domain management in relation to its assertiveness. Where SMEs have no assertive managers and many of them are unaware of its scope, benefits in the proper handling, respect, treatment of human resources under their charge why? simply because they have never concerned discover where are their weaknesses on the interrelations, try human, especially with work equipment. Through field research in many companies in the region, it has been determined the need to provide for the adequate management of human resources, knowledge, principles, in that rests the assertiveness, promoting within the class, workshops that enable the person concerned discover flaws and give way to the transformations that allows you to grow and put into practice all the basicsstandards, in that rests the assertiveness. In order to avoid that this will follow showing, the Chair has proposed providing all the scopes that conducive assertiveness and knowledge and tools that are delivered check with results, as already it has been achieving through some of its graduates. The Chair according to its programming of activities, favors three meetings of three hours, where the participant enters the scope provided by the assertiveness knowing it handle. Emphasis in pointing out, that conduct assertive as well as foster the achievement of harmonious relations, also helps to be able to ask or rather negotiate correctly with those around us, negotiation based on what you wish to send proper and respectfully without being timid or aggressive when speaking. Definitely, it is necessary to wake up the confidence and self-esteem of the staff, because if not it is achieved, it is a brake on the development of assertiveness, affecting organizational behavior of enterprise. Considered as noted Cardenas, that everything human being has the right to be who he is and to express what they think and feel. When this becomes assertive way ensures the utmost respect for others and for yourself. | <urn:uuid:d02bc376-8a9e-4d21-a31a-205eb17e4c90> | CC-MAIN-2022-33 | http://www.emusigmanu.com/tag/guilty | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571056.58/warc/CC-MAIN-20220809155137-20220809185137-00672.warc.gz | en | 0.973929 | 374 | 1.882813 | 2 |
Literary Analysis is a complete guide to understanding, analysing and responding to literature. Ensure that your argument is sensible from beginning to end. Attempt to read through your essay as in case you had never learn the text you are analyzing. Are you able to comply with the argument with just the assertions, proof, and analysis you’ve got provided? If you can’t, strive going back by way of and filling in any blanks.
So what is a literary analysis essay ? The fundamental definition is: it’s an editorial, measuring round 250-300 phrases (however in any other case could also be specified by your teacher or professor, so be certain that to test the necessities) that analyzes a literary work. It may analyze every side of, say, a novel: the fashion, the contribution to the literature usually, reflection of the writer’s biography in the essay, the plot, the literary language and so forth. Or, alternatively, it might concentrate on one of a few features which have just been mentioned. The idea of a literary essay may be very close to the way to write an article critique Nevertheless, the article of your vital analysis won’t be an article, however a literary work.
The writer mentions little particulars and objects that are associated to the characters, setting or plot of the story. Symbols are subtle meanings behind incidents and objects, especially in novels. The world of literature goes far past William Shakespeare and fiction basically. Here is a bunch of extra literary evaluation paper subjects for other great works of literature.
On this course, college students examine the assorted definitions and functions of literary language, and the formal elements of numerous style: narrative, poetry and essay. On this course, college students additionally examine the concept of literature as aesthetic phenomenon and its socio-cultural implications, by means of ideas akin to creator, reader, narrator and discourse, Major authors, themes, and genres from both Latin America and Spain are included, with primary ideas of contemporary literary criticism and principle. Taught in Spanish.
Our company is run by an administrative and management group, who co-ordinate the incoming orders. The administration workforce also co-ordinates our huge pool of writers. The writers themselves are very diverse, as they have virtually every conceivable qualification to their names, in all fields and in any respect ranges. Most of our writers are UK-primarily based, with some being based mostly in the USA, Australia or New Zealand; in impact they have all had a British schooling. All of them hold at the least a Bachelors diploma. A few of them hold a Ph.D., a lot of them have a Masters degree, and a few of them are on the way in which to their Masters. All of our writers are native English audio system, and so they know the distinction between US and UK spelling and grammar. In case there may be any doubt, all of our writers are given a quick showing the distinction between UK and US English.
When analyzing a textual content, from which a student will write a significant paper, it is advised that the scholar should first give attention to the weather of a story: plot, setting, environment, mood, character, theme and title. The subsequent logical strategy is to look at the language (devices and patterns) and form of the textual content (construction). Then the scholar might think about any of the next approaches resembling New Historicism, New Criticism, Archetypal Criticism or Cultural Criticism.
A Background In Quick Plans In essay samples
When analyzing literature, you’ll first want to contemplate the next parts from a unique perspective than whenever you’re just studying a ebook. True evaluation means approaching your textual content like a detective. Plot, characters, and setting all depart clues to deeper that means, and your job is to find them.
No-Hassle Secrets In essay samples – The Facts
The Options For Uncomplicated Plans Of essay samples
While the This Shows That” Technique for writing commentary is a wonderful tool for avoiding plot abstract, it nonetheless relies upon students understanding how one can explain the evidence. On this means, the This Exhibits That” Technique is proscribed, so I’ve developed a secondary method known as the LET” Methodology for writing commentary. This method helps guide students by giving them options for what to write about in their commentary sentences. Essentially, LET” stands for Literary Components and Techniques,” and the mini-lesson takes college students step-by-step by means of writing commentary based mostly upon literary gadgets. When college students are capable of acknowledge that each single citation comprises hidden messages about theme and that those messages come by means of literary devices, they can find the pathway to writing effective commentary.
Which means that apart from a wholesome dose of imagination and artistic considering, literary criticism involves a sober explanation of why and how this or that poem, story, novel or play was written. But in truth, there is not any proper reply to the query of tips on how to write a perfect literature essay.
How to finish a literary evaluation? It is about coping with the conclusion: The closing paragraph must present a sense of completeness and inform the studying viewers that is the tip of the textual content. Use completely different words to rewrite the thesis statement Unlike in introduction, in conclusion, the thesis assertion comes at the beginning thesis statement curious incident dog nighttime to remind the reader of the main argument ( learn more about argumentative analysis essay ). After that, make a summary of the main points launched within the body paragraphs. A student might embody a relevant remark concerning the analyzed e-book or story from a different perspective, however with out starting a new matter for discussion. | <urn:uuid:d919954a-f62f-4380-b2c5-5ccda7062cf6> | CC-MAIN-2022-33 | https://hesabdarirani.ir/options-for-rapid-secrets-in-literary-analysis-sample/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571950.76/warc/CC-MAIN-20220813111851-20220813141851-00672.warc.gz | en | 0.937066 | 1,289 | 2.890625 | 3 |
Alberta Heritage Railway Roundhouses
A “Roundhouse” is a term used to describe a steam-era locomotive servicing facility – built in a semi-circular form – that featured a common lead and turntable to allow access to the individual “stalls” where locomotives were serviced and repaired.
Constructed at important terminals and switching yards, many of the roundhouses across the North American rail network were demolished once railways switched from steam to diesel power.
In Alberta, through the efforts of dedicated community volunteers, two roundhouse sites of the Canadian Northern Railway continue to survive:
Big Valley Roundhouse – With Big Valley being the divisional point on the Canadian Northern’s Vegreville to Calgary branch, the company constructed a 5 stall roundhouse with its 70 ft turntable in 1912, and in 1918 another 5 stalls where added. The foundations of the turntable, coal dock, and stores building – together with the concrete walls of the roundhouse are now preserved as an Alberta Provincial Historic Resource, complete with interpretive signage to guide the many visitors who arrive each year aboard Alberta Prairie Railway’s popular excursion train operations.
Hanna Roundhouse – As divisional point on its “Goose Lake Line” between Saskatoon and Calgary, the Canadian Northern started construction on the Hanna roundhouse in 1913. Originally 10 stalls and a 70 ft turntable were constructed, with 5 additional stalls added in 1919. The Hanna Roundhouse Society together with the Canadian Northern Society is currently working to preserve and restore this important piece of railway history. This structure too is a Provincial Historic Resource.
The Big Valley and Hanna Roundhouses are part of the larger collection of buildings preserved by the Canadian Northern Society and its partners in central Alberta. For further information please see:
If you have the opportunity to visit the Big Valley or Hanna Roundhouses the day trips are well worthwhile. | <urn:uuid:6d2279e0-7b23-41ff-8ecc-98084b2c8b07> | CC-MAIN-2022-33 | https://chtr.ca/alberta-roundhouses/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571222.74/warc/CC-MAIN-20220810222056-20220811012056-00672.warc.gz | en | 0.951868 | 392 | 3.0625 | 3 |
And while UV rays make up a small portion of the sun's rays, they're the main cause of sun damage on the skin.
Nationwide rates of melanoma have more than tripled since the 1970s, despite better screening methods, more public awareness, and continued advances in treatment and diagnosis.
» RELATED: 10 ways to prevent hot car deaths
For every 100,000 people in the country, 21 new melanoma cases were reported from 2011-2015. Three died of cancer. In Georgia, the rate of new melanoma cases during that time range was even higher: 26.2 per 100,000 residents.
Here are some lesser-known skin cancer facts, plus tips on keeping your skin protected year-round.
Skin cancer isn't just about a bad sunburn
Many people with skin cancer were often surprised by their diagnosis, because they didn't necessarily have recent sunburns.
» RELATED: New 'tan in a bottle' drug could prevent cancer, study says
But the truth is, when it comes to basal cell carcinoma and squamous cell carcinoma, the two most common types of skin cancer, cumulative sun exposure – the kind that occurs over weeks and months and years – is just as damaging to your skin.
That means a week of laying by the pool for an hour poses about the same risk as one 7-hour beach day.
A cloudy day doesn't mean you're protected
Most of us know that we need sunscreen when it's bright and sunny, but what about when it's overcast?
The Skin Cancer Foundation estimates that up to 80 percent of the sun's harmful rays reach us on cloudy days -- which means you aren't protected simply because the sun isn't out.
What's more, UVA rays -- the one's responsible for skin aging, freckling and wrinkles, can pass through car windows, office windows and other types of glass. So, just because you're indoors, doesn't necessarily mean you're protected, either.
» RELATED: 7 surprising things that can increase your risk of cancer
Skin cancer doesn't always look like a mole
There are three different types of skin cancer, and a mole is only symptomatic of one.
Basal cell carcinoma can appear as a persistent pearly, or skin-colored bump that may crust or bleed. Squamous cell carcinoma can appear as a patch of thick, scaly skin with raised edges. They may also crust or bleed, and usually won't heal or go away on their own.
Melanomas can be a mole. But they can also look like a bump or blemish that bleeds, itches or changes color, size, shape, consistency or diameter. Concerned about a mole or mark on your skin? Try the ABCDE method.
» RELATED: Sugar can fuel cancerous cells, study says
The difference in SPF protection isn't as big as you think
Skin protection factor, or SPF, is the amount of sun required to burn the skin while wearing sunscreen. And higher isn't always better. Sometimes it can actually be worse, because many people will apply a high SPF sunscreen thinking they can stay out in the sun longer, which isn't true.
SPF 15 blocks around 94 percent of UV rays; SPF 30 blocks around 97 percent. An SPF of 50 will block about 98 percent of UV rays, while an SPF of 100 blocks 99 percent.
And none offer 100 percent protection.
To keep your skin protected:
- Wear sunscreen every day – rain or shine, indoors or out.
- Apply a broad-spectrum sunscreen of SPF 30 or greater 30 minutes before heading outside.
- If you plan on swimming, or participating in an activity that will cause you to sweat excessively, reapply sunscreen every two hours.
- Experts recommend using about one ounce when applying sunblock, or about one shot glass-full, depending on your body size.
- Avoid indoor tanning beds.
- Do a self skin-check monthly. Get undressed and take stock of freckles, moles and other marks using a mirror. If you notice that any of those marks are changing as time goes by, or they aren't healing, schedule an appointment with your dermatologist.
- Skin cancer is easy to treat and cure when it's caught early, so make sure you're keeping up with annul skin exams with your dermatologist. | <urn:uuid:1592d742-9b10-4c75-ac9e-8570508508ec> | CC-MAIN-2022-33 | https://www.ajc.com/lifestyles/health/everything-you-need-know-about-skin-cancer-and-how-prevent/CbjToZ8DvnmsGMtScF075H/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.949181 | 914 | 3.046875 | 3 |
All members of the US Naval Academy, including Midshipmen, faculty, and staff, can serve as resources to each other and help to identify and support Midshipmen who may be encountering difficulty. Faculty, company staff, and coaches and trainers often serve as the front line of mental health in their ability to recognize distressed students and persuade them to utilize the helping resources available.
Often students are undergoing difficulties related to the transition and adjustment to the USNA. In other cases, however, students may experience a less predictable crisis which challenges their capacity for coping effectively. These crises include the death of family members or friends, dissolution of important relationships or significant shifts in plans for their future. The follow pages have information about crises, warning signs, and referral processes for students and faculty and staff. Remember, if you have any doubts or concerns about a Midshipmen's safety or well-being, you are always welcome to consult with an MDC staffer.
Make the Connection is a website that provides personal accounts of people who have struggled with what you, or a friend, may be going through.
The resources you find on the MDC website are not meant for self diagnosis. Please seek out one of our care providers to talk through the possibilities if you have a concern about your--or a friend's--mental health.
The appearance of external hyperlinks does not constitute endorsement by the U.S. Navy of non-U.S. Government sites
or the information, products, or services contained therein. | <urn:uuid:39a83740-35db-4c24-a5fc-296bfc141ef9> | CC-MAIN-2022-33 | https://www.usna.edu/MDC/Resources/index.php | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.959864 | 313 | 1.65625 | 2 |
Begin of page section: Content
Democracy: A Security Risk?
Threats and Criminalisation of political Activism
Thursday, 01 Mar 2018
For some years, an authoritarian turnaround has occurred in different parts of the world. Autocratic governments seem to increasingly regard democracies as a security risk. In Europe, too, citizens increasingly experience repression when they demand their political and democratic rights. The arming of police and army, the nationwide surveillance and the tightening of laws are increasingly used not only for the fight against terror, but are increasingly used against their own citizens. Civil society engagement becomes more risky and requires more and more courage. Under the banner of security precautions civil rights are reduced.
At the same time, the crisis of Western democracies increases the need for initiatives that fight for the preservation of supposedly obvious rights. In this podium, activists talk about the repression they experience in their day-to-day work, experts talk about the tightening of laws that accompany the heightened anti-terrorism measures, and discuss possible strategies for dealing with anti-democratic currents.
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Skip to overview of page sections. | <urn:uuid:506a6950-1e61-4cfe-8480-65d5836c9038> | CC-MAIN-2022-33 | https://elevate.at/websites/2018/en/schedule/e18democracy/index.html | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571950.76/warc/CC-MAIN-20220813111851-20220813141851-00672.warc.gz | en | 0.948623 | 227 | 1.867188 | 2 |
Many in stock
11 g Protein 2 g Net Carbs* 1 g Sugar 7 g Fiber Contains 8 g of Total Fat Per Serving Naturally Flavored No Artificial Colors, Flavors or Preservatives No Maltitol What is the "Hidden Sugar Effect?" It's common knowledge that consuming foods that contain large amounts of sugar may cause your blood sugar to spike. But did you know other types of carbohydrates may have the same effect on blood sugar? At Atkins, we call this the "Hidden Sugar Effect". For example - a medium sized bagel has the same impact on blood sugar as 8 teaspoons of sugar*. At Atkins Chocolate Peanut Butter Bar has the same impact as 1.5 teaspoons of sugar.* *Based on glycemic load. *Counting Net Carbs? Glycerin is naturally sourced from vegetables and gives our bars a soft texture. Glycerin and fiber should be subtracted from the total carbs since they minimally impact blood...
Other IngredientsProtein blend (soy protein isolate, whey protein isolate, milk protein isolate), peanuts, polydextrose, vegetable glycerin, palm kernel and palm oil, gum arabic, cocoa powder (processed with alkali), contains less than 2% of: Natural flavors, peanut oil, salt, soy lecithin, sucralose. Contains soy, peanuts, milk. Made in a facility that also uses eggs, wheat and tree nuts.
Supplement FactsServing Size: 1 Bar (35 g) Servings Per Container: 5 Amount Per Serving % Daily Value Calories 150 Fat Calories 70 Total Fat 8 g 12% Saturated Fat 4 g 20% Trans Fat 0 g Polyunsaturated Fat 1 g Monounsaturated Fat 3 g Cholesterol 0 mg 0% Sodium 150 mg 6% Potassium 125 mg 4% Total Carbohydrate 13 g 4% Dietary Fiber 7 g 28% Sugars 1 g Glycerin 4 g Protein 11 g 20% Vitamin A 0% Vitamin C 0% Calcium 8% Iron 8% Percent Daily Values are based on a 2,000 calorie diet. Your Daily Values may be higher or lower depending on your calorie needs.
DisclaimerWhile VitaminsUK strives to ensure the accuracy of its product images and information, some manufacturing changes to packaging and/or ingredients may be pending update on our site. Although items may occasionally ship with alternate packaging, freshness is always guaranteed. We recommend that you read labels, warnings and directions of all products before use and not rely solely on the information provided by VitaminsUK.
Sleeve Length x Chest circumference x Waist circumference x Length
- XS (14.8" x 34.6" x 35" x 25.6")
- S (15.7" x 35.8" x 35.8" x 26.2")
- M (16.3" x 37.8" x 37.8" x 27.6")
- L (17.1" x 39.4" x 39.4" x 28.5")
Your About Us page might include:
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- Contact information Social links (Twitter, Facebook) | <urn:uuid:e56e2d55-b82c-4f19-b80b-9464fb5be222> | CC-MAIN-2022-33 | https://healthreaction.com/products/tk-05502 | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571950.76/warc/CC-MAIN-20220813111851-20220813141851-00672.warc.gz | en | 0.853623 | 690 | 1.914063 | 2 |
If you prefer to avoid the empty workbook to be created when Excel starts up, you can do so by editing the
command line that is used to start Excel.
Excel automatically creates three worksheets in each new workbook, but you can force it to create as many
worksheets as you need.
If you would like to better understand how some of these complex array formulas work, consider using a handy
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You can easily count the number of unique values of the range using a simple formula.
In order to get unique items in a range you can use the Advanced Filter to extract the unique values
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When you need as much space as possible on screen to view a workbook, you can collapse (or minimize) the
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Suppose you'd like to add a couple more commands to the Quick Access toolbar. Perhaps you miss the
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can quickly create and use AutoSum entries.
Candlestick chart is a style of bar-chart used primarily to describe price movements of a security,
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columns, while the intermediate values are denoted by floating columns. | <urn:uuid:7611ec0c-19a0-416a-9fd9-c8ff4ca197bf> | CC-MAIN-2022-33 | https://www.officetooltips.com/excel_2007/tips/7.html | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571584.72/warc/CC-MAIN-20220812045352-20220812075352-00672.warc.gz | en | 0.907397 | 382 | 2.390625 | 2 |
Most triathletes and coaches track a wide variety of performance metrics to see progress in training: heart rate, paces, times, power, and so on. These are all good indicators of whether training is moving in the right direction. An additional indicator I encourage everyone to look at is “confidence level.”
Being confident—and building a high confidence level in your own performance—is very important for racing successfully. Endurance events always require a lot of mental strength. Athletes who are confident that they can hold certain paces or specific efforts will be able to overcome tough phases in a race easier. Those who have doubts or are uncertain whether they can keep going at a certain speed are more likely to fail.
The tricky issue here is that, generally, success leads to more confidence, but, at the same time, confidence is needed to have a successful race. So, here are some ideas on how to build confidence in training as you get ready for your important “A” race.
Focus! Instead of paying attention to every aspect of training, set priorities and focus on one aspect at a time. For triathletes, it’s hard to have stellar workouts in all three sports every time.
Focus in phases on one discipline and make progress in this sport to build confidence. In the winter, focus on building strength; in spring, focus on building volume and mileage; and then, as you get closer to races, hone in on speed and intensity. Don’t try it all at the same time; that’s more likely to lead to failure and takes a way confidence.
Set ambitious but obtainable training goals. If you constantly miss your training goals, you will lose confidence. Set “stretch” goals that are specific to your phase of training, but make sure you can—and will—hit them. This builds confidence.
For example: During Ironman-distance training, I often set goals in the spring to achieve a certain training volume—such as 35 hours in ten days. With full-time work, this is hard but doable if I include two weekends. Achieving this goal gives me confidence that I can handle high volume.
About a month before an Ironman-distance race, I used to do a tough run workout—15 x 1,000 meters with 200 meters rest—and set a challenging, yet achievable, target pace for the 1,000s. It’s a tough workout; completing it at target pace was always a good confidence builder. Doing so told me that race fitness was there.
Take training races seriously, even if they are “B” or “C” tier races. Repeated failure or mediocre race results take away your confidence. So, if you do race, make sure in most cases that you have successful results. After a series of unsuccessful training races, it is less likely that you will go with confidence into your important “A” race and succeed.
If you train with groups, make sure to train with different levels of athletes. It’s great to do some training with faster athletes. It will help you get faster. For example: I suffered through plenty of bike miles behind pro triathlete James Bonney’s wheel, which nevertheless helped me to improve my cycling and gave me confidence in my cycling capabilities.
However, to build confidence, it is also beneficial to take the lead sometimes and be the fastest in a group. So, make sure to include both types of group workouts in your training.
Local age group athlete Jennifer Walker is a great example of how a high level of confidence can be a good indicator that success will follow. Walker started this training year with ambitious goals, and her target race was Ironman Lake Placid in July. In the winter months, we first worked on running. She set a half marathon personal record (PR) in March, which gave her a lot of confidence that her running was where it needed to be.
In the following months, Walker raced several triathlons up to half Ironman distance (70.3 miles). She took each race seriously enough to finish strong. As a result, she set a new half Ironman-distance PR, qualifying for Ironman 70.3 Worlds in Vegas, and won her age group at Ironman 70.3 in Kansas. She was also smart enough to skip a race after being sick in May. Chances were high that she would not have a good result anyway, and, by canceling, it her confidence level in her race performance stayed high.
With lots of focus and dedication, Walker stayed on top of a tough final build phase of Ironman-distance training. When we met a week before Ironman Lake Placid to talk through the race, I was impressed by her confidence that she would have a great race. The race result came as no surprise; she finished on the podium in her age group and qualified for Kona. Going into her “A” race with a lot of confidence was Walker’s key to success. Aloha! | <urn:uuid:babf1aa4-2c1b-4350-bc54-7ab8e627f732> | CC-MAIN-2022-33 | https://www.austinfitmagazine.com/September-2013/confidence-leads-to-success/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882570793.14/warc/CC-MAIN-20220808092125-20220808122125-00672.warc.gz | en | 0.97007 | 1,048 | 1.703125 | 2 |
GATA2 IN MDS
Myelodysplastic syndrome (MDS) is characterized by pancytopenia due to ineffective hematopoiesis and a propensity for acute myeloid leukemia (AML). MDS is frequent in old age, but rarely occurs in children and adolescents. Genetic work-up revealed that the mutational landscape differs between adults and young people, and that the latter frequently develop MDS on the background of a genetic syndrome.
In 2011, three syndromes were described to be caused by germline GATA2 mutations, indicating a broad phenotypic spectrum of the GATA2 deficiency syndrome. Immunodeficiency due to variable cytopenias is the major feature of affected individuals with B lymphocytopenia being the most consistent finding. The risk to develop MDS/AML was already noted in the index families, but unexpectedly, germline GATA2 mutations were also detected in pediatric MDS patients lacking a family history or syndromic features. The European Working Group of MDS in Childhood (EWOG-MDS) reports germline GATA2 mutations in 7% of all pediatric MDS with a higher prevalence in MDS with excess blasts (15%). There is a significant association with monosomy 7, der(1;7) and trisomy 8. Hematopoietic stem cell transplantation is curative resulting in outcomes similar to that observed for GATA2 wildtype MDS patients. Although most mutation carriers will eventually develop MDS/AML, disease manifestation may strongly be influenced by additional factors such as secondary events. We developed a mouse model reminiscent of the human disease with pancytopenia, bone marrow hypocellularity and leukemia occurring in a subset of animals. This model will help to identify mechanistic links between GATA2 haploinsufficiency and cooperating factors. | <urn:uuid:f7ed6b3c-c557-4521-a13b-87225cd85080> | CC-MAIN-2022-33 | https://cslide.ctimeetingtech.com/esid19/attendee/confcal/show/session/37 | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571950.76/warc/CC-MAIN-20220813111851-20220813141851-00672.warc.gz | en | 0.936641 | 391 | 2.859375 | 3 |
Animals With Stripes Fight List
Animals With Stripes Fight List Answers BANDICOOT KUDU RACCOON SKUNK SUGAR GLIDER WASP OKAPI LEMUR IGUANA HORSE HORNET GECKO GNUS BUMBLEBEE BEE BASS BADGER SPIDER ZEBRA LIGER LIZARD GAZELLE HYENA FISH CATERPILLAR CAT.
Animals with stripes fight list. For reference of character selection for new beginners Anyway its difficult to start the combo dog. Zebras are common zebrid animals with black and white strips to confuse the predators. We will help you solve the words.
The animal Nat Geo says has a notoriously cantankerous disposition and will fly into a maniacal rage when threatened by a predator fighting for a. ABCs of Animal World. 9 Sperm Whale Skin Is Super Thick.
23 cm 91 in Tinkers butterflyfish. 5H of the squirrel God with a. They are gregarious animals and large herds of them are commonly observed feeding in the open grasslands that they love.
This page contains links to the various wildlife found in Red Dead Redemption 2s world. In this guide you will find the complete list of animals you can tame in the game with their general stats and details. These stripes are similar to those of a zebra.
Crocs of course have some tough skin. There are some tough animals out there with some pretty thick hides. The formation of the stripes on their rear end of the Zebra differs greatly between the three species with Common Zebras having horizontal stripes.
Some places around the web even list the whale shark as having the thickest skin in the world at an amazing 15 centimeters 6 thick. ABCs of Animal World. The king cheetah is on the right with stripes.
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25. Adequate Living
1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.
2) Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection. | <urn:uuid:4cc4d33d-7d73-4c4f-a4e8-a290ac94b688> | CC-MAIN-2022-33 | https://go-hre.org/adequate-living/ | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882573744.90/warc/CC-MAIN-20220819161440-20220819191440-00472.warc.gz | en | 0.963093 | 112 | 2.546875 | 3 |
Chinese Surgeon Shows the Lungs of a 52-Year-Old Smoker
Dr Chen Jingyu, a Chinese surgeon from Wuxi People’s Hospital, uploaded a video that shows the lungs of a 52-year-old smoker who died from multiple lung diseases. Under the hashtag ‘jieyan’ (Mandarin for ‘quit smoking’), his video has reached more than 25 million people on social media. His lungs turned black from the tar in his lungs after chain smoking for 30 years.
The video was recorded by the surgeons and doctors from the Wuxi People’s Hospital in Jiangsu (China). Many Internet users dubbed this video as ‘best anti-smoking ad ever.’
‘Look at these lungs – do you still have the courage to smoke?’ Graphic content warning
Before you click on this video, you must be aware of what you are going to watch. The images show the lungs of a patient suffering from lung pulmonary emphysema, among other diseases, after the doctors extracted the organs. The lungs of this patient were charcoal in color and extremely inflamed from decades of tobacco residue clogging them up, instead of showing a healthy pink color.
According to Dr Chen, many smokers have lungs which look like this.”Our team decided to reject these lungs for transplant. If you’re a heavy smoker, your lungs may not be accepted even if you choose to donate them after death,” he explained.
He said that medics may have also inflated the lungs with air or fluid prior to harvesting them for donation. This makes them look much larger than the normal deflated lung postmortem, he explained.
The impact of chain smoking for more than 30 years
This horrifying video shows what years of smoking can do to your lungs. Dr Chen Jingyu received the organs donated by a 52-year-old who had chain smoked for more than 30 years before he died.
According to a 2018 study by China’s Center for Disease Control and Prevention, 350million adults (27 per cent) are smokers.
Years of smoking causes heart, brain, circulation, stomach and lung problems. Smoking can cause fatal diseases such as pneumonia, emphysema and lung cancer. Smoking causes 84% of deaths from lung cancer and 83% of deaths from chronic obstructive pulmonary disease (COPD), according to NHS.
In England, one in seven adults now smoke tobacco – around 5.9million people, down from 7.7million in 2011, when the figure was closer to one in five. This significant drop in the number of smokers in England is partially due to many adults switching to vaping.
According to a study published by Public Health England, vaping is at least 95 per cent safer than traditional smoking.
Content creator and marketer. Originally from Spain, I lived a few years in Scotland and China where I started to work for the vaping industry. Vaping is not only a profession for me but also a passion. I quit smoking thanks to vaping almost 3 years ago. I helped many smokers to switch to vaping since as I am convinced vaping is a much healhier alternative to tobbaco smoking. | <urn:uuid:5ce4468b-fffe-413d-b12c-45d503277731> | CC-MAIN-2022-33 | https://guide.heavengifts.com/lungs-of-a-52-year-old-smoker.html | s3://commoncrawl/crawl-data/CC-MAIN-2022-33/segments/1659882571950.76/warc/CC-MAIN-20220813111851-20220813141851-00672.warc.gz | en | 0.967459 | 659 | 2.125 | 2 |
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