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Thesis (M. P. H.)--University of Hong Kong, 2006. / Also available in print.

Thesis (M.P.H.)--University of Hong Kong, 2006.

Objective: The Patient Self-Determination Act of 1990 (PSDA) protects a patient’s right to predetermine the level of life-supporting care they are willing to receive (U.S. Department of Health and Human Services, 1993). In Arizona, the advance directive (AD) complies with the PSDA and is used to guide care in the event of cardiopulmonary failure. The AD may indicate “do not resuscitate” (DNR), which prohibits cardiopulmonary resuscitation in the event of cardiac arrest. In the institution used for this project, a palliative care team assists with identifying goals of care and helps guide interventions consistent with the AD. The purpose of this Doctor of Nursing Practice (DNP) project was to complete a retrospective chart review and identify patients admitted to the medical intensive care unit (ICU) with a DNR as indicated by a copy of the AD in the electronic health record (EHR) and determine if they received a palliative care consultation. This information could support a quality improvement project led by the DNP-prepared AGACNP focused on ensuring a palliative care consultation within 48 hours of admission for patients admitted to the ICU with a DNR. Methods: A search of the EHR identified patients admitted to the medical ICU over a 12-month period. The EHR of patients admitted with a DNR were reviewed to determine if they received a palliative care consultation during the ICU stay and the patient’s final disposition. Findings: A total of 38 patients had an AD indicating DNR status on admission to the medical ICU. Of those patients, 26 (68.4%) received a palliative care consultation. Twelve patients (31.6%) with a DNR status on admission did not receive a palliative care consultation. Additionally, five patients with a DNR (13.16%) died in the ICU without receiving a palliative care consultation. Conclusion: Twelve patients with an AD indicating a DNR did not receive a palliative care consultation, and five of those patients died in the ICU. The findings from this project support a quality improvement project to implement palliative care consults to review goals of care for patients with a pre-existing AD indicating a DNR code status.

This study determined the potential feasibility of surface catalyzed Fenton treatment to remediate soil and groundwater contaminated with bis(2-chloroethyl ether (BCEE), bis(2-chloroethoxy) methane (BCEM), and 1,2-dichloroethane (1,2-DCA) among other contaminants. Parameters that affect the contaminant loss rate such as pH, hydrogen peroxide concentration and solid/water ratio were systematically evaluated. Batch reactors were set-up utilizing either contaminated or uncontaminated soil that was mixed with synthetic groundwater containing the contaminants of interest. The results show an increase in contaminant reduction with a decrease in pH, an increase in hydrogen peroxide concentration, or an increase in the solid/water ratio. For the same set of conditions, contaminant reduction was greater for systems utilizing contaminated soil as compared to the systems containing uncontaminated soil. In addition, specific oxygen uptake rates were measured for an activated sludge exposed to different dilutions of untreated and surface catalyzed Fenton treated water to evaluate whether the residual BCEE, BCEM, and 1,2 DCA as well as their oxidation by products were potentially inhibitory or can potentially serve as a substrate for the activated sludge. The measured specific oxygen uptake rates show that the surface catalyzed Fenton treatment enhanced the biodegradability of the contaminated groundwater and served as a substrate for the activated sludge. / Master of Science

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The Loch Lomond Advance limits and raised marine shorelines in N. W. Argyll have been mapped and surveyed. Radiocarbon dated Lateglacial and Postglacial pollen sites at Salen and Loch Shiel provide the vegetational history and chronology for the area. 14 Loch Lomond Advance glacier termini and associated limits were mapped using the distribution of hummocky and fluted moraine, together with a survey of erratic boulders. 83% of the reconstructed former glaciers had a southerly aspect relating to southerly snow-bearing winds. The average firnline gradient was 7.5m/km increasing in altitude towards the north-east; the average firnline height for the area was 369m. The Main Lateglacial Shoreline, formed during the Loch Lomond Stadial, slopes towards 270 with a gradient of 0.15m/km from 9m in the east to Om in the west of the area. It was formed by freeze-thaw action operating under exceptional conditions, and its formation was influenced by rock type. Two Postglacial shorelines are recognized : the Main Postglacial shoreline that slopes towards 270, from 14m to 8m with a gradient of 0.06m/km, and a lower shoreline at approximately 5m which has no definite gradient. An absolute Lateglacial pollen site at Salen, Ardnamurchan, shows an early pioneer community of Rumex, Salix, Gramineae and Cyperaceae species being replaced by an Empetrum heath during the Lateglacial Interstadial. Subsequent stadial conditions are reflected by open herb communities and the onset of coarse minerogenic sedimentation. This minerogenic influx ceased around 10,000 to 9,700 B.P. with a rapid recolonization of the surrounding area by pioneer herbs, then dwarf shrub and finally deciduous woodland. Middle and Late Postglacial vegetational development is recorded by lacustrine sediments from Loch Shiel where the fossil pollen record shows that a mixed deciduous woodland of Quercus, Alnus, Betula and Corylus was progressively cleared by man. Palaeomagnetic and chemical records were obtained from the site. The Main Postglacial Transgression flooded Loch Shiel resulting in the deposition of shells of the marine bivlave Thyasira flexonosa.

Disputes between patients and providers regarding life-sustaining medical treatment (LSMT) are universal across all U.S. states, yet policies regarding these disputes differ significantly. This dissertation determines that all 50 states have advance directive laws that protect a patient’s right to refuse LSMT even when a healthcare provider objects, yet only some states have policies that protect the patient’s right to choose to continue LSMT when a healthcare provider objects (a dispute known as medical futility). Some states have pro-patient laws that protect the patient’s right to make the final decision, while other states have enacted pro-provider medical futility policies that explicitly grant the provider authority to remove LSMT against the patient’s wishes. Finally, in one state, the law delegates the final decision to a third-party: institutional healthcare ethics committees. This dissertation studies the innovation and adoption of these 17 state medical futility policies, examining the theory that values determine both whether the state adopts a medical futility policy as well as what type of medical futility policy a state will adopt- as the policy actors that represent these values: policy entrepreneurs and interest groups. A comparative case study of successful third-party policy adoption in Texas contrasted against a failed effort in Idaho could not affirm the necessity of policy entrepreneurs for policy adoption but did affirm the necessity of interest group consensus and the role of values. Furthermore, quantitative analysis failed to offer statistically-significant evidence of value indicators, but did suggest that government ideology and political party affiliation may potentially become indicators of the type of medical futility policy that states choose to adopt.