Chronic cardiovascular and pulmonary diseases are prevalent in the US home health population. Heart failure and chronic obstructive pulmonary disease are both chronic and terminal, but they are not always perceived as serious illnesses with imminent death. Therefore, they provide a context for advance care planning that is distinct from the diagnostic contexts of cancer, end-stage renal disease, or dementia. Advance care planning is defined as a process that supports adults at any age or stage of health in understanding and sharing their goals, values, and preferences about future medical care, including the designation of a surrogate decision-maker. This study tests the hypothesis that US home health agencies with higher percentages of patients with chronic cardiovascular and pulmonary conditions have less robust advance care planning protocols. The Spearman correlation coefficient was r = 0.22 (S = 74684, P =.025, 1-tailed), which was statistically significant and an unexpected finding. The greater percentage of patients with chronic cardiac and pulmonary diagnoses in an agency, the more robust the advance care planning protocol was. This supports our previous findings and existing literature indicating that agencies may be using exacerbation events marked by acute care use as opportunities to initiate or repeat advance care planning.

Tolerating transitions between activities and locations is an essential daily-living skill, as transitions are inevitable in most typical settings. However, for some individuals, requests to transition may occasion problem behavior which can interfere with daily routines and result in a more restrictive lifestyle. The unpredictability of transitions is often assumed to be aversive and functionally related to transition-related problem behavior. As a result, advance notice procedures are often recommended to reduce problem behavior during transitions. However, Brewer et al. (2014) found mixed results for the use of advance notice highlighting some studies where advance notice procedures reduced problem behavior and others where the procedures were inefficacious. In this study, we reviewed the relevant literature between 1994 and 2020, including studies reviewed by Brewer et al. (2014) and extended Brewer et al.’s (2014) review in a number of ways. We first summarized the current literature, including new studies published since Brewer et al.’s (2014) review, which included a total of 28 applications of advance notice published in 14 papers. Next, we identified key features of each study, including the presence or absence of demonstrated functional relations, inclusion of additional antecedent or consequent interventions, and evaluation and control of the effects of pre- and post-transition reinforcers on responding. Then we identified gaps in current knowledge regarding predictability and made research recommendations for addressing these gaps. Finally, we discuss practice recommendations for transition-related problem behavior based on current research.

Difficulties exist with designing and testing on a model scale. The purpose of this study is to examine variations in the flow field of a submarine due to hull/propulsor interaction and Reynolds scaling. The scope of this study includes the simulation of the flow past a 1) five-bladed marine propeller with 0° skew, 2) unappended submarine hull, 3) forward propelled submarine with asymmetrical stern appendages, and 4) submarine in crashback with asymmetrical stern appendages. The bare hull simulations are conducted for three different length scales: small model scale, large model scale, and full scale. The isolated propeller and appended submarine simulations are conducted on the large model scale. It is of interest how sensitive the various flow characteristics are to Reynolds number and the turbulence model. All simulations are at 0° angle of attack, and validated with experimental data where available.

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As a healthcare professional at the bedside, it has been very difficult to advocate for the patient while all parties involved cannot respect what the patient wants. Four out of five Americans do not have an advance directive. The history and court cases that have led the country to make patient’s right to make their own healthcare decisions has been decades in the making, yet still bring daily challenges within the healthcare system. When a patient’s wishes are not being honored, medical futility may lead to moral distress and compassion fatigue. Institutions provide multidisciplinary teams to address these issues, but if a patient’s capacity or competence is in question, their voice may not be heard. The toll on the healthcare provider and the patient can be permanently damaging, causing many nurses to leave the profession all together. I will attempt to determine the barriers to implementing the patient’s wishes, address the syndrome of moral distress among healthcare professionals, and attempt to offer solutions to promote well rounded, patient-centered care. / Urban Bioethics

Death is an inevitable part of life, yet many Americans fail to plan for this final part of life. Only about 1/3 of our country has an advance directive (Off White Papers, 2014). This underutilization of advance directives is reflected in our health care spending. It is estimated that 30% of all Medicare spending occurs during the last six months of a patient’s life. The numbers are even lower when broken down into sub-categories. Only 24% of older Black Americans possess an advance directive versus 44% of their older White counterparts (Huang, Neuhaus, & Chiong, 2016). Some studies found that African Americans were more likely to “express discomfort discussing death, want aggressive care at the end of life, have spiritual beliefs which conflict with the goals of palliative care, and distrust the healthcare system” (Johnson, Kuchibhatla, & Tulsky, 2008). Other studies have even concluded that Black race is an independent predictor of lack of advance directive possession (Huang et al., 2016). This paper further explores the possibility that race and ethnicity may simply be proxies for cultural values that impact advance directive possession. We’ll discuss the barriers, for both Black patients and health care providers, to advance directive possession as well as investigate culturally mindful interventions to combat the barriers. / Urban Bioethics

Death is inevitable, and research indicates that 80% of Americans wish to die at home. Does anyone know those wishes? Advance directives outline those wishes and personal decisions. Do advance directives make a significant difference in the experience of death for the patient, loved ones, and clinicians? Through interviews with loved ones of those who have died, as well as legal representative and a physician, this thesis examines the benefits and obstacles of having an advance directive, as well as the issues that have a high impact on whether and why an advance directive is written. Policy recommendations, business tactics, and community-based solutions are proposed to address these issues. It is clear that access to healthcare and the clinical professionals who can discuss end of life issues has a major impact on whether an advance directive is considered by the patient, along with health literacy skills and knowledge. / Urban Bioethics