This thesis investigates the legal validity of living wills (advance directives) in South Africa. The study explores the current status of living wills in South Africa and contains recommendations on how legal enforceability of living wills can be improved in the South African context. The Constitution of the Republic of South Africa, 1996, the common law and the National Health Act, 61 of 2003, serve as basic points of departure for this investigation. Shortcomings in the current South African legislation and proposed draft legislation including the Law Commission’s Draft Bill on End of Life Decisions, 1998, and The National Health Amendment Bill, 2019, as well as shortcomings in the common law, the field of medical ethics and medical practice are indicated and recommendations for an improved framework are made. For purposes of a legal comparative methodology, the legal frameworks of living wills in the Netherlands, England and Canada are investigated. Specific circumstances which could potentially hamper the legal enforcement of living wills are discussed, including: emergency situations, do-not-resuscitate orders, permanent vegetative states, dementia, cessation of artificial hydration and feeding, pregnancy, euthanasia, assisted suicide, palliative care, pain relief and organ donation. It is argued that a living will could be an important tool in enhancing the doctor-patient relationship, not only to the benefit of the autonomous patient whose dignity and other fundamental human rights should be protected, but also to the benefit of the doctor as the medical care provider. / Thesis (LLD)--University of Pretoria, 2019. / Public Law / LLD / Unrestricted

Advance warning signals (AWS) provide information warning drivers in advance of the end-of-green phase for an approaching signalized intersection. The purpose of this research was to develop guidelines for the placement of AWS in Utah, both conditions to evaluate the need for AWS installation and guidelines for the AWS system design. The conditions were based on literature of other transportation agencies that had similar AWS systems and were developed using the Policy Delphi method. The Policy Delphi method is the development of a specific policy area through the means of discussion by a committee of experts correlating views and information involving opportunity to react and assess different viewpoints until the committee is in agreement over the policies being recommended. Six conditions are recommended and discussed in detail, including: limited sight distance, posted speed, isolated intersection, high crash rate, approach grade, and heavy vehicle traffic volume. The guidelines for the AWS system design included details about three components: AWS component, advance detection component, and signal timing component. An evaluation matrix was developed by the Policy Delphi method for the purpose of evaluating and prioritizing a group of intersections for AWS installation. A total of 24 intersections were identified by the Utah Department of Transportation for this project that helped to develop and verify the conditions and evaluation matrix. The recommended guidelines and evaluation matrix results are described.

The purpose of this study is to explore what knowledge dementia caregivers have about advance care planning (ACP), how they learn to execute formal advance directives (ADs) or have engaged in an informal ACP process, and how they understand their roles as decision makers for the patients. Factors that contribute to the completion of an ACP process such as demographic, psychosocial, and situational factors are identified. From the grounded theory data analysis, a theory emerged about how ACP is accomplished and used by caregivers. Findings reveal that caregivers understand ACP as having the power to shape the dying process for dementia patients. It is not just about executing formal written ADs but how caregivers exercise that power. Caregivers’ knowledge and beliefs are reflected in their behavior regarding ACP in both how they do the ACP process and how they use ACP. For the caregivers in this study, the process of ACP occurs along a trajectory from: years before dementia to dementia diagnosis to end stage and death. At each of these stages, actions taken by the caregivers and their motivation are identified. Three key features of the ACP process in all three stages are examined: conversations within the family and with trusted others, gaining knowledge of ACP, and keeping ACP documents. How caregivers use ACP is based on how they define their roles as decision makers for their patients by: accepting responsibility for making difficult decisions regarding treatment for the patients, using ACP as an effective tool to shape the dying process for their patients, and doing battle with health care professionals to honor patients’ wishes. This definition is shaped by the meaning caregivers give to ACP, how caregivers understand life sustaining measures, and caregivers’ knowledge of patients’ end-of-life wishes. This new theory, the Dementia Caregiver Advance Care Planning Theory, adds new knowledge as the first model specific to dementia caregivers and adds dimension and depth to the current existing ACP models by detailing an ACP process, demonstrating the impact of conversations on the process, and identifying both the most important influences and the primary relationship in the decision making process.

The overall aim of the present thesis was to study factors related to transfers of older people between nursing homes, emergency department and hospital care. The thesis was based on four studies and used three methods: focus group discussions, structured review of electronic healthcare records, semi-structured interviews with registered nurses and general practitioners. Study I: nursing home nurses found it difficult to decide whether older residents should be referred to hospital from the nursing home. Hospital registered nurses reported often trying to stop premature discharges or having to carry out the discharge although it had not been fully prepared. Study II: transfer rate to ED was 594 over 9 months among a total of 431 residents (M 1.37 each). 25% were caused by falls and/or injuries, 63% resulted in hospitalization (M 7.12 days). The transfer rate was 0.00-1.03 transfers/bed; it was higher for private for-profit providers than for public/private non-profit providers. Study III: nursing homes with high transfer rates had fewer updated advance care plans than did nursing homes with lower transfer rates. More nurses from nursing homes with low transfer rates had a specialist education and training in dementia care and had worked longer in eldercare. Study IV: general practitioners perceived registered nurses’ continuity, competence and collaboration with family members as important to quality of care in nursing homes; inadequate staffing, lack of medical equipment and less-than-optimal IT systems for electronic healthcare records are impediments to patient safety. The findings indicate that organizational factors could explain differences in transfer rates between nursing homes. The studies highlight the importance of advance care planning together with residents and family members in facilitating future medical decisions. Registered nurses’ continuity and competence are perceived as crucial to quality of care. To meet increasing demands for more complex medical treatment at nursing homes and to provide high-quality palliative care several changes should be made: Nursing homes should be equipped with suitable medical equipment and registered nurse staff should be matched accordingly; importantly, registered nurses and general practitioners should be able to access each other’s healthcare record systems.

Thesis advisor: Megumi Inoue / End-of-life care planning is an opportunity for people to express how they want to spend the final stage of their lives by directing what type of medical treatment they wish or do not wish to receive. The completion of such planning is a way to exercise their autonomy, which is one of the fundamental ethical principles in medicine in the United States. Many older adults in the U.S., however, do not have such a plan or even discuss the topic with anyone. In order to understand the circumstances in which end-of-life planning is enacted, this study investigated two important research questions: (1) What are the sociodemographic and psychosocial factors that enhance or impede the completion of end-of-life planning? (2) How consistent is the content of a living will with the person's actual dying experience? These research questions were developed and examined as an application of expectancy theory, which explains the concepts of motivation and action. A series of logistic regression analyses were conducted. This study analyzed data from the Health and Retirement Study (HRS), which is a nationally representative sample of Americans over the age of 50. The analytic subsample included those who died between 2000 and 2010 (N = 6,668). The study found that persons who were older, who identified themselves as White, who had higher levels of income and education, and who were widowed or separated were more likely to be motivated to complete end-of-life planning. A higher level of sense of mastery was specifically relevant to documentation of living wills. On the other hand, a lower level of religiosity was specifically associated with having a durable power of attorney for health care. In addition, there was a clear connection between a request for palliative care and less troubling pain. Implications include conducting a community- or workplace-based public educational campaign, incorporating a culturally tailored approach for racial/ethnic minorities (e.g. faith-based interventions), using advance directives written in easy to understand language (e.g. Five Wishes), and funding Medicare provision for end-of-life care consultations between doctors and patients during annual physical exams. / Thesis (PhD) — Boston College, 2014. / Submitted to: Boston College. Graduate School of Social Work. / Discipline: Social Work.

Cloud computing is a multi billion dollar industry, based around outsourcing the provisioning and maintenance of computing resources. In particular, Infrastructure as a Service (IaaS) enables customers to purchase virtual machines in order to run arbitrary software. IaaS customers are given the option to purchase priority access, while providers choose whether customers are preempted based on priority level. The customer decision is based on their tolerance for preemption. However, this decision is a reaction to the provider choice of preemption policy and cost to purchase priority. In this work, a non-cooperative game is developed for an IaaS system offering resource reservations. An unobservable $M|G|1$ queue with priorities is used to model customer arrivals and service. Customers receive a potential priority from the provider, and choose between purchasing a reservation for that priority and accepting the lowest priority for no additional cost. Customers select the option which minimizes their total cost of waiting. This decision is based purely on statistics, as customers cannot communicate with each other. This work presents the impact of the provider preemption policy choice on the cost customers will pay for a reserved instance. A provider may implement a policy in which no customers are preempted (NP); a policy in which all customers are subject to preemption (PR); or a policy in which only the customers not making reservations are subject to preemption (HPR). It is shown that only the service load impacts the equilibrium possibilities in the NP and PR policies, but that the service variance is also a factor under the HPR policy. These factors impact the equilibrium possibilities associated to a given reservation cost. This work shows that the cost leading to a given equilibrium is greater under the HPR policy than under the NP or PR policies, implying greater incentive to purchase reservations. From this it is proven that a provider maximizes their potential revenue from customer reservations under an HPR policy. It is shown that this holds in general and under the constraint that the reservation cost must correspond to a unique equilibrium. / 2020-06-03T00:00:00Z

Philosophiae Doctor - PhD / Background: Extended-spectrum beta-lactamase-producing (ESBL) and carbapenemaseproducing Gram-negative bacilli showing resistance to cephalosporins and carbapenems respectively, have been reported from several countries globally and recently among Libyan combatants who have been transferred to European countries for advanced medical care. However, there is a lack of data about their presence in Misrata and in Libya in general. This is the first documented study aimed at investigating the prevalence and resistance mechanisms of ESBL and carbapenemase-producing K. pneumoniae isolates from Misrata. Materials and Methods: Two hundred Gram-negative bacillus isolates were collected and identified from hospitals and pathology laboratories in Misrata. Following antimicrobial susceptibility screening, those showing resistance to cephalosporin and carbapenem were tested for ESBL activity using the Modified double disc synergy test, Sensititer ESBL confirmatory MIC plates and MAST AmpC detection sets D52C and D68C. Carbapenemase activity was detected using RAPIDEC CARBA NP test, Modified Hodge test (MHT), carbapenem inactivation methods (CIM), carbapenem combined test (CCT), and by MAST carba puls set. ESBL and carbapenemases genes were detected using multiplex PCR. Results: K. pneumoniae was the predominant species (85/200) of the 14 species identified, with 56 (65.8%) showing carbapenem resistance, 16 (18.8%) were cephalosporin-resistant carbapenem-susceptible and 13 (15.2%) were susceptible to all antibiotics except ampicillin. OXA-48 was the only carbapenemase detected, with SHV, TEM and CTX-M group 1 found in almost all carbapenem and cephalosporin resistant K. pneumoniae. Rep-PCR analysis revealed multiple clones and some K. pneumoniae strains were genetically related or indistinguishable despite differences in ESBL genes or carbapenemase activity. Conclusion: The findings of this study show that carbapenemase- and ESBL-producing K. pneumoniae are prevalent in Misrata and emphasize the urgent need for optimized infection control and antibiotic stewardship programmes in the Libyan hospitals to prevent further spread of these organisms.

Nurse practitioners (NPs) are significant members of the health care team. Variation and lack of standardization in the practicum preparation of the NP has been identified as problematic. There is a need to improve NPs preparation to efficiently and independently impact health care. This project presented the 1-minute-preceptor (OMP) model as a standard tool in the practicum preparation of the NP through a preceptor-focused continuing education session. The aim of the OMP is to help ensure that students are exposed to the level of critical thinking and problem solving needed in the role of an independent, efficient NP. Knowles's adult learning theory and the educational design process model provided the theoretical framework and guided the development, implementation, and evaluation of the continuing education program. Participation in the continuing education program was voluntary. Pretests, posttests, and evaluations of the continuing education session were collected and analyzed. Ten preceptors participated in the educational session and evaluation. Based on pretest and posttest results, knowledge of the OMP model improved from 70% before the education program to 100% after the program. Participants also indicated interest in using a tool capable of ensuring an effective student-preceptor encounter, and 100% stated they would use the information presented in future preceptor–student interactions. Continuing education program evaluation results indicated participant satisfaction with the presentation. To positively impact social change, the findings of this project may be used by NPs and preceptors to effectively and efficiently impact patient outcomes early in practice.

Thesis (M.S.)--University of North Dakota, 2005. / Includes bibliographical references (leaves 67-74) Also available online.

Thesis (Ph. D.)--University of Washington, 2001. / Vita. Includes bibliographical references (leaves 212-216).