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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.

Advance directives (ADs) convey consumers' wishes about accepting or refusing future treatment if they become incompetent. The issue of making a particular AD, more commonly referred to as a living will, is the focus of this thesis. The typical direction of the living will is that life-sustaining activities such as the provision of mechanical ventilation should be withheld so that a person may die what is hoped to be a 'peaceful death'. Clearly the whole basis of the thinking behind the recognition of ADs is that patients' wishes should prevail. ADs have been championed by some as a means of preserving both dignity and autonomy at the end of life in the face of increasing medical advances in technology to preserve life indefinitely. ADs are seen as a means of promoting peace of mind in will-makers, of allowing carers and family to honour the person's wishes and of stimulating communication between all involved parties.While at present there is no statutory right for people in New Zealand to make ADs, it is considered they have rights to do so in common law as consumers of health and disability services in this country. Little is known about the views of New Zealanders making ADs or their justification for doing so. This small qualitative study, using a discourse analysis approach after Potter and Wetherell (1987), aimed to investigate how the participants justified making ADs. Six people were interviewed and the transcriptions were analysed identifying three dominant interpretative repertoires and three corresponding subject positions.The findings indicated that the participants positioned themselves: as independent self-determining individuals who knew when they were ready to make ADs after witnessing undesirable deaths of close family members; as judges of knowing when inappropriate treatments lead to undignified deaths; and as concerned parents who want to relieve their families of uncertainty in the future when making surrogate end-of-life decisions for them. Witnessing a prolonged family member's death in the past was a contributing factor to the participants making ADs. The participants' recall of these events led them to make their wishes known in advance so that their families, in turn, would not have to go through a similar experience at the terminal stages of their lives. The overarching motivations for formalising ADs was to avoid having life artificially prolonged by receiving life-sustaining treatments as well as the desire to die a dignified death.This study highlights the need for healthcare professionals to value the importance of advance planning with well adults before they lose the capacity to give informed choices at the end of life. The taking of a values history as part of this advance planning may inform family and healthcare professionals about peoples' general values and at the same time confirm and record end-of-life choices for future reference.