The overall aim of this thesis was to study palliative end-of-life care outside specialist palliative care settings, from an organizational perspective and from professionals’ and relatives’ experiences. In Study I 174 individuals were identified retrospectively from nursing records and palliative care identification forms as being in a palliative phase. Data were analyzed with descriptive and analytic statistical methods. In Study II a total of nine nurses working in primary home care, community care, and hospitals were interviewed. Phenomenological methodology was used to analyze data. In Study III 17 enrolled nurses, who worked in community or primary care and in a sitting service organization, participated in four focus group interviews. Data were analyzed with qualitative content analysis. In Study IV seven relatives from four families were interviewed twice. They had each cared in the private home for a dying family member who had received sitting service. Direct interpretation and categorical aggregation were used to analyze data. The results highlight challenges in palliative care, vulnerable situations, and a need of support (I–IV). Individuals’ needs for both palliative care and sitting service were identified, including those of a smaller part of the population who actually received the sitting service. (I). Registered nurses’ responsibilities included care at the same time for individuals in both palliative and curative phases. This created vulnerable situations for the nurses, since their ambitions concerning the care did not correspond to available resources (II). The enrolled nurses’ task was to manage ongoing life and dying in different care settings, to meet individual needs and still provide equivalent care. Despite experiences of vulnerable situations, they felt safe (III). Relatives experienced care situations differently, related to differences in families, the illness trajectory, the need for support, and the support offered. Without sufficient support, vulnerable situations occurred, which made the relatives feel insecure (IV). Thus, care situations in palliative end-of-life care can be experienced in different ways, with different levels of vulnerability. One implication of the research might be to suggest that professional caregivers, to supplement the relatives’ own resources with support tailored to the individual’s and the family’s needs

The aim of the study is, based on the staff’s perspective, to describe and analyse the existential needs of elderly in end-of-life living in nursing homes. The aim was also to examine how the staff perceive working with elderly in end-of-life care. Three qualitative focus groups were conducted by interviewing nursing home staff. The analysis is based on Weisman’s the appropriate death, Tornstam’s gerotranscendence and Hasenfeld’s human service organizations. The main findings were that the term ‘existential needs’ is described as wide and hard to define. Uneasiness and anxiety were common in the end-of-life and it was hard for the staff to meet the existential needs. The staff also described that the “little things” matter, such as holding one’s hand, as well as being present with the elderly. The relationship between the elderly and the staff was vital in order for the elderly to have as good an end-of-life and death experience as possible. The staff felt sorrow when the elderly had passed away and had little time to grieve. In difference to earlier research the staff did not request further education nor tutoring, however they wanted more time to grieve and process the deaths of the elderly.

Bakgrund: Sjuksköterskan arbetar nära vuxna patienter i livets slutskede där försök till läkande behandling gått över till en palliativ behandling. Många av dessa patienter har en komplicerad symtombild som kräver kunskaper i symtomhantering och de har också ofta oro, ångest och funderingar kring existentiella frågor som sjuksköterskan kan behöva hantera.Syfte: Syftet var att beskriva sjuksköterskors erfarenheter av att vårda vuxna patienter i livets slutskedeMetod: Metoden som valdes var en litteraturbaserad studie grundat på kvalitativ forskning, baserat på tolv vetenskapliga artiklar.  Resultat: Ur analysen framträdde tre kategorier såsom Frustration, skicklig kommunikatör, få till ett nära samarbete med åtta underkategorier. Slutsats: Sjuksköterskors erfarenheter vid vård i livets slutskede påvisar betydelsen av att relationer mellan patienten, anhöriga och vårdpersonal skapas.

This research focuses on improving the remanufacturing process efficiency by estimating the workstation utilization through identifying percentage of %Blocking and %Waiting on individual workstations within a remanufacturing flow line. It attempts to achieve this aim such that improved use of methods to overcome the effect of variability can be employed. Extensive literature review revealed the requirement of strategies to recover End of Life products due to the introduction and implementation of legislative directives demanding manufacturers to recover the End of Life resources. Upon analyzing the range of product recovery strategies, End of Life product remanufacturing has emerged as an appropriate and suitable strategy to be used since it extends the operational life of existing products without the need for the new resources required when making products. Remanufacturing is a process in which a product is disassembled to component level. Each of the components will be thoroughly examined for defects. Upon identifying defects, they will either be repaired or components will be replaced. This process in turn increases the product life span. However, remanufacturing is not widely used process applied into various industry sectors due to the fact that it is labour intensive and expensive process compared to new products. Although remanufacturing process is in infancy where small number of industry such as Automotive and Aerospace are deriving benefit from it by making effective use of remanufacturing. Ideally, the suitable manufacturing methods i.e. flow processing system, should be used to remanufacture products. However when flow processing is deployed, it is found that there are a number of factors affecting the process that if not tackled, will result in poor performance and poor efficiency of the overall remanufacturing system. This inefficiency is primarily due to the number of sources of variation found in terms of supply, product design, parts specification, operation and demand variability. Further investigation led to the characterizing the remanufacturing variability and identified ways the effect of this variability can be removed or reduced using Lean principles e.g. Single Minute Exchange of Dies and use of an appropriate manufacturing system. Based on the information revised in literature and experimental design, novel equations were developed along with a set of rules that accurately measures the workstation utilization in terms of %Blocking and %Waiting on individual workstation.

Music therapy plays an integral role in end-of-life care, positively impacting emotional, social, physical, cognitive and spiritual health. The purpose of this integrative review was to collect and compile studies (N= 55) between 2000 and 2016 on the topic of music therapy interventions in end-of-life care, in order to provide both music therapy students and therapists access to the most recent and commonly used music therapy interventions and goals. Results of the integrative literature review indicate that the most common intervention for all age groups in end-of-life care is songwriting and composition, with the most common therapeutic goal being emotional expression and catharsis. Details of music therapy interventions, goals and song details are written in tables for readers to refer to as a guide. Further research is needed with each specific age group and setting, in order to provide refined results beyond what is revealed through this review. Additionally, evaluating therapeutic outcomes of the interventions and goals obtained through this integrative review is another step that can be taken for future research.

Bakgrund: Specialistsjuksköterskans uppgifter på en barnintensivvårdsavdelning (BIVA) är att vårda barn och det innefattar även att vårda barn i livets slutskede. Av de barn som vårdas på en barnintensivavdelning avlider cirka två procent. Att vårda barn och familjen i en situation där fortsatt vård och överlevnad för barnet är utsiktslöst är en tung och ansvarsfull uppgift. Syfte: Studiens syfte var att belysa specialistsjuksköterskors upplevelser av att ha vårdat ett barn vid livets slutskede på en BIVA. Metod: Som datasamlingsmetod användes semistrukturerade intervjuer med sju specialistutbildade sjuksköterskor. Intervjuerna genomfördes med hjälp av en intervjuguide bestående av en huvudfråga och därefter följdfrågor. Data bearbetades utifrån kvalitativ innehållsanalys med en beskrivande ansats. Resultat: Resultatet presenteras i tre kategorier och tio subkategorier. De tre kategorierna var följande: Att känna sig trygg och erfaren i att vårda ett döende barn, familjen i fokus samt upplevelsen av stöd och strategier i det komplexa vårdandet. Diskussion: Trots att upplevelsen av att vårda barn i livets slut är en tung och känslomässig uppgift ansåg samtliga informanter det som en ansvarsfull och positiv uppgift där de kunde göra föräldrarnas sista stund med sina barn till ett fint och ljust minne. / One of the caring tasks that specialist nurses, working in the (PICU) perform, and have to face in the daily profession is to care for children who are facing the end of life in Sweden. Approximately two percent of all the children being cared for in the PICU dies. To care for children and their families when further treatment is futile is a heavy surrounding life and death. The goal of this study was to investigate the experiences of specialist nurses caring for children at the end of life. Qualitative content analyze were used as a method. Seven semi-structured interviews, with a descriptive approach, were transcribed to condensed meanings. Finally, the meaning was coded into ten subcategories within three main categories. Conclusion of this study indicated that pediatric intensive care nurses indicated their work heavy emotionally. The nurses play a vital role to the family´s final time whit their children. It is in the hands of the nurses to support and make the final time as valuable and beautiful as possible for the family.

Bakgrund: Sjuksköterskor behöver möta närstående till personer som vårdas palliativt. Sjuksköterskan kan skapa meningsfulla relationer med närstående och använda denne som en resurs för patienten. Närståendestöd är en av hörnstenarna inom den palliativa vården. Sociala relationer är en av de 6 S:n som används vid personcentrerad palliativ vård, då närstående kan tillföra fler dimensioner till patientens livsberättelse. Syfte: Syftet med denna litteraturstudie var att beskriva sjuksköterskans erfarenheter av att möta närstående till patienter inom palliativ vård. Metod: Metoden var en litteraturöversikt där tolv vetenskapliga artiklar inkluderades. Artiklarna hämtades från databaserna CINAHL Complete och Pubmed och analyserades med hjälp av Fribergs analysmetod. Resultat: Två teman identifierades: yttre och inre förutsättningar för sjuksköterskan. Yttre förutsättningar för sjuksköterskan delades in subteman såsom tidens betydelse, vårdmiljöns inverkan och när närstående har en annan åsikt. I inre förutsättningar för sjuksköterskan framkom sjuksköterskans förmåga att involvera närstående, sjuksköterskans förmåga att utveckla sin kompetens i mötet med närstående, kommunikationens betydelse och förutsättningar att skapa teamarbete. Diskussion: Med de 6 S:n som teoretisk utgångspunkt har litteraturöversiktens resultat diskuterats utifrån bakgrund och annan relevant litteratur. Närstående behövs i vården kring patienten men det är inte alltid som närståendes vilja är densamma som patientens eller vårdgivarens. För att sjuksköterskan ska kunna använda närstående som en resurs krävs tydlig kommunikation och stöd från sjuksköterskan i arbetet mot ett gemensamt mål för palliativ vård. / Background: Nurses need to face next of kin to people who receive palliative care. The nurse can create meaningful relationships with the next of kin and can use them as a resource for the patient. Support for the next of kin is a cornerstone in palliative care. Social relations are one of the 6 S:s used for person-centered palliative care when next of kin can add more dimensions to the patient's life story. Aim: The purpose of this study was to describe nurses' experiences in meeting next of kin to patients in palliative care. Method: The method was a literature review where twelve scientific articles were included. Articles were taken from the databases CINAHL Complete and Pubmed and analyzed using analysis of Friberg. Results: Two themes were identified: external and internal conditions for the nurse. External conditions for the nurse divided into subthemes such as time significance, the care environment impact and when the next of kin has a different opinion. The internal conditions for the nurse came up as the nurse's ability to involve next of kin, nurses' ability to develop their skills in the meeting with next of kin, the importance of communication and the ability to create teamwork. Discussion: With the 6 S:s as a theoretical basis, this literature review has been discussed from the basis of the background and other relevant literature. Next of kin are needed in the health care around the patient but it is not a guarantee that the next of kin`s wishes is the same as the wishes of the patients or the caregivers. For the nurse to use next of kin as a resource it requires clear communication and support from the nurse in the work towards a common goal of palliative care.

Bakgrund: Döden är något varje individ kommer att möta och i samband med detta uppstår många tankar och känslor. Det är viktigt att vårdpersonalen har kunskap om detta för att kunna ge en god vård. Inom palliativ vård är huvudmålet att främja välbefinnandet hos patienter i livets slutskede. Syfte: Att belysa patienters upplevelserav att leva nära döden i palliativ vård. Metod: En litteraturstudie gjordes där tio kvalitativa studier granskades. Resultat: Granskningen av de vetenskapliga artiklarna resulterade i fyra rubriker, upplevelser av meningsfullhet inför döden, upplevelser av acceptans inför döden, upplevelser av att pendla mellan hopp och förtvivlan inför döden och upplevelser av ensamhet inför döden. Slutsats: Resultatet i studien visade på att många tankar och känslor uppkommer i samband med döden. Patienter väljer att isolera sig mot omvärlden och upplever därför en ensamhet. Genom acceptans kunde patienter finna mening vilket var mycket betydelsefullt för dem. Resultatet av studien kan bidra till en bättre förståelse för vårdpersonal som möter patienter i livets slutskede. / Background: Death is something that every human will face someday and in relation to this many thoughts and feelings will arise. It’s important that the healthcare staff have the knowledge to meet this thoughts and feelings to encourage a good care. In palliative care, the main goal is that the patients have a good quality of life at the end of life. Aim: To illumine patient’s experiences of facing death in palliative care.Method: A literature review was made and ten qualitative studies were used.Results: The research articles led to four categories, experience of meaningfulness near death, experience to acceptance near death, experience to seesaw between hope and despair near death and experience of loneliness near death. Conclusion: The results showed that many thoughts and feelings were developed among the patients in the relation to facing death. Patients chose to insulate themselves from the outside world and expressed that they felt loneliness. By acceptance of facing death the patients were more able to find meaning in life which became a very important thing in their lives. The results can contribute to a better understanding among the healthcare staff.

Bakgrund: Cancer är en vanligt förekommande sjukdom där antalet diagnostiserade ökar. Sjuksköterskan kan i sitt yrke möta dessa patienter, därför är det en fördel att få en djupare insikt om dessa patienters upplevelser. I livets slutskede är upplevelsen av livskvalitet av betydelse. Begrepp som är betydelsefulla för livskvaliteten är hälsa, lidande och hopp. Syfte: Studiens syfte var att belysa faktorer som påverkar livskvaliteten i livets slutskede hos patienter med cancer. Metod: En litteraturbaserad studie som utgår från tolv kvalitativa vetenskapliga artiklar. Resultat: Ur analysen framkom tre kategorier; viljan att fortsätta leva som vanligt, känslomässigt förhållande till andra och kunna hantera tankar och känslor om liv och död med nio underkategorier. Diskussion: För patienter medför det utmaningar i livet att insjukna i cancer. Utmaningar består av att hålla fast vid sina rutiner i det dagliga livet, sina relationer, finna mening och vara hoppfull. Konklusion: Studien belyser betydelsen av att vårdpersonal uppmuntrar och stödjer patienten i att hålla fast vid sociala kontakter eftersom sociala relationer är betydande för patientens livskvalitet. Studien påvisar att patienter kan känna sig obekväma när de tvingas tala om döden vid fel tillfälle, därför bör vårdpersonal vara lyhörda kring patientens mottaglighet att samtala om döden. / Background: Cancer is a common disease in which the number of diagnosed increases. In the nursing profession it’s possible to encounter this group of patient’s and therefore it’s an advantage to get a deeper insight of these patients' experiences. In the end of this patient’s life the experience of the quality of life is significant. Concepts that are important of the quality of life are health, suffering and hope. Aim: The aim of this study was to illuminate the factors that affect the quality of life of terminally ill patients with cancer. Method: A qualitative literature based study based on twelve qualitative research articles. Results: Three categories emerged from the analysis; the desire of continuing living as usual, emotional relationships to others and be able to manage thoughts and feelings about life and death with nine subcategories. Discussion: For patients, it brings challenges to life by developing cancer. Challenges of sticking to their routines of daily life, their relationships, find meaning and to be hopeful. Conclusion: The study highlights importance of encourage and support from the health professionals to help patient keep their social contacts, because it’s significant for the patient’s quality of life. The study demonstrates that patients may feel uncomfortable when forced to talk about death at the wrong time, therefore health professionals should be more keen about the patient’s susceptibility to talk about death.

Bakgrund: Målet med palliativ vård är att lindra patientens lidande, där är kommunikation samt relation en av de fyra hörnstenarna. Sjuksköterskans kommunikation är yrkesrelaterad och av stödjande karaktär, där respekt, tillit och trygghet är viktigt. Syfte: Att beskriva sjuksköterskors erfarenheter av att kommunicera med patienter i livets slutskede samt att beskriva de ingående studiernas undersökningsgrupper. Metod: En beskrivande litteraturstudie som baserades på tretton artiklar med kvalitativ ansats. De söktes fram via databaserna Cinahl och PubMed/MEDLINE samt genom manuell sökning. Resultat: Sjuksköterskans kommunikation är essentiellt i vårdandet av patienter i livets slutskede. Förutsättningar för det goda empatiska samtalet var sjuksköterskans roll som aktiv lyssnare och dennes förmåga till att vara medmänsklig, ärlig samt empatisk. Yrkeserfarenhet ansågs gynna kommunikationen och oerfarenhet försvårade den. Kommunikationen mellan sjuksköterska och patient kunde väcka svårhanterade känslor hos sjuksköterskan, exempelvis frustration. Påverkbara faktorer var tid, prioriteringar och miljöaspekter samt icke-verbal kommunikation. Ytterligare påverkbara faktorer avseende kommunikation var religiösa övertygelser samt kulturella skillnader och normer. Samtliga artiklar beskrev och presenterade deltagarnas arbetsplats. Deltagarna i fyra av tretton studier arbetade med palliativ vård. Alla studier beskrev i vilket land studierna genomfördes och fyra av tretton studier genomfördes i Norden. Fyra studier presenterade inte yrkeserfarenhet eller ålder. Slutsats: Sjuksköterskor har olika erfarenheter av att kommunicera med patienter i livets slutskede och kommunikation är central i omvårdnaden. Kommunikation bör därför utgöra en större del i sjuksköterskeutbildningen, för att nyexaminerade sjuksköterskor ska känna sig väl förberedda inför yrket. / Background: The aim of palliative care is to relieve the suffering of the patient, where communication and relationship constitutes one of the four cornerstones. The nurses' communication is professional and supportive, where respect, trust and a feeling of security are essential. Aim: To describe nurses' experiences of communicating with patients at the end of life and describing the characteristics of the study participants in the reviewed studies. Method: A descriptive literature study, which was based on thirteen articles with a qualitative approach. The articles were found in the databases Cinahl and PubMed/MEDLINE and through manual search. Results: Nurses' way of communication is essential in the care of patients at the end of life. Prerequisites for a good emphatic communication are the nurses' role as an active listener and to have the ability to be compassionate, honest and empathic. Professional experience was considered beneficial to communication, since inexperience often seem to hampered it. The communication between the nurse and the patient could raise emotional reactions which were difficult to handle for the nurse, such as frustration. Factors that influenced communication was time, priorities and environmental aspects as well as the non-verbal communcation, religious beliefs and cultural differences and norms. All articles presented the participants workplace. Participants in four out of thirteen studies worked with palliative care. All studies presented the country in which they were made and four studies where made in Scandinavia. Four articles didn't present work experience nor age. Conclusions: Nurses' have different experiences of communicating with patients at the end of life and the communication is a central part of nursing care. Communication should be a major part of nursing education, because newly graduated nurses should feel well prepared for the nursing profession.