A presente pesquisa teve como principal objetivo propor uma estrutura inicial para a implantação da logística reversa no setor automobilístico brasileiro. Para tanto, foi utilizado o método de pesquisa misto, compreendendo tanto a pesquisa qualitativa como a quantitativa. Para a parte qualitativa foram aplicados questionários a empresas do setor automobilístico, uma representando as montadoras, outra representando as seguradoras, desmanches e uma empresa que opera com sucata, no intuito de captar a percepção das mesmas quanto ao tema. Para a parte quantitativa, o ferramental utilizado foi o método de programação linear, sendo a aplicação do modelo realizada para o estado de São Paulo, devido à sua representatividade no setor automobilístico brasileiro e às ações já encaminhadas, neste estado, no sentido de implantação de uma logística reversa de automóveis de forma padronizada. Foram especificados seis cenários, para melhor análise do modelo, considerando, diferentes disponibilidades na oferta de automóveis, na capacidade instalada de sucateiros e no número de sucateiros. Na parte qualitativa, os resultados apontaram para a divergência quanto à opinião dos agentes, sugerindo que não há um consenso formado quanto à implantação da logística reversa no setor automobilístico brasileiro. Na parte quantitativa, os resultados da aplicação do modelo matemático apontam para a viabilidade de implantação deste processo e para a necessidade de ampliação da capacidade de instalada para reciclagem de metais. / This research aimed at proposing an initial framework for the implementation of reverse logistics in the Brazilian automotive industry. For this, it was used the mixed research method, comprising both qualitative and quantitative research. For the qualitative part, questionnaires were applied to companies in the automotive sector, representing the automakers, another representing insurers, miscarriages and also a company that operates scrap in order to capture the perception of them for the subject. In the quantitative part, the tool used was the linear programming method, being the application made to State of São Paulo, due to its share in the Brazilian automotive industry and the actions already under way in this state, to implement reverse logistics vehicles in a standardized way. Six scenarios were specified, for better analysis of the model, considering different availabilities in car supply, the installed capacity of scrap and the number of scrap dealers. In the qualitative part, the results pointed to the divergence for the views of the agents, suggesting that there is no consensus formed about the implementation of reverse logistics in the Brazilian automotive industry. In the quantitative part, the results of the application of the mathematical model point out to the implementation of this process feasibility and the need for the increase in the installed capacity for metal recycling.

With a large amount of tyres being discarded every year, the question of how to manage the end-of-life tyres (ELTs) has become a serious issue. Thus this study identifies different driving forces for this management and the most possible scenarios for the future management of ELTs. The study also compares the business as usual model with a waste hierarchy model to explore the possibilities for optimizing management of ELTs through cascading. This study collects opinions about the driving forces of ELT management from 29 experts working in the area. Important driving forces identified were: price of substitute products, recycled materials’ market, environmental legislation, and technology. This study also surveys 23 experts in the tyre area about the most possible scenarios for ELTs in 2020. One of the more believed in futures was: “Due to increasingly limited fossil fuels and a rise of sustainability awareness, applications for ELTs are growing both in material and energy recycling.” This suggests that a shift toward an equal recycling situation of ELTs among material and energy might be likely to happen by 2020. Based on the most possible scenario for ELTs in 2020, a comparison between waste hierarchy model and business as usual model has been performed. The result shows that the (cascading) waste hierarchy model would likely create more environmental benefits than business as usual model. This is done though the saving and cycling of more materials from energy recovery into material recycling.

Background: The need for palliative care and end-of-life care increases as the world population grows older and as people, more extensively, suffer from chronic diseases. End-of-life care is described as a part of palliative care and people in need of end-of-life care can be met anywhere in the health care system, therefore, education about end-of-life care is necessary for nursing students. Assisted suicide, or, euthanasia is legal in Belgium and can also be a part of end-of-life care, which makes it a convenient subject to include in nursing education in Belgium.Aim: The aim was to delve into the experiences of nursing students in Belgium regarding their education in end-of-life care.Method: The school project had a qualitative-descriptive design, with an inductive approach, and was analyzed through a qualitative content analysis.Result: The results describe how Belgian nursing students experience end-of-life care, their perception of euthanasia and their satisfaction with their end-of-life care education.Conclusion: Belgian nursing students are in general pleased with their education in end-of-life care. However, there is still room for development regarding education in end-of-life care and euthanasia.

Discussions of autonomy at the end of life in health care contexts is no new phenomenon. However, what seems to have changed in issues of autonomy is cases where patients want to refuse a treatment to cases where patients are demanding more treatment when medical professionals may not agree or be able to provide them with the medical treatment. Some key competing interests impacting patient autonomy include beneficence-doing what is in the best interests of the health or well-being of the patient- and resource limitations. Here, I will explore distributive justice theories that impact the end of life and how they constrain autonomy.

Les pertes liées à la capacité fonctionnelle, au réseau social et à l'approche de la mort, sont autant de menaces pour le bien-être en général mais représentent aussi des opportunités de transformation et de croissance par l'intégration des parties de sa vie en un tout cohérent et l'acceptation que la mort représente la fin naturelle de la vie. Ainsi la recherche d'un sens à sa vie est importante à n'importe quel âge et plus encore dans le grand âge. La présente étude s'est intéressée au rôle que joue le sens de la vie dans les stratégies d'adaptation et les attitudes face à une mort prochaine. Elle se divise en quatre chapitres. Le premier chapitre présente la problématique sous-jacente à la recherche, la question de recherche, la recension des écrits sur les principaux thèmes, les objectifs ainsi que le cadre théorique. Le deuxième chapitre traite de la méthodologie utilisée, des stratégies d'observation et d'analyse, des obstacles méthodologiques et des considérations éthiques. Le troisième chapitre présente les caractéristiques des participants, le processus d'analyse, les résultats et leur interprétation. Le quatrième chapitre présente la synthèse des résultats, une comparaison avec les autres études, le modèle exploratoire du lien entre sens de la vie, stratégies d'adaptation et attitudes face à la mort, la portée et les limites de la recherche ainsi que les pistes de recherches. La conclusion comprend des recommandations pour l'intervention tant au niveau du personnel soignant que pour les personnes âgées et leur entourage.

Background: The End of Life Care Strategy stated that there should be a reduction of expected deaths in the acute setting. In order to achieve this goal, when it has been identified that where the patient's preferred place of care is home, clinicians need to be able to recognise when a patient is dying in order to achieve their preferred place of death. The aims of this study were to identify any factors that help or hinder a clinician when they are determining when irreversible dying begins and to seek consensus on which of these topics would be useful to include in an education programme. Method: A 3 stage mixed methods study was developed. Phase 1was a Systematic Review of current primary research in order to provide an evidence base for the study. Phase 2 involved unstructured interviews with clinicians in the acute setting utilising the Grounded Theory approach to the analysis identify potential factors. Phase 3 was a Delphi study used to identify which of these factors would be useful in an education programme. Conclusions: The Systematic Review identified four themes "Patient Observation", "Knowledge of the Patient", "Communication" and "Attitudes of the Clinician". These were confirmed by the interviews and a further theme "Experience" identified. The over-arching theme emerging from the findings of the interviews was that clinicians have a fear of getting the timing of the recognition of irreversible dying wrong because the decision making process is so complex and this is exacerbated by fear of missing the treatable. Many factors identified in the interviews were acknowledged as factors that could be included in an education package. It was also identified that there is the need for a culture shift in society regarding death and dying and a change in the philosophy of care for health care professionals.

Background: To be the close relative of a terminally ill person, who is receiving special palliative care, is a life changing experience. According to the guide lines for palliative care both the patients and their family members have the right to support, and to be part of the caring process. For nurses to be able to meet the needs of relatives, understanding their experience of special palliative care is crucial. Aim: To highlight the family´s experience of palliative care from specialist palliative operations. Method: A method based on the analysis of qualitative research was used, in order to contribute to evidence-based care. Ten scientific articles were analysed. Results: Emotions of guilt and relief were common amongst family members. The family members experienced that the nurses where a safe harbor when the family members received the support they needed. Sometimes the family members felt as if their homes and their private sphere became a workplace. Conclusion: Honest, straight, and clear communication was of great importance. For family members to be able to ask nurses for help and to feel supported in different situations was also important. The physical symptoms of death approaching became symbols of grief and sorrow.

Background: Nurses continuously meets and cares for dying patients, which can be perceived as both rewarding and stressful. To manage death and dying patients adequately, nurses need to reflect on what death means and her/his own perception of death and dying. Research showed that many nurses felt that they had a lack of knowledge and practical skills regarding end of life care. Objective: The purpose of this study was to illuminate nurses’ experiences of caring for patients in end-of-life care. Method: A literature-based study was used, based on analysis of qualitative data. Thirteen articles were analysed according to Friberg´s five-step model. The analysis resulted in four themes and eight subthemes. Results: Four main themes emerged from the analysis: 1) Deficient environment and organization 2) Deficient knowledge and practical skills 3) Support is an important factor 4) Response to end-of-life care. Conslusion: Education and training in end-of-life care was important. This should be implemented more, both in nursing education and in clinical practice. Support from management and colleagues was highly valued by nurses and should occur to a greater extent, as a way of preventing negative effects, such as burnout, and as a way of improving the care of dying patients and their relatives.

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.

Thesis advisor: Kathleen McInnis-Dittrich / Cancer caregivers are key stakeholders across the cancer trajectory, particularly in the final weeks of life and the bereavement period that follows. Current measures are limited in capturing caregiver assessment of the quality of end-of-life (EOL) care. Because none include caregiver perception of patient suffering or prolongation of death, the author sought to develop and validate a new measure of caregiver-perceived quality of EOL care that includes these dimensions. Data for this study comes from Coping with Cancer (CwC), a multisite, prospective, longitudinal study of advanced cancer patients and their caregivers (N=275 dyads). CwC investigators interviewed cancer patients and caregivers prior to the patient's death, and then caregivers again following the patient's death, on a range of psychosocial issues related to EOL care and bereavement. The present study represents a refinement of the author's previous work in developing and validating the Caregiver Evaluation of Quality of End-of-Life Care (CEQUEL) scale, a comprehensive measure of caregiver-perceived quality of EOL care. Factor analysis revealed four distinct factors: Prolongation of Death, Perceived Suffering, Shared Decision-Making, and Preparation for the Death. Each item loaded strongly on only a single factor. The author examined the new measure's factor structure, and evaluated its reliability (using Cronbach's α) and convergent validity (via associations between CEQUEL and key EOL outcomes). CEQUEL and its subscales showed moderate to acceptable Cronbach's α (range: 0.52-0.78). Higher scores (indicating better perceived quality of care) were positively associated with therapeutic alliance (ρ=.13; p≤.05) and hospice enrollment (z=-2.09; ≤;.05), and negatively associated with bereaved caregiver regret (ρ=-.36, p≤.001) and a diagnosis of Posttraumatic Stress Disorder (z=-2.06; p≤.05). Scores did not vary by caregiver characteristics other than religious affiliation, with Catholics scoring lower than non-Catholics, and those without religious affiliation scoring lower than those with an affiliation. Models predicting CEQUEL scores were compared using multiple regression analysis and AICc values. In unadjusted analyses, dying in a hospital, inpatient hospice length of stay (LOS) < 1 week, patients feeling seen as a whole person by their physician, and caregiver religiosity predicted CEQUEL scores. Only dying in a hospital (B=-1.65, SE=0.42, p=0.000) and inpatient hospice LOS < 1 week (B=-1.87, SE=-.69, p=0.008) remained significant in adjusted analysis. These findings suggest that CEQUEL is a brief, valid measure of quality of EOL care from the caregiver's perspective. This study also identifies key factors that can be modified to improve caregiver evaluation of quality of care and associated bereavement outcomes. CEQUEL is the first scale of its kind to include perceived suffering and prolongation of death. If validated in future work, it may prove a useful quality indicator for the delivery of EOL care and a risk indicator for poor bereavement adjustment. Implications for research, clinical practice and policy are discussed. / Thesis (PhD) — Boston College, 2013. / Submitted to: Boston College. Graduate School of Social Work. / Discipline: Social Work.