Background: Multiple factors influence end of life care and can lead to barriers in the experience of care for patients and the delivery of care for physicians. It is vital to determine the possible challenges physicians may face in providing end of life care in order to understand and decrease these challenges. Objective: The purpose of this study was to identify and understand the different challenges physicians face in the provision of quality end of life care. Methods: First, a scoping review was conducted on five databases to gather knowledge on the current literature on physician-perceived challenges in end of life care. Subsequently, a secondary data analysis was performed from the results of a pan-Canadian study with 1 060 respondents on medical end of life practices to: (1) measure the frequency of physician-perceived challenges based on the last patient who died under their care in the last 12 months, and (2) assess the relationship between the challenges and the physician’s or patient’s sociodemographic characteristics. Results: The results of the scoping review on 40 studies identified ten challenges: physician’s characteristics, family issues, team conflicts, team and family conflicts, institutional and organizational factors, training and educational factors, religious challenges, ethnicity and value-related challenges, human rights issues, and language challenges. Results from the secondary data analysis revealed that 26.9% of physicians reported at least one challenge, such as family conflicts, in the provision of end of life care with the last patient who died under their care in the last 12 months. Conclusion: These challenges restrict quality end of life care. As such, targeted strategies should be implemented to mitigate these barriers to end of life care and improve care.

Through a post-colonial narrative turn, scholars created space for alternative illness narratives to be performed; narratives that reflected the fragmented and unpredictable ways of ailing bodies, and allowed for multiple and diverse identities to be constructed. However, even with this post-colonial turn, illness narratives in U.S. culture often depict situations in which individuals overcome their illnesses, and death is somehow avoided (Langellier & Peterson, 2004), which present potential constraints for what narratives individuals at the end-of-life (EOL) are able to tell and what identities they are able to construct. Using post-colonial narrative theory (Frank, 1995) as a framework, I engaged in a thematic narrative analysis of 16 hospice patient narratives, to understand whether narratives and identity constructions are constrained for dying individuals as they attempt to make sense of the end-of-life. Patients constructed the five identities of the experienced individual, the believer, the ailing individual, the good dier, and the individual who is still living, through several themes. Ideals of both post-colonialism and modernism were present in identity constructions, suggesting some acceptance of alternative narratives for individuals at the EOL. However, notably a new type of colonization emerged as patients' identity constructions and themes reflected elements of ars moriendi or the good death (Faust, 2008). Specifically, it appears that end-of-life narratives must reflect that the individual nearing the end-of-life is doing so in a culturally acceptable way which involves acceptance, sacrificial or selfless qualities, dying gladly, and dying not alone. This nuanced type of colonization suggests that specific illness situations might present unique narrative colonization. I end by offering practical implications for health care providers and family. Specifically, these findings might inform traditional practitioners and encourage them to broaden the clinical definition of the good death, with an understanding that elements such as esteem and emotional support or empowerment might be paramount for some patients' good deaths. Additionally, these findings offer awareness to family members regarding cultural expectations of the good death, so that they might consider whether they are adding pressure to their loved ones to achieve such a death.

With aging of the baby boomer population, older adults living longer, and no known cure for dementia, the prevalence of dementia in older adults will inevitably rise. Dementia is a terminal illness, although it may not be recognized as such. Family caregivers to persons with dementia provide invaluable care, often at the expense of their own health and well-being. Over the past two decades there has been an abundance of research that examines the various and complex aspects of caring for a relative with dementia. However, there is a paucity of research that has been conducted on the experiences of family caregivers providing end-of-life care. The conceptual framework that guides this research is based on the work of Martin Heidegger. A thorough search of the literature reveals that the main themes of this end-of-life experience studied to date are the experience of grief and loss, and the manifestations of depression in family caregivers. A number of gaps in the literature remain that limit our understanding of the end-of-life care experience. The purpose of the present study is to begin to address this neglected area of research. As a result, the research question is: What is the meaning of the lived experience of family caregivers who provided end-of-life care for a relative who died with advanced dementia? This question was addressed using an interpretive phenomenology based on the work of Munhall. The study utilized a purposeful sample of family caregivers (n = 11) whose relative with dementia died in the last year. Two to three in-person, unstructured interviews were completed with each participant as a way to glean an understanding of their experiences and offer opportunities for the participant to verify their end-of-life caregiving story. A total of 27 interviews were recorded and transcribed verbatim. Transcripts were hermeneutically analyzed in order to create individual narratives for each participant, reveal the essence of this experience, discuss the influence of the life worlds, consider the taken for granted, and generate an overall study narrative. These findings reveal the complex nature of the end-of-life caregiving experience with dementia.

Increasing consumption and transportation gears the use of transport utilities which cause environmental effects over the globe. Environmental performance of three different types of pallets such as Re-load, plastic and corrugated fibreboard pallets are evaluated in this project. LCA tool is used to assess and compare their environmental performance in all phase of their life cycle but more focusing on end of life phase.   This study gives more emphasis to waste treatment options such as incineration, landfilling and recycling. Three different end of life scenarios have been used in this study such as 100% incineration, 100% landfilling and 100% recycling.   This study includes results of all the phases of all three types of pallets which are analysed in this report. More detailed results could be seen in excel sheets. Results of impact analysis tells that landfilling contributes to 14793 Kg CO2 of global warming potential in case of corrugated pallets. Incineration contributes to 12148.6 Kg CO2 of global warming potential. Recycling contributes to 7136 Kg CO2 of global warming. Re-load pallets show the major contribution of global warming is from landfilling approx 813.2 Kg CO2 of global warming potential. Recycling and incineration contribute to 438 Kg CO2 and 726.7 Kg CO2 of global warming potential respectively. In plastic case incineration contributes the most to global warming approximate 1183.8 Kg CO2 of global warming potential. Landfilling and recycling contribute almost the same approximate 932.6 Kg CO2 of global warming potential and 924.5 Kg CO2 of global warming potential respectively. Acidification impact show corrugated pallets cause high emissions when they are treat with landfilling and give negative values of incineration. In Eutriphication impact corrugated pallets are considered better in a sence they are inbetween 150 and 100 kg of PO-4. Re-load pallets give the least values when they are applied to different end of life scenarios.   According to the results recycling could be replace other waste treatment options because of less impact through out the end of life. Secondly, Reload pallets represent a environmental friendly product which can be improved more after this study. Lack of LCI data is the major problem in this study because it is not easily accessible and it is very time consuming part of this study. Results might be different if more data is available.   This study can be helpful for further study, for instance more replaceable scenarios will show different results for all three types of pallets. Moreover, it helps to compare more pallet types which are already in the market or propose to come in the market.

The purpose of this study was to develop an inductive theory describing the process that hospice nurses use to identify and respond to their patients' suffering. Additionally, the study sought to describe the coping strategies that hospice nurses used when working with patients they considered to be suffering. By examining nurses' responses to suffering, this study is the first step in developing effective interventions to alleviate patient suffering and mitigate its consequences on the nurses caring for those patients. Additionally, by knowing the different strategies that nurses use to cope when working with suffering patients, nurse administrators could institute educational programs, build supportive environments, and develop policies to support nurses as they deal with these difficult clinical situations. This is especially important in a hospice environment where the registered nurse is the focal point for ensuring ongoing patient assessment and implementation of the interdisciplinary plan of care by the various team members. Charmaz (2006) description of grounded theory methodology guided the study design and analysis. Participants identified and responded to their patients' suffering within the context of the nurse-patient relationship. Phases of the relationship included: preparation, establishment, cultivation, maintenance, and letting go. The participants gained insight into the psychosocial and existential aspects of the patient's psyches by cultivating the nurse-patient relationship. Within this relational context, the participants used a four-phase process: observation, issue assessment, suffering, and intervention to respond to their patient's suffering. In addition to pain and other signs of physical suffering, the participants identified other aspects of suffering: role losses, the patient's fear of the impending death, the patient's aloneness, and the patient's feelings of guilt or regret. Interestingly, suffering also was considered a family affair and could involve the loss of self-identity. While the participants recognized the importance of self-care, often they had difficulty naming strategies used to respond and cope with their patients' suffering. Clinical supervision and emotional support through mentoring and practical guidance need to be further developed to help nurses cope with the complexity of feelings that arise when caring for dying people. / text

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With new medical advances in technology, there has been a push from the legal, medical and political communities to re-examine the policies of end-of-life-care. End-of-life-care (EOLC) is a term that refers to not only a patient’s final hours of life, but also the medical care of individuals with terminal illnesses or conditions that have become advanced and incurable. For the purpose of this paper, I will be referring to physician-assisted death and active euthanasia as forms of end-of-care. The Politics of End-of –Life-Care: Active Euthanasia and Physician-assisted Death examines the political disjuncture between the evidence presented in favour of active euthanasia (AE), physician-assisted death (PAD) and the current practice of refusing to grant AE and PAD legal status in Canada. It will examine the political dynamics underlying the disjuncture using political pressure groups, constructivism, rational choice, institutionalism and structuralism. There is empirical evidence that demonstrates support for the legalization of AE and PAD. Sixty-seven percent of Canadians support AE /PAD and 80 percent support allowing physicians to assist in AE and PAD (Angus Reid 2012) however, Parliament has not legalized AE/PAD and the CMA has not sanctioned AE /PAD. The two sides of the debate have clearly communicated their arguments. The arguments on each side are strong and have merit. Conversely, the arguments against AE and PAD appear to hold more weight with institutions than with the public. This thesis examines a number of different reasons for why AE/PAD remains illegal in Canada despite society’s widespread support for AE/PAD. The results of the research found no one method explains the disjuncture between the evidence presented in favour of active euthanasia and the current practice of refusing to grant it legal status. However, discursive institutionalism does help elites to generate and communicate the discourse of AE and PAD. It also explains how discourse can also occur from the bottom which results in a new discourse. For example, physicians, politicians, and the public who have deviated from the accepted discourse on AE and PAD can help to create a new discourse regarding AE and PAD policies.

The technological complexity of the ICU is often focused on saving lives however, it is frequently a place to support the dying. Because of the serious nature of critical illness, patients are unable to communicate their wishes, values and views. Family members are often called upon to communicate the critically ill patients’ wishes and many report feeling burdened with the task. The distress described may lead to difficulty mobilizing coping mechanisms and may affect their ability to make appropriate decisions for their family member’s care. Hence, an in depth understanding of the surrogate’s experience is critical to plan effective interventions and provide anticipatory guidance to support the process of making decisions around end of life care. Objective The purpose of the study is to describe the surrogate decision makers’ appraisals of the demands of decision making for a critically ill adult intensive care unit patient and the coping strategies employed by them during this experience. Method A descriptive study design using a qualitative interviewing approach extracted perceived stressors and coping strategies using systematic, focused thematic analysis guided by Folkman and Lazarus’ Stress and Coping Paradigm. Findings Respondents appraisals identified the following perceived stressors: doubt of self efficacy, unknowns, impingement of real life, and problematic relay of information. The surrogates’ perception of their ability to manage the decision making process required their awareness of the decision making role and magnitude of illness, their need to form partnerships, time to reflect on prior discussions and experience, and their appraisal of the patients’ suffering. Participants described emotion and problem based coping strategies they employed during the task. To emotionally justify their decisions, surrogates’ referred to their understanding of patient wishes and sought solace and comfort from the health care staff. In addition, surrogates used strategies to solve problems encountered including dealing with others, employing strategies to decrease their uncertainty and mobilizing time to process the events unfolding. Conclusions End of life decisions in the intensive care are complex and demanding. A better understanding of the process may guide health care professionals in developing focused interventions to assist surrogates through a painful process. / Thesis (Master, Nursing) -- Queen's University, 2008-04-25 09:29:27.1

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The purpose of this study was, first, to further our understanding of the experience of dying in a long-term care (LTC) facility from the perspective of family members and second, to identify the relationships between the various factors which may influence satisfaction with end-of-life care. Using a sequential mixed methods design, a convenience sample of 87 family members completed a survey interview using a modified version of the Toolkit of Instruments to Measure End-of-life Care (TIME) Nursing Home Version in the first phase of the study. Findings from the parametric and non-parametric analyses indicated that family satisfaction with end-of-life care was best predicted by contact and communication with nursing staff, feeling that care provided at the end of life met expectations, staff providing consistent care, feeling that the health care aide listened to their concerns about care and that respondents felt they had received enough emotional support. Being transferred to hospital in the last month of life, dying in a place other than the LTC facility, and respondent age and employment status were all associated with significant mean differences in satisfaction scores. In the second phase, three focus groups were conducted to further explore areas of satisfaction and dissatisfaction with end-of-life care. Focus groups provided confirmation of the findings of the first phase of the study and were instrumental in developing a list of ten recommendations for improvements in end-of-life care delivery. Recommendations for future research are made based on the study results.