Cerebral vascular accidents (CVAs) rank as the third leading cause of death in Canada with more than 50,000 of these events occurring annually. The evidence base from which to provide end-of- life care to patients dying from a CVA is currently limited, and there is a dearth of research examining the experiences of nurses charged with the responsibility of caring for these patients. In order to begin to address this gap in the literature, a qualitative study, using van Manen’s interpretive phenomenology was conducted to examine and describe the lived experiences of nurses working on an acute neurosciences unit in a tertiary hospital. Nine nurses were interviewed initially, and two nurses participated in follow-up interviews to confirm the interpretation of the data. This manuscript will discuss the essence of nurses’ lived experience in caring for these patients, as well as implications for education, practice, and future research.

Introduction There is a need in palliative care for development of structured methods to assess quality and support improvement. This need is present both within and outside specialised palliative care. Honest information from physicians is regarded as an important part of palliative care. Information about the transition to end-of-life care (ITEOL), conveyed by physicians to patients, has also been described as a ‘breakpoint conversation’. Quality registers enable monitoring and improvement of quality of care, and clinical research. The Swedish Register of Palliative Care (SRPC) is a Swedish national quality register that collects data from hospitals, hospices, nursing homes and home care, with an end-of-life questionnaire (ELQ) about palliative care content focusing on the last week of life. Aims Study I – The aim was to examine the validity of the ELQ from the SRPC. Study II – The aim was to examine whether participation in the SRPC increases the quality of palliative care over a three-year period regarding eight items in the ELQ. Study III – The aim was to examine whether an educational intervention for physicians and nurses in nursing homes and hospitals increases the proportion of patients who receive ITEOL. Study IV – The aim was to describe how patients with cancer perceive the information they receive from physicians during palliative chemotherapy. Methods Study I – Data from 100 medical records and data from the paper versions of the ELQ filled in at a specialised palliative unit were compared with data reported to the SRPC. Study II – Data from eight items in the ELQ reported to the SRPC from all healthcare units that had reported patients continuously during a three-year period were compared year-by-year with logistic regression. Study III – Two municipalities (in charge of nursing homes) and two hospitals were randomised to receive an interactive half-day course about ITEOL for physicians and nurses. Four hospitals and four municipalities were assigned matched controls. The proportion of patients who received ITEOL before and after the intervention was measured with the ELQ. The effect of the intervention was analysed with a multivariable logistic regression model. Study IV – Fifteen semi-structured interviews with patients with incurable cancer were conducted, transcribed verbatim and analysed with qualitative content analysis. Results Study I – The questions in the ELQ showed a congruity of 22% to 100% when comparing data from medical records with data reported to the SRPC. Eight questions fell below 80%. The paper versions filled in at the unit and the data reported to the SRPC showed a congruity of between 91% and 100%. Study II – The prevalence of six symptoms decreased. The prescription of PRN (pro re nata – ‘as needed’) medications for pain, nausea, anxiety and death rattle increased. A higher proportion of patients died in their place of preference. The patient’s next of kin was more often offered a follow-up appointment after the patient’s death. There was no change in the proportion of patients or next of kin who received ITEOL. Study III – The proportion of patients in the intervention group who received ITEOL increased from 35.1% (during a six-month period before the intervention) to 42.0% (during a six-month period after the intervention). The proportion in the control group increased from 30.4% to 33.7%. The effect of the intervention was significant (p=0.005) in the multivariable model. Study IV – Three categories were disclosed during the analytical process: ‘living with a death sentence’, ‘depending on chemotherapy’, and ‘living with uncertainty’. Conclusions A national quality register has the potential of contributing to quality improvement in palliative care. Study I showed varied validity in the ELQ, implying a need to modify the questionnaire. Study II showed that participation in the SRPC was covariant with quality improvements in end-of-life care over time. Study III showed that more patients received ITEOL after an educative half-day intervention directed to physicians and nurses. Study IV showed that patients undergoing palliative chemotherapy perceived that their disease was incurable and deadly, and that conditions for future treatment and survival were uncertain.

Depuis ces trente dernières années, la qualité de vie tend à devenir un critère d’évaluation des thérapeutiques incontournable que cela soit dans un contexte de recherche clinique ou dans un contexte d’individualisation de la prise en charge médicale. L’évaluation de la qualité de vie permet de tenir compte du ressenti du patient quant à sa prise en charge que cela soit sur des aspects purement physiques ou symptomatiques que sur des aspects psychologiques, sociaux ou environnementaux. Dans un contexte de fin de vie où les possibilités thérapeutiques sont limitées et où les symptômes peuvent être extrêmement invalidants, l’évaluation de la qualité de vie s’impose d’évidence.Afin d’appréhender le plus justement possible les particularités de la méthodologie permettant l’évaluation de la qualité de vie des patients en fin de vie atteints d’un cancer, il semblait important, dans un premier temps, de présenter le concept de « qualité de vie relative à la santé », afin de définir les éléments clés quant à sa compréhension et à son utilisation (définition, conceptualisation, instruments de mesures, analyse). La période de la fin de la vie étant une étape particulière de la vie d’un patient, nous avons dans un second temps, cherché à définir le cadre temporel de cette période et définir ainsi, plus précisément, les caractéristiques de la population étudiée. Il est en effet essentiel de tenir compte des spécificités de ces patients pour évaluer, le mieux possible, leur qualité de vie.Les articles relatifs à ce travail de recherche sont présentés dans une seconde partie et discutés ensuite.Ce travail souligne la nécessité de développer des instruments permettant l’évaluation de la qualité de vie des patients en fin de vie atteints d’un cancer dans le respect de leur sensibilité et de la méthodologie essentielle à la validation / In the last thirty years, health related quality of life has become an unavoidable endpoint in a clinical research context and in a therapeutic individualization context. Quality of life evaluation allows us to consider patient health care perceptions; in respect to physical or symptomatic domains or in respect to psychological, social or environmental domains. In a specific end of life context, where treatment opportunities are limited and adverse events could be extremely disabling, the evaluation of the quality of life is obvious. To distinguish more precisely the methodological subtleties of the evaluation of cancer patient end of life quality of life, it seemed important, firstly, to present the concept of health related quality of life, in order to define the main elements concerning both understanding and use of quality of life assessment (definition, conceptualization, tools, measuring instruments, analysis). Because the end of life is a specific time, we sought to define secondly, the time frame of this period, and therefore defined more precisely patient characteristics. It was essential to take into account the specificity of these patients to best evaluate their quality of life.Research related articles are presented in a second part of this work and discussed there afterThis work underlines the necessity to develop measuring instruments to permit quality of life evaluation in a context of end of life with respecting both patient needs and methodological requirements

The purpose of this thesis to increase the understanding of how Extended Producer Responsibility (EPR) affects the economy. EPR is a principle stating that producers should be responsible for the environmental impact of their products throughout the life cycle. In four out of five essays, scrapping of end-of-life vehicles in Sweden is used as an example. In Essay I the interdependency of the consumers’ and the producers’ responsibilities are stressed. It is concluded that the financial solution should be separated from the producer in order to ensure that future liabilities can be met. The main contribution of Essay II is that an increased premium will result in an increased number of returned vehicles. In Essay III it is shown that when the environmental harm is constant and relatively low, a deposit-refund system is preferred to an unfounded system. In cases where high environmental harm occurs the optimal choice would be a system combining both deposits and fines. Essay IV concludes that a funded system would have been a better way to finance the premium than an unfunded system in terms of higher rate of return. In Essay V the analysis is no longer limited to ELVs, and a model with endogenous growth is applied to the case where all the products in the economy are covered by EPR. It is found that both the growth and the level of output is favoured by the choice of a funded scheme. / Syftet med avhandlingen är att studera hur ekonomin påverkas av utökat producentansvar. Utökat producentansvar är ett sätt att internalisera miljökostnader i marknadspriset. Producentansvaret för bilar, så som det implementerats i den svenska lagstiftningen, har lagts till den tidigare lagstiftningen utan några större anpassningar. Effekterna av detta har inte tidigare utretts. Först analyseras dess konsekvenser i en översiktlig artikel. Därefter följer en ekonometrisk artikel vars syfte är att testa effekten av den nuvarande bilskrotningspremien. Det visade sig att en höjd premie ökar antalet återlämnade fordon. Sedan används en rättsekonomisk ansats för att förutsättningslöst, dvs. utan att ta den befintliga lagstiftning som utgångspunkt, analysera nedskräpningsproblematiken. Möjligheten att använda ett pantsystem jämförs med att använda böter för att styra individernas beteende. Det visade sig att om miljöpåverkan är relativt liten så är ett pantsystem att föredra, men om även fall med stor miljöpåverkan inkluderas skulle det optimala vara att använda både böter och pant. Därefter jämförs två alternativa sätt att finansiera premien, ett fonderat system jämförs med ett ”Pay-As–You-Go” system. Resultatet indikerar att ett fonderat system hade varit att föredra under den studerade perioden. Slutligen studeras effekterna av producenternas framtida åtaganden till följd av det utökade producentansvaret med hjälp av modell med endogen tillväxt. Det visade sig att både tillväxttakten och nivån på produktionen skulle ha gynnats av ett fonderat system.

Bakgrund: Sjuksköterskorna har en central roll i samarbetet kring vårdandet i livets slutskede. Det etiska har stor betydelse i detta sammanhang. Maktlöshet, osäkerhet och otydlighet skapade etiska konflikter i vården generellt i samband med kommunikation, relationer och samarbete. Här beskrivs vad vård i livets slutskede innefattar, sjuksköterskans roll, etik i vårdandet och vad etiska svårigheter är. Syfte: Denna översikts syfte var att beskriva sjuksköterskors upplevelser av etiskt svåra situationer inom vård i livets slutskede. Metod: Studien är en allmän litteraturöversikt som syftar till att skapa en översikt över det nuvarande kunskapsläget inom ämnet. Översikten bygger på elva artiklar, som har granskats och analyserats kritiskt. Som teoretisk utgångspunkt valdes Travelbees (1971) "human – to – human relationships" teori. Resultat: Resultatet presenteras i olika teman som handlar om vård i livets slutskede och i vilka situationer de etiska svårigheterna uppstår. Etiska svårigheter uppkom i samarbetet och i samarbetsrelationer. Sjuksköterskorna upplevde maktlöshet, osäkerhet, otydlighet och brister i vården vilket skapade etiska konflikter i den palliativa vården. Dessa upplevelser uppkom i samband med otillräcklig eller ingen kommunikation, samt otrygga relationer mellan alla parter och maktlöshet i alla möten. Diskussion: Diskussionen utgår från Travelbees (1971) mellanmänskliga relationsteori. Öppenhet i kommunikationen och goda samt djupa relationer diskuteras. Vilket har betydelse för ett meningsfullt samarbete för att minska de etiskt svåra situationerna i vårdandet, samt att hjälpa till att bevara patienternas autonomi. Även tillräckliga resurser och kunskaper som är betydelsefulla för förtroendefullt samarbete diskuteras. / Background: The nurses have a central role in cooperation in end of life care. The ethics are of great importance in this context. Powerlessness, insecurity and ambiguity created ethical conflicts in health care generally related to communication, relationships and cooperation. Described here are what life care includes, the nurse's role, ethics in the care and what ethical difficulties are. Aim: The purpose of this overview was to describe nurses' experiences of ethically difficult situations in end of life care. Methods: This study is a general literature review that aims to create an overview of the current state of knowledge in the subject. The review is based on eleven articles, which were reviewed and analyzed critically. As a theoretical basis Travelbees (1971) "human - to - human relationships" theory was selected. Results: The results are presented in different themes which deals with end of life care and in which situations the ethical difficulties arises. Ethical difficulties appeared in cooperation and cooperative relationships. The nurses experienced powerlessness, uncertainty, lack of clarity and lack in the care, which created ethical conflicts in the palliative care. These experiences appeared in connection with inadequate or no communication, and precarious relationships between all parties and powerlessness in all meetings. Discussions: The discussion is based on Travelbees (1971) interpersonal relations theory. Openness in communication and good and deep relationship are discussed. This is significant for meaningful cooperation to reduce the ethically difficult situations in caring, and to help maintain patient autonomy. Also sufficient resources and skills that are important for the trustful cooperation are discussed.

With a growing population on earth the amount of end-of-life vehicles (ELVs) and other scrap steel increases. The European Directive 2000/53/CE” requires a minimum of 95 % reuse and recovery and 85 % re-use and recycling no later than 1 January 2015, for end-of life vehicles. This imposes a need for more efficient recycling and recovery. Despite this shredder residue (SR) is commonly land filled. This report investigated the magnetic fines residue generated at Stena Metall shredder facility in Halmstad, Sweden. Magnetic fines is a complex material containing e.g. ferrous metals, non-ferrous metals, glass, plastic, rubber, polyurethane, sand, dirt, brominated flame retardants and PCB. Characterisation of the material and discussion around area of application resulted in suggestions for possible recycling alternatives. Characterisation included e.g. particle size, total organic content, x-ray fluorescence, x-ray powder diffraction and elemental analysis with a focus on the metals. The results indicated a higher organic content in larger particles and an increasing content of e.g. lead, cadmium and mercury in smaller particles. X-ray fluorescence can be used to measure lead in magnetic fines. The conclusion was that the combustible organic content needs to be separated before further metal recycling can be applied. If magnetic fines should be used in construction pollutants probably either needs to be removed or encapsulated to prevent exposure to humans and environment.

Background: Palliative care is a type of care, which does not cure but eases the suffering caused by the disease. The goal of palliative care is not to extend or shorten the patient's life, but to relieve pain and distressing symptoms and to promote the patients’ quality of life (QOL). QOL can be understood as a subjective sense of happiness of existence, which means that the patient is experiencing life when her total life situation is consistent with her ​​wishes. A central task of the nurse in palliative care is to create conditions for improved QOL for the patient. Aim: The aim of this literature review was to describe patients’ perceptions’ of quality of life in the final stages of life in palliative care. Methods: A literature review based on ten scientific articles was used. The qualitative analysis method was used to compile the results into various theme based on the literature reviews purpose. Results: Five different themes were identified; to preserve social relationships, support from health care, have physical and mental well being, maintain normality and have faith in God. These themes described patients' experiences of QOL in palliative care. Being surrounded by family and friends in the last days of life was revealed as significant conditions in an increased QOL. The nurse's sensitivity and good caring with the patient was described as important experience safety and care as meaningful in the end of life. Discussions: In discussion two themes were discussed: the preservation of social relationships and support from the health care, which were the most prominent of the patients as experiences of QOL. These two themes were tied to the 6 S:n model and discussed.

Background: The death of a spouse is among the most distressing life events faced by older adults and frequently follows long periods of providing extensive care and support. Although many spouses are resilient following loss, a number of bereaved spousal caregivers have poor psychological well-being and may benefit from clinical services. However, it can be difficult to determine who may most benefit from bereavement services and why some individuals are at greater risk for poor bereavement; thus, there is a need for greater understanding of the process of bereavement. Therefore, the purpose of this dissertation was to investigate a number of theoretically relevant factors within the context of bereavement after caregiving as possible predictors of psychological well-being following loss. Specifically, former caregivers' perceptions of loved ones' end-of-life suffering, rumination, and feelings of relief were investigated as possible predictors of caregivers symptoms of depression, grief, and complicated grief following loss. Method: Participants included 61 former spousal caregivers of hospice patients 50 years of age or older who lost a spouse in the last 6-18 months. Individuals completed an interview that included retrospective recall of perceptions of loved ones' physical, emotional, and existential suffering, current frequency of thoughts about loved ones' suffering, stress-reactive rumination, and feelings of relief following the death. Participants also completed measures assessing current symptoms of depression, present feelings of grief, and complicated grief. Descriptive information about care recipients was obtained via retrospective review of hospice electronic medical records following participant interview. Several regression analyses were conducted to investigate the relationship of possible predictor variables to bereavement outcomes and interactions among predictor variables. Results: Findings revealed important relationships between rumination, feelings of relief, and former caregivers' psychological well-being follow loss. Higher rumination and less feelings of relief were associated with worse bereavement outcomes. In addition, interaction analyses revealed that rumination and feelings of relief moderated the relationship between participants' perceptions of their spouses' emotional end-of-life suffering and psychological distress. Other descriptive predictors of depression, grief, and complicated grief were identified. Discussion: Participants were highly distressed former caregivers who were highly engaged in caregiving duties prior to loss. About 40% reported no feelings of relief following the loss, and over one-fourth of participants still had frequent ruminations about their loved ones' suffering. High stress-reactive rumination was an important predictor of bereaved spouses' psychological distress. Clinical interventions, such as cognitive behavioral therapy, could focus on identifying, redirecting, and reducing distressing thoughts or the negative feelings associated with them, such as ruminations associated with loved ones' end-of-life suffering. Future longitudinal research should examine the relationships between rumination, feelings of relief, perceived suffering, and bereavement outcomes in order to identify patterns that may inform clinical interventions.

Delirium is a disturbance of consciousness and cognition that affects many terminally ill patients before death. It can manifest as confusion, hallucinations, and restlessness, all of which are known to be distressing to patients, families, and professional caregivers. Underlying the contemporary palliative care movement is a belief in the idea that a good death is possible; that dying can be made better for patients and families through the proper palliation of distressing symptoms and through proper attention to psychological, social, and spiritual issues that affect wellbeing at the end of life. Given that delirium is potentially disruptive to all that the good death assumes, i.e., mental awareness, patient-family communication, peace and comfort, the question was asked: What is the relationship between end-of-life delirium and the good death in hospice care? Ethnographic fieldwork was conducted at a freestanding residential hospice over a period of 15 months in a suburban community in eastern Canada. The research methods included participant observation (320 hours over 80 field visits), interviews with 28 hospice caregivers, and document analysis. The findings of this study provide an in-depth examination of the nature of caregiving relationships with patients and with families in end-of-life care. They illustrate how a commitment toward providing for the good death prevails within the cultural community of hospice, and how the conceptualization, assessment, and management of end-of-life delirium are organized within such a commitment. In this setting, experiences of conscious and cognitive change in dying are woven by hospice caregivers into a coherent system of meaning that is accommodated into prevailing scripts of what it means to die well. At the same time, delirium itself provides a facilitative context whereby processes of supporting families through the patient’s death are enabled. This study highlights the relevance of considering the contextual and cultural features of individual end-of-life care settings that wish to examine, and perhaps improve, the ways in which care of delirious patients and their families is provided.

Withdrawal of life support therapy involves controlled removal of life support modalities including artificial respiration and circulation with intent to provide a comfortable death. Withdrawal of life support therapy is necessary prior to procedures such as organ donation after cardio-circulatory death, but remains poorly explored in current literature. To enhance the current evidence, we conducted a thorough structured review, an observational study, and a qualitative comparison of components comprising withdrawal of life support therapy in both donor and non-donor patient groups. At all stages, we considered how results impacted donation after cardio-circulatory death. Withdrawal of life support therapy processes vary between countries, hospitals, practitioners, and patients. Variability in practice impacts care and outcomes for both donor and non-donor patients. Improved definitions and consensus about the process of withdrawal of life support therapy may improve patient care, success of organ donation after cardio-circulatory death, and uptake of donation protocols.