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.

In the last fifty years, hospice palliative care has changed the modern understanding of dying. Rather than focusing on death, it promotes the facilitation of optimizing life for patients whose conditions have worsened beyong the possibility of recovery or cure. As such, this thesis is a response to the demands of architecture to support this unique stage of life. It analyzes and posits guidelines for designing spaces which must cater to the specific and vastly different needs of the palliative care specialists, family members, and the patients themselves. Also, it seeks to examine the nuanced complexities and poetics involved in a proposed architectural design for a hospice in downtown Toronto. The typology for a hospice is one that is both complex and evolving. It must combine the domestic scale of a home with the efficiency and standardization of an institution. The contemporary hospice must also accommodate rituals and beliefs surrounding the end of life that vary greatly from the many cultures that make up the contemporary city. At the very least, the building must provide inspiration and a hope for a peaceful and dignified transition, recognizing also that this is no longer a traditional place for cure. The distinctions suggest a reconsideration of what is needed and what is expected for those involved in and affected by the dying process. This thesis will explore the architectural possibilities inherent in a new social understanding of the end of life that defies the fatalistic view of an inevitable death, in favour of a hope for dying with dignity while embracing an opportunity to experience liminality during our final days.

A total of 1,018 charts of people who died from August 1, 2008 through July 31, 2009 were reviewed to describe and examine current end-of-life care needs and care practices provided in two acute care hospitals. The mean age of those who died was 72.5, the majority of decedents were elderly (73.8%), a slight majority were male (53.0%), a slight majority were not married (53.0%), and most were urbanites (79.5%). The most common primary diagnosis was cancer (36.2%). More than half of deaths were expected (54.6%). Only 40.3% of those who had an expected death had a palliative care referral. Of all decedents, 13.8% had CPR performed, and a total of 13.9% of people died without having a DNR order. A written will was provided in 30.8% of cases. Most had technologies in use at the time of death (97.3%). Of those who died with pain, most received analgesia (98.6%).

Palliativ vård innebär att sjukdomen inte kan botas och beskrivs ibland som vård i livets slutskede. Syftet med studien var att beskriva sjuksköterskors upplevelse av arbete med vuxna patienter som är i behov av palliativ vård, att beskriva hur sjuksköterskor kan hantera svåra situationer som kan uppstå i arbetet med vuxna patienter i den palliativa vårdens senare fas samt att granska de utvalda artiklarnas urvalsmetod och undersökningsgrupp. Metoden är en litteraturstudie med en deskriptiv design. Resultatet visade att sjuksköterskorna upplevde en djupare relation med patienten än den vanliga sjuksköterska-patient relationen. Det upplevdes viktigt med bra kommunikation med patienten, vilket sjuksköterskorna strävade efter. Känslor som sjuksköterskan kunde känna var maktlöshet, frustration, stolthet och tillfredställelse. Det största upplevda ansvaret var att patienten ska få dö med värdighet på ett fridfullt sätt. Sjuksköterskorna upplevde att det var en viktig strategi att kunna stänga av från arbetet. Mötet med patienter får sjuksköterskan att fundera över existentiella frågor. Slutsatserna är dels att den valda omvårdnadsteorin stämmer väl in i sjuksköterskornas upplevelser av den palliativa vården och den andra slutsatsen är att sjuksköterskorna praktiserar vården både utifrån definitionen på vad palliativ vård är samt utifrån de fyra hörnstenarna. / Palliative care means that the patient suffer from an incurable disease and is sometimes described as end-of-life care. The aim of the study was to describe the nurses experience in working with adult patients in need of palliative care, describe how nurses handle difficult situations that can arise while working with adult patients in the later stage of palliative care, as well as review selection method and the sample of the chosen articles. The method is a literature review with a descriptive design. The result showed that the nurses experienced a deeper relation with the patient than that of the normal nurse-patient relation. It is important with a good communication with the patient, something that the nurses strived towards. The feelings nurses expressed where a sense of powerlessness, frustration, pride and a sense of fulfilment. The largest experienced responsibility was that the patient should be allowed to die with dignity in a peaceful manner. The nurses’ ability to leave the work at the workplace was an important strategy for the nurses when it comes to their wellbeing. Meeting with the patients made the nurses contemplate over existential questions. The conclusions are that the chosen nursing theory matches the nurses’ experiences of palliative care and that the nurses practice their care based on the definition of palliative care and the four cornerstones of palliative care.

Bakgrund: Tidigare forskning har visat att parenteral nutrition ges till patienter som befinner sig i livets slutskede även om den medicinska nyttan är oklar. Syfte: Att genom en vetenskaplig litteraturöversikt beskriva sjuksköterskors erfarenheter av vad som är betydelsefullt i arbetet med parenteral nutrition för patienter i livets slutskede. Metod: Examensarbetet är utformat som en litteraturöversikt. Tretton artiklar med kvalitativ och kvantitativ design valdes ut. Artiklarna söktes på databaserna CINAHL och Pubmed Resultat: Delaktighet i vårdteam var av stor betydelse, ett fungerade samarbete där sjuksköterskan ville och fick möjlighet att arbeta som omvårdnadsansvarig upplevdes av sjuksköterskan resultera i god personcentrerad vård. Erfarenhet och egna känslor spelar en betydande roll i hur mycket sjuksköterskan vågar och vill vara delaktig i beslut angående PN i livets slutskede, och vilken relation som skapas med patientens närstående. Slutsats: Ökad kunskap om parenteral nutrition i livets slutskede och personcentrerad vård behövs för att sjuksköterskorna ska våga vara aktivt delaktig och stärka patienten i livets slutskede. / Background: Previous research shows that parenteral nutrition is administered to patients who are at the end of life, even though the medical benefit is unclear. Aim: Through a scientific literature review describe nurses' experiences of what is important in the work of parenteral nutrition for patients in the end of life. Method: A literature review, based on 13 articles with both qualitative and quantitative design. The articles were searched on databases CINAHL and PubMed Result: Participation in care team was of great importance, a working partnership where the nurse wanted and had the opportunity to work as a care manager experienced by nurse’s result in good person-centered care. Experience and own emotions play a significant role in how much the nurse dare and want to be involved in decisions regarding PN at the end of life , and the relationship that is created with the patient's relatives. Conclusion: Increased knowledge of parenteral nutrition in palliative care and person-centered care needed for nurses to dare to be actively involved and to strengthen the patient in the final stages of life.

Background: In the background section the following terms are described: Palliative care and holistic view, care at the end-of-life, ethical problems in the end-of-life care and ethical problem and ethical dilemma. Aim: The purpose of this literature review was to describe nurses’ experiences of ethical problems in the end-of-life care of patients. Method: A literature review was selected as a method in this study based on eightscientific articles. Articles were reviewed and analyzed critically by the author. Travelbees’ theory (1971) “human- to- human relationships” was selected as a theoretical basis. Results: The result presents six themes as follows: Decision-making, ineffective treatments and therapies, insufficient communication, the lack of cooperation, inadequate respect for patient’s autonomy and uncertainty in caring role. These themes present how nurses deal with end-of-life care and in which situations ethical problems arise. Discussions: The result was discussed in relation to Travelbees’ theory (1971) “human-to-human relationships”. Nurses’ different experiences according to their different responsibilities such as insufficient communication and cooperation, decision-making processes, uncertainty in caring role and inadequate respect for patients’ autonomy were discussed. / Bakgrund: I bakgrunden beskrivs följande termer: Palliativ vård och holistiskt synsätt, vård vid livets slutskede, etiska problem i livets slutskede och definitionerna av etiskt problem och etiskt dilemma. Syfte: Syftet med denna litteraturöversikt var att beskriva sjuksköterskors upplevelser av etiska problem i vården av patienter i livets slutskede. Metod: En litteraturöversikt valdes som metod i denna studie som bygger på åtta vetenskapliga artiklar. Artiklarna granskades och analyserades av författaren. Travelbees teori (1971) “human-to-human relationships” valdes som en teoretisk grund. Resultat: Resultatet presenterar sex teman enligt följande: Beslutsfattande, ineffektiva behandlingar och terapier, otillräcklig kommunikation, bristande samarbete, otillräcklig respekt för patientens autonomi och osäkerhet i vårdande roll. Dessa teman presenterar hur sjuksköterskor hanterar vård vid livets slutskede och i vilka situationer etiska problem uppstår. Diskussion: Resultatet diskuterades utifrånTravelbees’ theory (1971) “human- to- human relationships”. Sjuksköterskors olika erfarenheter i enlighet med deras olika ansvarsområden såsom otillräcklig kommunikation och samarbete, beslutsprocesser, osäkerheten i vårdanderoll och bristande respekt för patientens autonomi diskuterades.

Bakgrund: Omvårdnad är sjuksköterskans spetskompetens och innebär ett stort ansvar vid vård av patient i livets slutskede. Här ställs sjuksköterskan inför särskilda prövningar då patientens önskan och professionens etiska förhållningssätt inte alltid överensstämmer. De flesta inom professionen kommer högst troligtvis vårda en patient i livets slutskede. Syfte: Att beskriva sjuksköterskans upplevelse av att vårda palliativa patienter i livets slutskede.   Metod: Kvalitativ litteraturöversikt med induktiv ansats, baserad på tio artiklar. Artiklarna framtogs från databaserna CINHAL with full text och PSYKinfo, publicerade mellan 2008 – 2018.  Artiklarna analyserades och sammanställdes enligt Fribergs femstegsmodell. Resultat: Teman som framkom var sjuksköterskans olika emotionella upplevelser samt upplevelser som påverkar omvårdnaden av patient i livets slutskede. Sjuksköterskan upplevde vård av patient i livets slutskede på många olika sätt. Exempel på dessa var ett behov utav copingstrategier, reflektion över sin egna dödlighet och emotionell påverkan. Olika faktorer som stress och kommunikationssvårigheter påverkade sjuksköterskans upplevelse. Slutsats: Vårdsituationen har visat sig vara känslomässigt utmanande och väcka existentiella funderingar hos sjuksköterskan. Trots en utmanande situation på många sätt ansågs utövandet av vården vara ett privilegie och något meningsfullt hos sjuksköterskan.

This thesis analyses doctors empathising with patients in palliative care interactions. Historically, palliative care has treated not only patients physical pain but their emotional pain, as well. Although the importance of empathy (defined for the purposes of this thesis as The doctor s expressed understanding of the patient s emotional experience ) has been emphasised in this environment, however, there has been no prior research showing how palliative care doctors actually empathise with their patients in practice. Drawing upon 37 recordings of doctor-patient consultations collected in a UK hospice, this thesis addresses this omission by using conversation analysis (CA) to analyse several facets of empathy in this environment. The analysis begins in chapter four by considering the ways in which doctors can empathise with patients. It shows how doctors can empathise semantically, either by reworking what the patient has themselves said or by showing understanding on a normative basis. It also considers non-semantic ways of displaying empathy (e.g. response cries), showing how these are fundamentally different to the semantic type of empathic display. Overall, this chapter shows that empathy is not restricted to particular formats but, rather, is dependent upon the content of the doctor s turn. The analysis then moves on consider the wider context of doctors empathic responses. Chapter five, first of all, analyses cases where patients emotions become the topic of the interaction, either because the doctor asks about them directly or because the patient raises an emotionally-implicative topic. The emphasis here is on how palliative care doctors can talk to patients about, and empathise with, their emotions without necessarily having to do anything about those emotions. Chapter six then focuses on cases where patients emotions are discussed alongside the more task-driven aspects of the consultation, either because the patient s physical condition has had an emotional impact on them or because their presenting problem is inherently emotional. In contrast to chapter five, then, the source of the patient s emotions here can be treated by the doctor without the emotions being topicalised. The final two chapters of the analysis focus on doctors empathising with patients not in response to something that the patient has said but in the service of some task. Chapter seven shows how doctors can empathically bridge the gap between their medical and the patient s experiential perspectives at moments where it becomes clear that there is a disparity between the two. These include moments where the patient expresses expectations that go beyond what can realistically be provided, moments where the patient might take offence at the doctor s advice and moments where the doctor must reassure patients about their symptoms without seeming to criticise their emotional responses to those symptoms. Chapter eight, meanwhile, shows how doctors can empathically demonstrate that their practice is being driven by a due consideration of the patient s feelings. Specifically, it shows how doctors can draw upon patients feelings in helping them come to a decision about a treatment, cite those feelings when accounting for a treatment that they have recommended and frame a difficult topic as an outgrowth of sentiments that the patient has already expressed. In conclusion, this thesis shows how empathy is not clearly demarcated in palliative care. While there are cases where patients emotions are discussed and empathised with for the sake of discussing and empathising with them, more commonly, empathy and emotion are interwoven alongside and into the task-driven aspects of consultations. This thesis thus shows the interactional manifestation of palliative care s underlying philosophy, with patients emotional pain addressed alongside their physical pain in an integrated, holistic way.

Les produits high-tech sont couramment utilisés dans de nombreux secteurs industriels ainsi que dans nos vies de tous les jours. Ils améliorent notre qualité de vie, mais à quel prix ? En effet, la fabrication, l’utilisation et la fin-de-vie de ces produits high-tech génèrent des impacts environnementaux, économiques et sociaux importants. Ces impacts proviennent principalement des matériaux utilisés, de l’énergie consommée pour leur fabrication et pendant leur utilisation et des mauvaises conditions de travail pour l’extraction des matières premières et leur transformation. L’étape de fin-de-vie des produits high-tech contribue également à une grande partie des impacts, car cette phase est souvent négligée lors du processus de conception.Certaines études ont été faites afin de réduire l’impact environnemental des produits, mais ne considèrent qu’une partie des étapes de cycle de vie (par ex. la fabrication) et excluent d’autres étapes comme la fin-de-vie. D’autres études essayent d’intégrer les contraintes de toutes les étapes de cycle de vie mais négligent l’intégration des enjeux environnementaux et ne considèrent que les enjeux classiques de la conception (coûts, qualité, performance, etc.). D’autres études encore visent à intégrer les contraintes de toutes les étapes de cycle de vie et les enjeux environnementaux, mais ne sont pas adaptées à l’évolution rapide des développements dans le cas des produits high-tech (nouvelles technologies, nouveaux matériaux, etc.).Nous proposons donc un outil d’aide à la conception de produits high-tech, qui a pour objectif la prise en compte de toutes les étapes de cycle de vie — et notamment de la fin-de-vie — pour mieux considérer les enjeux environnementaux en plus des enjeux classiques de la conception. Il s’agit d’un modèle-produit agile pour l’écoconception : le MPAE, capable de guider les concepteurs tout au long du processus de conception sur les questions environnementales, malgré les nombreuses alternatives de conception envisagées lors de la conception des produits high-tech.Dans cette thèse, l’outil est appliqué sur un cas théorique de conception avec l’exemple des batteries Li-ion utilisées dans les véhicules électriques. Le modèle développé permet de cibler les paramètres de conception et les acteurs du cycle de vie à l’origine des impacts environnementaux, pour mieux considérer et tenter de les réduire.En résumé, cette thèse réinterroge l’application du concept de modèle produit dans le cas de la prise en compte des impacts environnementaux en conception afin d’aboutir à leur intégration efficace. / High-tech products are widely used in many industrial sectors as well as in our everyday lives. They improve our quality of life, but with a high price to pay? The manufacture, use and end-of-life of these products cause strong environmental, economic and social impacts. These impacts are mainly due to the materials and to the energy used for the manufacturing, to their use, but also to bad working conditions to obtain raw materials. The end-of-life stage for high-tech products is a huge source of impacts because not considered during the design.Some researches have been conducted to reduce the environmental impact of high-tech products, but they only consider partially the life cycle stages (eg. The manufacturing phases) and exclude other stages, such as the end-de- life. Further studies are trying to integrate all the life cycle constraints but neglect the integration of environmental issues and they only consider the classical design constraints (cost, quality, performance, etc.). Other studies aimed at integrating the al the life cycle constraints and the environmental issues, but they are not adapted to quick features evolutions during the design process of high-tech product (new technologies, new materials, etc.We therefore propose a tool to guide the design of high-tech products, which aims to integrate all life-cycle stages including the end-of-life and environmental issues in addition to classic design issues. This is an agile product model for eco-design (APME), which considers the rapid evolution of the solutions during the development of high-tech products.In this thesis, the model is theoretically applied in a case study related to Li-ion batteries for electric automotive applications. The developed model is able to highlight the main design parameters and the main actors of the product life cycle which induce high environmental impacts to try to reduce them.This thesis considers the use of the product model concept when taking into account environmental impacts during the design process, for their efficient integration.

The acute care setting is designed to provide short-term care for people who require treatment for a severe episode of acute illness and exacerbations of chronic conditions. Yet, more than half of Canadians die in acute hospitals every year. Evidence shows that nurses in acute care units feel limited in their ability to provide quality end-of-life care due to a variety of factors. As a result, the needs of patients that are dying are often overlooked, which can cause them to experience a loss of identity and control, as well as suffering at the end-of-life; a unique time in one’s life trajectory marked by significant changes in personhood. Personhood is the philosophical underpinning of the frequently used concept ‘person-centered care’ – one of the fundamental ideologies of nursing and a central concept in palliative care. An interpretive description design was used to explore the following research question: What do nurses’ stories reveal about the ways in which they engage, or fail to engage, with personhood in end-of-life care in acute care units? To appreciate the culture in which participant stories were situated, a literature review of acute care culture, end-of-life care in acute care units, and the concept of personhood was conducted. Eight nurses from an acute medical-surgical ward of a tertiary care hospital in Eastern Ontario were interviewed for this study. Thematic analysis was used to analyze the data, which elucidated tensions between participants’ ability to enact ethical end-of- life care reflective of their values and the contextual constraints of working in a culture of biomedicine. Exploring these tensions provided insight on the nuances and complexities of navigating ethical end-of-life care in an acute care setting as well as implications for nursing practice, education, and research with particular attention to promoting moral communities in acute care that value personhood and biomedicine equally.