Background Palliative care services have widened beyond cancer in recent years, yet frail older adults rarely receive such services. There is a need to understand the dynamic multidimensional end-of-life experiences of this group in order to assess how or if a palliative approach could be beneficial. Physical end-of-life trajectories for frail older people have been described but there remains little person centred research that describes changing experiences across physical, social, psychological and existential dimensions. Aims and objectives To explore the changing multidimensional experiences of frail older people towards the end of life and to reflect on the utility of a qualitative longitudinal multi-perspective design for this population. Methods Thirteen cognitively intact, community dwelling older adults considered to be moderately or severely frail, using a clinical frailty scale, and thirteen nominated informal carers participated in up to three narrative interviews over eighteen months. Eight nominated professionals were also interviewed. The interviews were participant led, audio-recorded and fully transcribed. The ‘voice centred relational’ narrative method, incorporating analyses of multidimensional experience, was used to analyse the data. The data were then analysed longitudinally to compile case studies for each older person. Findings The narratives of these frail older people approaching the end of life illustrate patterns of multidimensional experience that differ from the end-of-life trajectories of other groups. All participants experienced physical decline however three possible patterns of psychological, social and existential experience emerged. These were stable, regressive and tragic according to the capacity to hold on to core values, and maintain a sense of self and of belonging in the world and are illustrated using visual trajectories. When the sense of self was threatened these frail older people lacked valued alternative identities and struggled with the absence of clear causative factors to explain their circumstances. The participants frequently described fears of burdening others, of moving to a nursing home or of developing dementia more than fears of dying. Losses and sustaining factors are described for physical, social, psychological and existential dimensions revealing the importance of social and community networks for supporting frail older people. There were constraints and benefits to using a qualitative longitudinal multi-perspective method, however the method enabled a deep, contextualised and rich understanding of the dynamic experiences of frail older people. Conclusion Frail older people may be supported towards the end of life by considering ways to promote the integration of the self. This may involve promoting valued alternative identities, protecting personhood through social and health care practices and by investigating ways to alleviate or make tolerable greatest fears. Community health and social care structures and social and community networks appear essential for addressing the end-of-life needs of frail older people. A qualitative, longitudinal, multi-perspective design was beneficial for investigating the experiences of frail older people.

Nonmalignant respiratory diseases (NMRD), such as Chronic Obstructive Pulmonary Disease (COPD), are a leading cause of morbidity worldwide. Research has shown that patients with NMRD in the UK, Canada and the US have less access to palliative care services than patients with other respiratory diseases such as lung cancer. Discussing preferences for end-of-life care in NMRD can be difficult for patients, carers and health professionals, however it is essential to ensure that the patient’s wishes are met, particularly when resources are scarce. Despite similar nationalised health care systems in the UK and Canada, a recent report by the Economist Intelligence Unit ranked overall quality of end-of- life care in the UK first out of forty, while Canada was ranked ninth out of forty. Therefore, it was deemed useful to investigate how end-of-life for people with NMRD is discussed between health professionals and patients in the UK and Canada and to develop an instrument allowing health professionals to determine constraints and opportunities for facilitating such discussions in each country as comparing care between countries is helpful to determine the best solutions for individuals and families with complex needs. This study was guided by the Medical Research Council guidelines for developing and implementing complex interventions, and the research process followed the requirements for the development phase of these guidelines. First, two systematic reviews were carried out to establish the evidence base regarding of end-of-life discussions. The first focused on how end-of-life is discussed in NMRD, while the second focused exclusively on end-of-life discussions in a single NMRD (COPD) in the UK and Canada only. The findings of the systematic reviews pointed toward the need for further training of health professionals to iii discuss end-of-life with this patient group, as well as the lack indicators that this patient group is ready or willing to discuss end-of-life. Then, a Delphi study was conducted with specialist respiratory nurses in the UK to determine expert opinion on how health professionals know a patient with NMRD is ready to discuss end-of-life, and to establish the key considerations and topics in such discussions. This study was replicated in Canada with health professionals working with patients with NMRD. Each Delphi study resulted in a country specific tool to assist less experienced health professionals discuss end-of-life with this patient group. Finally, the findings of these Delphi studies were compared to determine what health professionals in each country could learn from each other, as well as specific considerations in each country, and areas for future research. The findings from the comparison process demonstrated that the emotional intelligence of health professionals, the patient education context and the recognition of cultural issues were all important factors when approaching end-of-life discussions. Findings from each phase of the intervention development process resulted in a theoretical model of how end-of-life is discussed in the UK and Canada. This model identifies constraints and opportunities for such discussions from a systems level perspective including: end-of-life policies, prognosis in non-malignant respiratory disease, time, clinical indicators, initiation responsibility, the educational role of health professionals, emotional intelligence, cultural competence and readiness versus willingness to discuss end-of-life. Recommendations are made from the findings of this study for research, clinical practice, education and policy. A detailed plan for the next stage of the development of the intervention is included.

Background: Every year 250,000 children worldwide receive the unimaginable diagnosis of cancer. A cancer diagnosis inflicts a major impact on the family situation. They must deal with an entirely, both emotionally and socially new situation they are not prepared for. It is of great importance that the nurse has adequate knowledge to be able to provide the best possible care to the entire family. Aim: The aim of this study was to describe the family members' experiences of losing a child in cancer. Method: A method to contribute to evidence-based nursing with ground in analysis of qualitative research was performed to get a better understanding of families' experiences. An analysis of thirteen qualitative articles was carried out. The analysis resulted in five main themes and sixteen subthemes. Results: The results of the study showed that families losing a child in cancer are having a heart-breaking time. They described combative feelings between hope and despair. The mothers often took care of the sick child at home and the fathers kept their minds busy while working. The families put all their own needs and sorrows aside. The siblings felt lonely since the parents took care of the sick child. After the passing, the family kept a bond to the deceased child through memories and dreams. Conclusion: The families experienced a greater need of support from the nurses and the hospital staff, during the time when the child was sick and after the death.

The purpose of this study was to describe Registered Nurses’ attitudes toward death and their perspectives on education and training related to death and end-of-life patient care. A complementary goal was to determine whether nurses’ attitudes and perspectives are associated with background variables. The three attitudes toward death included anxiety, escape, and neutral attitudes. The background variables of the nurses included formal educational level, age, gender, ethnicity, years of nursing practice, state of residence, and area of nursing practice. A survey including four sections was used for data collection. The first section of the survey utilized an established 32-item survey based on the Death Attitude Profile Revised survey developed by Wong, Reker, and Gesser in 1994. The questions asked how nurses felt about the topic of death. The second section of the survey was about the extent of palliative care education and training, while the third section was concerned with the demographics of the respondents. Part four of the survey included two open-ended questions regarding attitudes toward death and how prepared respondents felt in meeting their patients’ end-of-life needs. The survey was sent to state nurses’ associations across the United States in 2015. Survey Monkey was the link for the survey and it was opened for a three-week period. The original responses totaled 248 participants. Responses with any missing values were excluded. The final dataset included 167 total responses. Data was analyzed using descriptive statistics and regression analysis to determine the association between the variables of interest. The results of the study were most significant in relation to anxiety toward death. Nurses who were more experienced on the job, female, and with more formal education had lower anxiety levels, as did nurses with a higher confidence level in dealing with death. For the neutral attitudes, the best predictor was the rating of the nurses’ end-of-life preparation. The best predictor of the escape attitude was years of nursing experience. The results supported the need for college level end-of-life education and the significance role of nursing experience in relation to less anxiety towards death. The surprising result was that post-college end-of-life education actually increased the anxiety attitude toward death. More research is needed to ascertain if these results could be replicated. There is a need to determine what type of post-collegiate education would decrease death anxiety in nurses.

In resource recovery from end-of-life printed circuit board (PCB), the physical processing route is considered most environmentally friendly. The −75 µm fraction generated during the comminution assays well above many precious and base metal deposits, but contributes overall drop in value recovery. This investigation was aimed at exploiting the versatility of froth flotation for beneficiation of the PCB comminution fines. Chemical composition characterisation work shows wet assay of constituents in the sample vary with digestion condition. Absolute assays as for hazardous constituents thus require comparison of data from more than one digestion condition. Comparative assaying of samples from beneficiation treatments can use aqua regia digestion which gives a less hazardous procedure compared to hydrogen fluoride combined with microwave and nitric acid treatments. It also gives leach liquor from which all constituent elements can be analysed, compared to that from total digestion via sodium peroxide fusion. For this sample total digestion will therefore not always give better results compared to partial digestion. Findings also show that thermogravimetric analysis may not be recommended in PCB characterisation. It gave no distinct inflexion point to characterize any constituent. This is due to the very diverse material constituents of the sample. Further on characterisation, the sample gave a loose bulk density lighter than water, and true sample density of 3 g/cm3. This coupled with surface hydrophobicity observed necessitates that pulping the sample must be done under water. Light optical and scanning electron microscopy showed particle liberation was very high, but not total. Morphology of the metallic particles was very diverse, with average circularity shape factor of 0.63. This coupled with the material diversity is a major constraint in sub-sieve size analysis of the sample. As shown by scanning electron microscopy energy dispersive X-ray spectroscopy, the liberated particles themselves contain more than one chemical element, being alloys. Beneficiation operation therefore cannot attempt to separate such particles into constituent elements but some bulk collection of metallic values into a concentrate. Reverse flotation of metallic values based on a scheme described as natural hydrophobic response (NHR) was found successful. Favorable kinetics under the scheme gave about 500 rpm and 500 ml/min aeration rate, at 300 g sample in a 3.5 l Leeds cell. Without the use of a collector, natural hydrophobic response was observed. The system also gave a stable froth without the aid of a frother. Investigations (surface tension and dynamic froth stability height measurements, combined with general literature) show the NHR froth is a fine particle stabilised froth, and not surfactant stabilised. Au and Pd, were among the elements best enriched into the sink; 64 % recovery for Au at enrichment ratio of three. Flotation over narrower and coarser fraction (+106 – 75 µm) shows the NHR scheme can be successfully applied at this size. Chemical conditioning schemes investigated shows very minimal responses to reagents. Potassium amyl xanthate (PAX) did not condition the metallic particles for flotation remarkably as it does with native metals. Sulfidation with sodium hydrogen sulfide shows a little improvement in response to PAX. Sodium mercaptobenzothiazole – a very selective collector for tarnished copper and lead minerals – did not show such selectivity in the PCB comminution fines pulp. Some cationic pull with tetrabutyl ammonium chloride towards selective pull of non-metallic values after NHR pull has subsided was observed, although very little also. Macromolecular depression with carboxyl methyl cellulose did not subdue the natural hydrophobic response up to profuse percentage dosages. Depression by lowering surface tension, described as gamma depression, using Betamin 127A (active constituent: ethoxy nonyl phenol) was effective to wet hydrophobic particles, but still not helpful for selective pull after chemical conditioning. At the lowered surface tension, frothing sets in coupled with entrainment. Probable causatives for the poor response to reagents are surface oxidation of the metallic particles and depression by calcium ions in pulp. Surface studies with field emission scanning electron microscope and auger electron spectroscopy composition depth profiling, show presence of organic layers on the surface of the metallic particles. The surfaces were also found to be oxidised down to about 340 nm depth profiled. None of the surfaces is a pure alloy, but occurring in forms that will be relatively inert to reagents. Beside these, from aqua regia wet assaying, the sample contains about 7 % calcium by mass, and ICP-MS trace element analysis of the process water confirms calcium presence up to 7 ppm equilibrium concentration in the pulp. Judging from the responses, the natural hydrophobic response scheme can be well recommended for PCB comminution fines flotation. Optimisation of the performance of the scheme responds remarkably well to kinetic parameters variation. With the generally low impeller energy and aeration rate found favourable for PCB CF flotation, and the zero reagent cost (no collector, no frother) of the NHR scheme, PCB comminution fines flotation shows good prospects. / Thesis (PhD)--University of Pretoria, 2010. / Materials Science and Metallurgical Engineering / unrestricted

Background: Caring for an elderly person at the end of life means a complex care situation for healthcare professionals. There are several factors to consider in this regard; the patient's, relatives and healthcare staff as described in this work from the nurse. Aim: The purpose of the study was to describe municipality nurses' experiences of caring for older people in the final stages of life. Method: The study had a descriptive design with a qualitative approach. Data were collected through eight interviews and analyzed using a qualitative manifest content analysis, whereas five categories and ten sub-categories emerged. Results: The result is that the nurse practitioners saw this work as meaningful but also emotional stress. Feelings like insufficiency, participation, adequacy and existential issues were raised at the nurse's nurse. The palliative care complexity was visualized as the patient's self-determination, relatives, and nursing staff's needs were made visible and met. Conclusion: Palliative care is a person-centered care based on patient needs, which proved to be complex. Corresponding to these expectations and implementing the required care creates experiences, good and less good, with nurses who consciously or not, affect them regardless of patient or care opportunity and give a chance of reflection, further experience and opportunity to grow as a person and in profession. Keywords: C aring, end-of-life care, elderly care, nurses’ experience, palliative care

Bakgrund: Alla vet med säkerhet att vi en gång kommer att dö. När någon närmar sig livets slut uppstår problem av psykisk, fysisk, social och existentiell karaktär. Döden kan mötas på olika sätt och hur mötet blir är individuellt. Patienten går igenom olika faser på vägen vilket resulterar i lidande och ifrågasättande av livsvärld. Syfte: Att belysa patienters upplevelse av att befinna sig i livets slut. Metod: Studien är en kvalitativ narrativ litteraturstudie med grund i självbiografier, dessa speglar upplevelser av att befinna sig i livets slut. Resultat: Patienter i livets slutskede får ett behov av att söka meningen till varför sjukdomen drabbat dem. De för resonemang om existens och hur den kommande döden påverkar dem och deras anhöriga. Patienter beskriver känslan av bakslag när tillståndet försämras efter en period av bättring. De funderar över vad som faktiskt är viktigt i livet och hur sorg hanteras. Slutsats: Det är ett viktigt ämne att ta upp då relativt lite material finns. Mer forskning behövs för att ännu bättre kunna ge patienterna den vård de behöver. / Background: Everyone knows for sure that we will once die. When someone approaches the end of life, problems of mental, physical, social and existential nature arise. Death can be met in different ways and how that meeting will be is individual. The patient goes through different phases along the way, resulting in suffering and questioning of life. Purpose: To highlight the patient's experience of being in the end of life. Method: The study is a qualitative narrative literature study based on autobiography, which reflect the experiences of being in the end of life. Result: Patients in the end of life have a need to seek the meaning of why the disease has affected them. They argue about existence and how the upcoming death affects them and their relatives. Patients describe the feeling of setback when the condition deteriorates after a period of improvement. They think about what is actually important in life and how sorrow is handled. Conclusion: It is an important topic to address when relatively little material is available. More research is needed to better provide patients with the care they need.

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.

Les matériaux biocomposites, en particulier les composites matrice thermoplastique biosourcée ou non renforcée de charges ou de fibres végétales, connaissent actuellement un essor significatif et présentent pour l'avenir un gisement grandissant de matières en fin de vie. En conséquence, l'étude du comportement de ces matériaux au regard de différents scénarios de fin de vie que sont le recyclage mécanique, le compostage et l'incinération constitue un enjeu scientifique et technologique important. Le premier objectif de cette thèse est d'étudier la fin de vie par retransformation (cycles successifs d'injection et de broyage) de biocomposites à matrice polypropylène (PP) chargé de farine de bois. L'impact de la taille des particules de bois et d'un agent de couplage a été évalué. Une très bonne stabilité mécanique jusqu'à 7 cycles de retransformation a été observée malgré des dégradations des différents composants du matériau. Le comportement face à la retransformation après vieillissement artificiel accéléré ou après une exposition naturelle en extérieur a été étudié. La tendance majeure dégagée est un phénomène de « régénération » des propriétés mécaniques par retransformation, et cela malgré des dégradations importantes après vieillissement. Il a été également été observé que l'ajout de bois a tendance à limiter la photodégradation du PP. Le second objectif est d'étudier la fin de vie de biocomposites à matrice acide polylactique (PLA) renforcé de fibres de lin. L'impact de différents paramètres de formulation, de la technique de mise en œuvre et d'un vieillissement hygrothermique sur la retransformation de ces matériaux a été évalué. Les mêmes phénomènes de « régénération » sont observés, ce qui montre l'effet bénéfique de la retransformation. La fin de vie par compostage et par biodégradation est traitée. Des mesures d'énergies de combustion ont enfin permis d'estimer le potentiel de valorisation par incinération qui serait en lien avec le niveau de dégradation du PLA. / Nowadays, biocomposite materials are booming and will be a growing end-of-life issue for the future. They are based on a thermoplastic matrix (oil-based or bio-based) reinforced with vegetable fillers or fibers. Consequently, the study of their end of life through recycling, composting and incineration is a scientific and technologic challenge.The first goal of this thesis is to study the reprocessing end of life (successive injection and grinding cycles) of polypropylene (PP) based biocomposites filled with wood flour. The impact of the wood particle size and a coupling agent was assessed. Thus, a very good mechanical stability was observed up to 7 reprocessing cycles despite some degradation from the material components. Then, the reprocessing after artificial or natural UV weathering was carried out. The major trend is a “regeneration” phenomenon of mechanical properties after reprocessing in spite of strong degradations after UV weathering. Moreover, the addition of wood filler tends to restrain the PP photochemical degradation.The second goal is to study the end of life of polylactic acid (PLA) based biocomposites reinforced with flax fibers. The impact of the composition, the processing technic and humidity weathering on the reprocessing was assessed. Similar “regeneration” phenomena were observed leading to conclude to the beneficial effect of reprocessing. Then composting and biodegradation aspects were investigated. Heat release rate measurements enabled to estimate the incineration potential which could be linked to the PLA degradation rate.