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.

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.

Investment decisions on electric power networks have developed to balance network functionality and cost efficiency by analyzing the main risks associated with network operation. Ageing infrastructures, like large power transformers in particular, aggravate the stress of management, because the failure of a power transformer could cause power supply interruption, network reliability reduction, large economic losses and also environment impacts. Transformer asset management is therefore aimed to develop a cost-efficient replacement strategy to get the most usage of transformers. The main objective of this thesis is to understand how UK National Grid transformer assets failure trend can be used, as the engineering evidence to help make financial decisions related to transformer replacements. The studies in this thesis are implemented via two main approaches. First statistical analyses methods are undertaken. This approach is realized to be non-optimal, because the transformer failure mechanism at the normal operation stage is different from that when transformers are aged. Secondly, the transformer physical ageing model is used to estimate thermal lifetimes under the ageing failure mechanism. In conjunction with the random hazard rate obtained by statistical analyses, the actual National Grid transformer population failure hazard with service age is derived. Statistical analyses are carried out based on the ages of National Grid failed and in-service transformers. Transformer lifetime data are fitted into various distribution models by the least square estimator (LSE) and maximum likelihood estimator (MLE). Statistics are however powerless to suggest the population future failure trend due to their intrinsic limitations. National Grid operational experience actually indicates a stable and low value of the random failure hazard rate during the transformer early operation ages. The engineering knowledge however suggests an ageing failure mechanism exists which corresponds to an increasing hazard in the future. Transformer lifetime under ageing failure mechanism is conservatively indicated by its thermal end-of-life corresponding to a specific level of insulation paper mechanical strength. By analyzing National Grid scrapped transformers’ lowest degree of polymerization (DP), these transformers are estimated to have deteriorated at different rates and their thermal lifetimes distribute over a wide age range. The limited number of scrapped transformers cannot adequately indicate the ageing status of the whole population. A transformer’s thermal lifetime is determined by its loading condition, thermal design characteristics and installation site ambient temperature. However, these input data are usually incomplete for an individual transformer.A simplified approach is developed to predict the National Grid in-service transformer’s thermal lifetime by using information from scrapped transformers. The in-service transformer population thermal hazard curve under ageing failure mechanism can thus be obtained.Due to the independent effect from transformer random failure mechanism and ageing failure mechanism, the National Grid transformer population actual failure hazard curve with age is therefore derived as the superposition of the random failure hazard and the thermal hazard. Transformer asset managers are concerned about the knee point age, since aged transformer assets threaten network reliability and the transformer replacement strategy needs to be implemented effectively.

Customers expect electricity to be not only available but also affordable whenever they need it. Due to the stochastic nature of power system component failure, the management of power interruption is challenging. Although the reliability of supply can usually be increased by employing redundant equipment; this means that affordability is compromised. At present, many power utilities have a considerable amount of aged equipment in their networks. Although they have already started replacement planning, the price control schemes imposed by regulatory authorities constrain their capital expenditure budget. This thesis has studied the influence of the end-of-life failure of power transformers on transmission system reliability in order to make decisions on their replacement. Power transformers are selected for the analysis because they are technically complex, expensive, and main feed points of electricity for end users. In addition, surveys on ageing asset show that 50% of transformer populations, in many utilities, have been classified as old since the year 2008. The focus of these reliability analyses is to identify the most critical transformers and to establish a reliability based replacement framework. Modelling of end-of-life failure was reviewed, and the state-of-the-art method of its incorporation into system reliability was adopted. A reliability assessment tool within DIgSILENT PowerFactory package was developed in order to perform reliability studies. This thesis has four original contributions surrounding transmission system reliability analysis. The first contribution is the development of a cost-effective framework that concerns the application of reliability studies on asset replacement decision making. The developed framework has employed reliability importance measures, the Pareto analysis and economic comparison based on reliability incentive/penalty schemes. All the three elements of the framework are original applications to system reliability area. The second contribution is the integration of unconventional end-of-life failure models into system reliability. The unconventional model used in this study is Arrhenius-Weibull distribution, which characterises end-of-life failure under different loading conditions. This study has evaluated the added value provided by including loading levels in failure models and how this enhances the understanding of the effect of operational factors on system reliability. The third contribution is the investigation of dependent failure of power transformers caused by thermal stress. This investigation has led to the development of two probabilistic indicators to rank power transformer based on their criticality to multiple failure events. These new indicators have related the transformer reliability to its age and loading levels. In the fourth contribution, comprehensive studies of the effect of uncertainty associated with failure model parameters were performed. The first study has established bases for a system related approach for refining failure models. The approach is based on assessing the sensitivity of the system reliability or the system reliability applications to the uncertainty in failure model parameters. In the second study, two quantification methods were adopted to propagate the uncertainty in failure model parameters to system reliability indices. These are the second order probability and evidence theory. The last uncertainty study has described the use of sampling based sensitivity analysis to identify the most critical transformers and their area of vulnerability. Studies throughout the thesis have been performed on a realistic transmission network and the IEEE Reliability Test System.

Bakgrund: Palliativ vård går ut på att främja patientens autonomi, förbättra livskvaliteten och lindra lidandet för patienten och hens anhöriga ända fram till livets slutskede. Den palliativa vården bygger på de fyra hörnstenarna: symtomlindring, närståendestöd, teamarbete och kommunikation. Sjuksköterskans omvårdnad utgår från dessa hörnstenar där patienten och dess anhöriga ska ses som en helhet utifrån fysiska, psykiska, sociala och existentiella behov.  Syfte: Syftet är att beskriva sjuksköterskans upplevelse av att vårda patienter i livets slutskede. Metod:Litteraturöversikten är baserad på åtta vetenskapliga kvalitativa artiklar tagna från databasen CINAHL Complete och som analyserats utifrån Fribergs analysmetod. I denna litteraturöversikt användes Benners teori som teoretisk utgångspunkt.   Resultat:Sjuksköterskans upplevelser och erfarenheter inom palliativ vård presenterades i denna litteraturöversikt i fyra huvudteman: Mötet med döden och döende patienter, Sjuksköterskans upplevelser av eget lidande att vårda döende patienter, Sjuksköterskans behov av stöd och relationsskapande. Diskussion: I litteraturöversiktens diskussion har resultatet diskuterats i tre huvudteman: erfarenhetens betydelse, kollegialt stöd och närhet och distans. Detta utifrån Benners teori, som talar om sjuksköterskans utveckling från novis till expert. / Background: The essence of palliative care is to promote patients autonomy, improve the life quality, and relieve suffering of the patient and their family until life’s finiteness. Palliative care consists of four cornerstones: symptom relief, relative support, teamwork, and communication. These cornerstones set the foundation for nursing care where patients and their families are seen as an entirety in terms of the physical, physiological, social, and existential needs. Aim: The aim of this literature review is to describe nurse´s experience of caring for patients in the end of life. Method: The literature review is based on eight qualitative studies taken from the CINAHL Complete database and was analyzed using Friberg’s analysis method. In this literature review Banner’s theory was used as the theoretical starting point. Results: Nurse´s experience within palliative care was described in four main themes: facing death and dying patients, nurse´s experience of own suffering from caring for dying patients, nurse´s need for support, and creating a relationship. Discussion: During the discussion of the results in this literature review three main themes emerged: importance of experience, collegiate support, and closeness and distance. Benners theory was used that describes nurse´s progress from novice to expert.

Familial caregivers are providing increasing amounts of care to advanced cancer patients. Increased understanding of caregivers' needs is vital in providing necessary support to lessen caregiver burden and comorbidity. This study examines particular information needs across a variety of specific events in the advanced cancer disease trajectory. A cross-sectional sample of 107 familial caregivers (24 current and 83 bereaved) of people with advanced cancer completed a needs assessment survey along with a measure of health information-seeking behavior. Analyses extend current research by including more specific disease-related events along the advanced cancer trajectory through bereavement. In all information categories, endorsement of wanted information differed across broad stages of Cancer Progression, Treatment, End of Life, and Post-Patient Death. For all information categories, except Dying and Spirituality, greatest information was wanted at the Cancer Progression stage. Information need also differed across specific events within broad stages. The categories of Disease/Medical and Relating to the Patient were the most endorsed at events involving patient care. Spirituality was least endorsed. At patient death, Caregiver Well-being has the highest endorsement. For events thereafter, information on Caregiver Well-being, Spirituality, Future Outlook, and Family and Close Others was most endorsed. Information needs did not differ based on age or education. Whether or not a caregiver had experienced a given event on the cancer trajectory impacted some categories of information desired at the events of leaving the hospital for home, going into hospice, patient death, immediately after death, and bereavement. In all cases, those who had experienced the event wanted more information. In comparing current to bereaved caregivers, no differences in information endorsement occurred for events of the Cancer progression or Treatment stages. This study also involved the validation and factor analysis the Health Information-Seeking Behavior Survey. Two factors, Health Information-Seeking and Health Information-Avoiding, emerged. Health Information-Seeking correlates positively with some of the information categories at some of the stages. Increased understanding of caregiver needs at specific key events in the advanced cancer illness trajectory can now be used to inform the development of effective familial caregiver education interventions.