Bakgrund: Sveriges befolkning är beräknad att växa och studier visar på att många skulle föredra att dö i hemmet över instutitonell vårdplats. God palliativ sjukvård kräver tillgänglighet och kompetens samt följsamhet till de fyra hörnstenarna. Patienter känner en stress över att involvera anhöriga i deras situation därför är det viktigt att ta reda på hur de anhöriga ser på situationen.  Syfte: Syftet med litteraturstudien är att beskriva anhörigas upplevelser av palliativ vård i hemmet. Metod: Litteraturstudie baserad på nio kvalitativa studier. Data insamlades från Databaserna Cinahl och Psycinfo. Sökord för att forma korrekt söksträng innehöll: palliative care, family, family perspective mm. Med avgränsningar så som english text och år:2000-2020. Analys utfördes enligt en femstegsanalys. Resultat: Två tema hittades med tre respektive sub-tema. Delaktighet och Relationer var huvudtemana. Sub-temana bestod av: Förändring i vardagen; Ansvar; Tillräcklig eller bristfällig information; Relationen med formella vårdgivare; Relationen med övrig släkt och vänner; Relationen med patienten. Konklusion: Vården hemma hos patienter bör alltid tänka på att de närstående som bor, eller tillfälligt bor, tillsammans med patienten också är en del av vården som behöver stöd, hjälp och information. / Background: Sweden's population is expected to grow, studies show that many would prefer to die at home over institutional place of care. Good palliative care requires accessibility and competence and is designed from the four cornerstones. Patients feel a stress over involving relatives in their situation, therefore it is important to find out how the relatives view the situation. Aim: The purpose of this study is describing relatives' experiences of palliative care at home. Methods: Literature study based on nine qualitative studies. Data were collected from the Cinahl and Psycinfo databases. Keywords forming the correct search string contained: palliative care, family, family perspective etc. With boundaries such as english text and year: 2000-2020. Analysis was performed according to a five-step analysis. Result: Two main themes were identified with three sub-themes respectively. Participation and Relationships were the main themes. Sub-themes consisted of: Change in everyday life; Responsibility; Sufficient or incomplete information; The relationship with formal caregivers; The relationship with other relatives and friends; The relationship with the patient. Conclusion: At home caretakers should always keep in mind that the relatives who live, or temporarily live, together with the patient are also part of the care that needs support, help and information.

With a large amount of tyres being discarded every year, the question of how to manage the end-of-life tyres (ELTs) has become a serious issue. Thus this study identifies different driving forces for this management and the most possible scenarios for the future management of ELTs. The study also compares the business as usual model with a waste hierarchy model to explore the possibilities for optimizing management of ELTs through cascading. This study collects opinions about the driving forces of ELT management from 29 experts working in the area. Important driving forces identified were: price of substitute products, recycled materials’ market, environmental legislation, and technology. This study also surveys 23 experts in the tyre area about the most possible scenarios for ELTs in 2020. One of the more believed in futures was: “Due to increasingly limited fossil fuels and a rise of sustainability awareness, applications for ELTs are growing both in material and energy recycling.” This suggests that a shift toward an equal recycling situation of ELTs among material and energy might be likely to happen by 2020. Based on the most possible scenario for ELTs in 2020, a comparison between waste hierarchy model and business as usual model has been performed. The result shows that the (cascading) waste hierarchy model would likely create more environmental benefits than business as usual model. This is done though the saving and cycling of more materials from energy recovery into material recycling.

Recycling and recovery of materials and energy from waste is a key factor to mitigate virgin material demands and reduce resource consumption by utilising waste as a resource for new products. However, some critical materials, such as neodymium, are barely recycled because of missing information on amount and disposition of these critical materials within the waste streams. The goal of the study is to quantify recycling potentials from small and electric motors originating from end-of-life vehicles (ELV), electric bicycles and industrial machinery in Germany and the EU with focus on currently lost rare earth elements. Furthermore, innovative approaches to improve recycling of these motors shall be investigated. Therefore, a calculation model to predict current and future waste streams and the incorporated recycling potentials has been developed. The results show an increasing trend of recycling potentials from small and electric motors for all waste streams. The recycling potential of neodymium is estimated at a range of 150 t to 240 t in 2020 in Germany. However, data inaccuracy and the calculation model are likely to cause overestimation of actually available recycling potential and have to be interpreted carefully. In conclusion, disassembly of small and electric motors from ELV and electric bicycles in combination with a subsequent specific recycling process has been identified as promising to improve utilisation of the recycling potentials of rare earth elements from small and electric motors. However, in case recycling quotas are the prior goal of improvement, the application and further optimisation of post shredder technology is more relevant.

Bakgrund: Omvårdnadsarbetet på akutmottagningar innefattar, utöver vårdande av allvarliga skador och livshotande sjukdomstillstånd, omhändertagande av patienter i livets slutskede. Sjukhus har påvisade kvalitetsbrister i vården vid livets slutskede. Den sista vårdtiden påverkar patienters och anhörigas lidande och livskvalitet. Syfte: Studiens syfte var att beskriva sjuksköterskors upplevelser av att vårda patienter i livets slutskede på akutmottagningar. Metod: Allmän kvalitativ litteraturöversikt på åtta kvalitativa och tre mixade vetenskapliga artiklar. Resultat: Utifrån analyserade artiklar framställdes fyra kategorier som beskriver sjuksköterskors upplevelser av vård i livets slutskede på akutmottagningar; Yttre aspekter som inte går att påverka, Anhörigas inverkan på vården, Samverkan och kommunikationen är betydelsefull och Det komplexa med omvårdnaden. Diskussion: Sjuksköterskors arbete påverkas negativt av hög arbetsbelastning och underbemanning. Akutmottagningars miljö utgör ett strukturellt hinder för sjuksköterskor att bedriva god omvårdnad i livets slutskede. Trots försök till inkorporering av patient och anhöriga i omvårdnaden kvarstår upplevelser av att de inte vårdas efter sina egna önskningar. Slutsats: Vård i livets slutskede är inte optimalt på akutmottagningar. Begränsad avskildhet, underbemanning, okunskap och anhöriga påverkar omvårdnaden. God kommunikation, avskildhet och tid krävs för att kunna erbjuda god omvårdnad. Trots bristerna kan sjuksköterskor främja en god död på akutmottagningar. / Background: Nurses’ work in emergency departments includes caring for serious injuries and life-threatening illnesses as well as caring for patients in the end-of-life. Hospitals have quality deficiencies in end-of-life care. End-of-life care affects patients and relatives suffering and quality of life. Aim: The aim of this study was to describe nurses' experiences of caring for patients at the end-of-life in emergency departments. Method: General qualitative literature review of eight qualitative and three mixed articles. Result: Four categories regarding nurses' experiences of caring for patients at the end of life in emergency departments evolved: External factors that cannot be influenced, Relatives impact on the care, The interaction and communication is important and The complexity of nursing. Discussion: Nurses' work is negatively affected by high workloads and understaffing. The work environment is an obstacle for nurses to provide good end-of-life care. Despite attempts to incorporate relatives and patients, they are not cared for according to their own wishes. Conclusion: End-of-life care is not optimal in emergency departments. Limited privacy, understaffing and lack of knowledge have negative effects on nursing. Good communication and privacy are required to offer good care. Despite this, nurses can promote a good death at emergency departments.

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Objectives: To describe the characteristics of children who died and their modes of dying in a South African Paediatric Intensive Care Unit (PICU). Design: Retrospective review of data extracted from the Child Healthcare Problem Identification Programme (Child PIP)and the PICU summary system (admission and death records) on children of any age who died in the PICU between 01 January 2013 and 31 December 2017. Setting: Single-centre tertiary institution. Patients: All children who died during PICU admission were included. Measurements and Main Results: Four-hundred and fifty-one (54% male; median (IQR) age 7 (1-30) months) patients died in PICU on median (IQR) 3 (1-7) days after PICU admission; 103 (22.8%) had a cardiac arrest prior to PICU admission. Mode of death in 23.7% (n=107) was withdrawal of life sustaining therapies; 36.1% (n=163) died after limitation of life sustaining therapies; 22.0% (n=99) died after failed resuscitation and 17.3% (n=78) were diagnosed brain dead. Ultimately, 270 (60%) children died after the decision to limit or withdraw life sustaining therapies. There was no difference in the number of deaths during office and after-hours periods (45.5% vs. 54%; p = 0.07). Severe sepsis (21.9%) was the most common condition associated with death, followed by cardiac disease (18.6%).Ninety-four (20.8%) patients were readmitted to the PICU within the same year; 278 (61.6%) had complex chronic disorders. During the last phase of life, 75.0% (n=342) were on inotropes, 95.9% (n=428) were ventilated, 12.0% (n=45) received inhaled nitric oxide and 10.8% (n=46) renal replacement therapy. Only 1.5% (n=7) of children became organ donors and postmortems were done in 47.2% (n=213) of the patients. Conclusions: Most PICU deaths occurred after a decision to limit or withdraw life-sustaining therapy. Severe sepsis was the most common condition associated with death. Referral for organ donation was extremely rare.

Bakgrund: Inom hälso- och sjukvården är det främsta målet för patienter med cancersjukdom en kurativ behandling - behandling som botar. När cancern inte längre är möjlig att bota byter vården riktning till palliativ vård. Den Palliativa vården är delad i två faser där den första fasen är längre och påbörjas tidigare i sjukdomsförloppet än den andra fasen som är i slutskedet av patientens liv. Personcentrerad vård har valt som teoretiskt perspektiv.   Syfte: Att belysa sjuksköterskans upplevelse av att vårda patienter med cancersjukdom i livets slutskede.   Metod: Genomfördes som litteraturöversikt grundat på tolv vetenskapliga artiklar varav åtta med kvalitativa ansats, tre med kvantitativa och en artikel med mixad metod.   Resultat: Tre kategorier sammanställdes utifrån de vetenskapliga artiklarna personlig utveckling, andlighet och psykisk påverkan. Resultatet visade att sjuksköterskan utvecklas i sin profession vid arbetet vi patienter med en cancersjukdom. Även att sjuksköterskan upplever existentiella dilemman vid relationen de skapar med sina patienter. Den psykiska påverkan var att sjuksköterskorna upplevde depression och sorg när de vårdade patienter med en cancersjukdom i livets slutskede.    Konklusion: För sjuksköterskeprofessionen visar det på ett behov av mer utbildning för framförallt nyexaminerade sjuksköterskor i att hantera situationer som innehåller svåra frågor och är känslosamma. Även att sjuksköterskans arbete kommer att påverka de efter flera år med att arbeta med patienter med en cancersjukdom i livets slutskede. / Background: In healthcare, the main goal for patients with cancer is curative treatment - treatment that cures. When the cancer is no longer curable, care changes direction to palliative care. Palliative care is divided into two phases where the first phase is longer and begins earlier in the course of the disease than the second phase which is in the final stages of the patient's life. person-centered care has chosen as a theoretical perspective.  Purpose: To shed light on the nurse's experience of caring for patients with cancer at the end of life.  Method: Conducted as a literature review based on twelve scientific articles, eight with qualitative approach, three with quantitative and one article with mixed method  Results: Three categories were compiled based on the scientific articles personal development, spirituality and psychological influence. The results showed that the nurse develops in her profession when working with patients with cancer. Also that the nurse experiences existential dilemmas in the relationship they create with their patients. The psychological effect was that the nurses experienced depression and grief when they cared for patients with a cancerous disease at the end of life.  Conclusion: For the nursing profession, it shows a need for more training, especially for newly graduated nurses in dealing with situations that contain difficult questions and are emotional. Also that the nurse's work will affect those after several years of working with patients with a cancerous disease in the final stages of life.

Bakgrund: Från internationell forskning framkommer att det finns kunskap om hur sjuksköterskor som arbetar på vårdavdelningar inom akutvården upplever omvårdnaden av patienter i livets slutskede. Dock finns sparsamt med forskning inom detta område i en svensk kontext. Syfte: Studiens syfte var att belysa hur sjuksköterskor som arbetar på vårdavdelningar inom akutvården upplever omvårdnaden av patienter i livets slutskede. Metod: Studien har en empirisk design med kvalitativ ansats. Samtalsintervjuer med fyra legitimerade sjuksköterskor genomfördes och analyserades med hjälp av modifierad innehållsanalys, editing analysis style, enligt Malterud (2009). Resultat: Ur analysen utkristalliserades tre kategorier vilka beskriver hur sjuksköterskan, inom den akuta kontexten, upplever omvårdnaden av patienter i livets slutskede: Godtycklig anpassning, Den obarmhärtiga omvårdnadsverkligheten och Den goda omvårdnaden – En önskedröm? Slutsats: Analysens resultat vittnar om att sjuksköterskans beslutsautonomi är hotad i omvårdnaden av patienter i livets slutskede inom den akuta kontexten, att sjuksköterskan har svårt att leva upp till kraven i omvårdnaden som dessa patienter har rätt till samt att sjuksköterskan saknar närhet till patienten. Detta innebär att hon inte alltid kan göra gott och därmed riskerar att skada patienten, vilket leder till att rättvisa i omvårdnaden inte alltid kan skipas i en kontext som delas av den kurativa och den palliativa patienten. I en ytterligare tolkning menas att den palliativa patientens människovärde kränks. Klinisk betydelse: En konsekvens av studien är att rekommendera vårdavdelningar inom akutvården att vidta åtgärder som förbättrar sjuksköterskans möjligheter att utföra en tillfredställande omvårdnad av patienter som avslutar livet inom denna vårdkontext. / Background: International research indicates that there is knowledge of nurses’ perceptions of palliative nursing care in wards in acute care settings. However, there is little research in this field in a Swedish context. Aim: The aim of this study was to elucidate nurses’ perceptions of palliative nursing care in wards in acute care settings. Method: The study has an empirical design with a qualitative approach. Interviews with four registered nurses were analyzed using the modified content analysis, editing analysis style, by Malterud (2009). Results: From the analysis three categories emerged which describe how the nurse, within the emergency context, experience the caring of patients near end of life: Arbitrary adaption, The unmerciful nursing reality and The good care – A utopia? Conclusion: The result of the analysis showed that the nurse decision-making autonomy is threatened in the care of patient in palliative care in the acute context, that the nurse finds it difficult to live up to the demands of the care that these patients are entitled to and that the nurse lacks closeness to the patient. This means that the nurse cannot always do good and risks to harm the patient, which leads to that justice cannot always be guaranteed in a context that is shared by the curative and the palliative patient. In a further interpretation the dignity of the palliative patient is violated. Clinical significance: A consequence with the study is to recommend wards in acute care settings to take actions to improve nurses’ ability to perform an adequate nursing care of patients who end life within this context.

Despite hospice and palliative care services being available for patients at the end-of-life, it remains an easily accessible health care service which has been mostly underutilized and/or misunderstood. For this project, the practice problem was underutilization of hospice and palliative care services. A systematic review of the literature which focused on under usage of end-of-life care was conducted. MEDLINE, CINAHL, and ProQuest Nursing and Allied Source databases were searched (2005 to 2017). Studies that evaluated interventions for increasing hospice and palliative care services were selected. Conceptual variables included studies that addressed the under usage of end-of-life care. Kolcoba's comfort theory, Parse's theory of human becoming and Chochinov's dignity model was included to identify the issue, gather the data, and help transfer researched data into practice. The tools applied for analysis and synthesis were the appraisal of guidelines research and evaluation and the grading of recommendations, assessment, development and evaluation. The under usage of hospice and palliative care according to this systematic review, has resulted in (a)suffering negative effects on patients at the end of life, who do not receive adequate palliative or comfort care, (b) additional distress for families dealing with grief and denial, and (c) may result in unneeded acute care, adding significantly to the cost of care. This doctoral project formed a cogent set of recommendations consisting of, communication guidance and community education for a local hospice agency and the community. The contribution of positive social change in this community was through education and knowledge to bridge the gap into practice and improve end-of-life care in the community.