Background: Critical Care Nurses have previously noted obstacles in caring for dying patients. Obstacles noted by nurses working in more urban settings have been reported. What is not known is the obstacles to providing end-of-life (EOL) care as perceived by nurses working in Critical Access Hospitals (CAHs). Objective: To determine the stories/experiences related to obstacles in providing EOL care as reported by nurses working in CAHs. Methods: This was an exploratory, cross-sectional study. Previous quantitative data has been reported. Documentation of the qualitative stories/experiences of nurses working in CAHs related to obstacles to providing EOL care for dying patients and their families. Results: Sixty-four CAH nurses provided 96 categorizable responses. Two major categories emerged related to either Family, Physician, & Ancillary staff issues or Nursing, Environment, Protocols, and Miscellaneous issues. Issues related to family behaviors included families insisting on futile care, disagreeing about DNR/DNI orders, issues with out-of-town family members, or even family members who suggested to the nurse to hasten the death of their family member. Physician behaviors related to providing false hope, dishonest communication, continuing futile treatments, or not ordering pain medications. Nursing issues included not having enough time to provide EOL care, already knowing the patient/family, or actions of compassion for the dying patient and family. Conclusion: Family issues continue to be obstacles to providing EOL care for nurses regardless of urban or rural setting. Physician behaviors are also consistent regardless of setting. Education of family members regarding issues with EOL care in ICUs is challenging because it is likely the families first experience with ICU terminology and technology. Further research into EOL care in CAHs is needed.

BACKGROUND: People survive repeated health crises that used to be fatal and, at times, treatment intended to prolong life, prolongs death instead. Many people die in hospitals although they say they prefer to die at home. At the same time, research identifies multiple ways the American healthcare system is ill equipped to serve patients at the end of life. Presently, 20% of Americans die in Intensive Care Units (ICU), thus ICUs represent an important setting for learning about end-of-life care and death in America today. PURPOSE: To explore the nature of ICU care as perceived by family members, this qualitative study analyzed 693 reports from surveys mailed to family members of patients who died in the ICU of a major Boston hospital between 2009 and 2015. The study focused on experiences of received services as reported in responses to the survey’s three open-ended questions regarding helpful and unhelpful aspects of care surrounding the patient’s death. Family member experiences with social work services were also explored. METHODS: Data were assessed using the Family-centered Care (FCC) model, an emerging framework for provision of best practices in hospital settings. This framework emphasizes that patients, families, and health care providers work in partnership to set treatment goals. Since FCC has been correlated with better outcomes, one research objective here was to explore the extent to which family members’ experiences reflected the presence of FCC. The study also assessed family members’ experiences that fell outside the realm of FCC. Using NVivo software, analysis was guided by Braun and Clarke’s (2012) six-phase thematic analysis approach. FINDINGS AND IMPLICATIONS: Family members described numerous positive experiences. Deaths were humane and the delivery of FCC was evident. An in-depth data analysis provided illuminating details of FCC and explicated over 47 themes important to families’ ICU experiences. Families reported that they received emotional support, were well-informed, and were treated with respect. Findings suggest that FCC is possible in an ICU setting, supporting the use of FCC in ICU care and suggesting that it could profoundly improve the quality of end-of-life care. Responses concerning the role of social work were limited.

Background – Most likely, nurses will be in contact with patients and their relatives in palliative care at the end of life at some point in their careers. Studies have shown that relatives (family members or close friends) play a crucial role in palliative care, and that communication is a key factor in providing support for relatives. For optimal care provision, it is essential for nurses to consider and comprehend the experiences of relatives involved in palliative care at the end of life. Aim – The aim of the study was to describe the experiences of being relative to a person receiving palliative care in the end of life. Method – For this study a literature-based study grounded in analysis of qualitative researchwas used (Friberg, 2017). The qualitative method aims to create an understanding of individual’s experiences, perceptions, and needs. Nine scientific studies where analyzed. Results – Three themes where found; 1) The importance of communication and cooperation, 2) Respect and understanding, 3) Emotional challenges. Relatives express a need for clear and accessible information to alleviate stress and enhance their ability to support their loved ones effectively. Active involvement in care decisions and a person-centered approach were underscored as pivotal. Conclusion – The study underscores the significance of tailored information dissemination, active involvement of relatives in care decisions, and a person-centered approach to honor the dignity of patients in end-of-life care. Addressing these aspects can significantly improve the end-of-life experience for patients and their relatives. / Syftet med denna studie var att beskriva erfarenheter av att vara närstående till en person som erhöll palliativ vård i livets slutskede. Närstående påverkas betydligt av situationen då livets slutskede hos deras anhörige väcker många olika känslor och upplevelser. Efter noggrann granskning och analys av nio vetenskapliga artiklar framkom att närstående önskade att få detaljerad information och ville vara mer involverade i vårdbeslut som tas för deras anhörige. När närstående fick vara delaktiga i vården ökade deras välbefinnande. Resultatet tydliggjorde även vikten av att bevara patientens integritet genom att individanpassa vården för att säkerställa en lugn och fridfull palliativ vård i livets slutskede. Närstående uttryckte en önskan om att undvika onödigt lidande för sin anhörige. Närstående menade att detta kunde uppnås genom att deras anhörige fick smärtlindring vid behov. Dessutom efterfrågade närstående stöd från sjuksköterskan, vilket visade sig vara av stor betydelse för att hantera denna känsliga period i livet. Diskussionen belyser sjuksköterskans centrala roll i att möta närståendes behov. Detta inkluderar att patientens integritet beaktas genom att ge en respektfull vård. Diskussionen framhåller närståendes behov av stöd och sjuksköterskans roll i att tillhandahålla känslomässigt stöd och lindra lidande. Genom att bättre förstå och tillgodose närståendes behov kan sjuksköterskan skapa en mer stödjande och empatisk vårdmiljö för både patienten och deras närstående under livets slutskede.

Background: Critical care nurses (CCNs) provide end-of-life (EOL) care for critically ill patients. CCNs face many obstacles while trying to provide quality EOL care. Some research has been published focusing on obstacles CCNs face while trying to provide quality EOL care; however, research focusing on family behavior obstacles is limited.Objective: To determine if magnitude scores (obstacle item size x obstacle item frequency of occurrence) have changed since previous magnitude score data were first gathered in 1999.Methods: A random geographically dispersed sample of 2,000 members of the American Association of Critical-Care Nurses (AACN) was surveyed. Responses from quantitative Likert- type items were statistically analyzed for mean and standard deviation for size of obstacle and how frequently each item occurred. Current data were then compared to similar data gathered in 1999.Results: Six items’ magnitude scores significantly increased over time. Four of the six items related to issues with families including families not accepting poor prognosis, interfamily fighting about continuing or stopping life-support, families requesting life-sustaining measures contrary to the patients’ wishes and, families not understanding the term “life-saving” measures. Two other items included nurses knowing patients’ poor prognosis before families knows and unit visiting hours that were too liberal.Seven items significantly decreased in magnitude score over time, including two items specifically related to physician behavior such as physicians who would not let patients die from the disease process or physicians who avoid talking to family members. Other items which significantly decreased were poor design of units, visiting hours that were too restrictive, no available support personnel, and when the nurse’s opinion regarding direction of care was not valued or considered.Conclusions: EOL care obstacles emphasized in 1999 are still valid and pertinent. Based on magnitude scores, some EOL obstacles related to families increased significantly, whereas, obstacles related to ICU environment and physicians have significantly decreased. Based on this information, recommendations for areas of improvement include improved EOL education for families and nurses.

Bakgrund: Sjuksköterskor ska arbeta utefter en helhetssyn från de fyra hörnstenarna för att stödja och lindra lidande samt främja en god död vid palliativ vård. Som sjuksköterska ska du bemöta patienten med öppenhet för att skapa en tillit och främja en god vård. Syfte: Att studera sjuksköterskors upplevelser av palliativ vård.  Metod: Den valda metoden var en litteraturöversikt av tio kvalitativa och två kvantitativa artiklar som svarade på studiens syfte.  Resultat: I studien framkom två huvudteman och fyra subteman. Dessa påvisar att sjuksköterskor upplever osäkerhet och stora känslor inom den palliativa vården. Även en vilja att främja en värdig död finns hos sjuksköterskorna. Konklusion: Sjuksköterskor upplever att kontinuerlig utbildning ökar kunskap och trygghet samt att de får med sig verktyg som kan främja en god död. / Background: The nurse has to work according to a holistic view from the four cornerstones to support and relieve suffering and promote a good death in palliative care. As a nurse, you have to treat the patient with openness to create trust and promote good care. Aim: The aim was to study nurses experience of palliative care. Method: The chosen method was a literature review of ten qualitative and two quantitative articles that responded to the purpose of the study.  Findings: Two main themes and four subthemes emerged in the study. These show that nurses experience uncertainty and great emotions in palliative care. The nurses also have a desire to promote a dignified death. Conclusion: Nurses feel that continuous education increases knowledge and security and that they get implements that can promote a good death.

Bakgrund: En patient bedöms vara i livets slutskede när allmäntillståndet är nedsatt, ytterligare behandling inte kommer förbättra tillståendet och eventuell försämring riskerar dödlig utgång. För att uppnå bästa möjliga livskvalitet i livets slutskede och inte påskynda eller fördröja döden används palliativ vård. Palliativ vård syftar till att förebygga, lindra lidande och främja livskvalitén för patienter och anhöriga. Sjuksköterskans ansvar är att lindra lidande, främja livskvalitet och en värdig död. Syfte: Syftet är att beskriva sjuksköterskans erfarenheter av att möta patienter i livets slutskede. Metod: En kvalitativ litteraturöversikt med tematisk analysmetod. Resultat: Ett huvudtema identifierades: ”Utmaningar i yrkesrollen” med tre subteman; ”känslomässig påfrestning”, ”meningsfull professionell och personlig utveckling” och ”betydelsen av stöd, samverkan och hanteringsstrategier”. Slutsats: Sjuksköterskorna upplevde vården i livets slutskede som känslomässigt och psykiskt dränerande. Mötena beskrevs vara meningsfulla, givande och utmanande och leda till personlig och professionell utveckling. De upplevde ett personligt lidande, reflekterade kring existentiella frågor samt tvingades balansera mellan att vara emotionellt närvarande och emotionellt distanserade. Sjuksköterskorna ville vara tillgängliga för patienterna med behov av existentiellt och emotionellt stöd samtidigt som de behövde hantera sina reflektioner kring liv och död. Även vikten av hanteringsstrategier samt stödjande kollegor belystes. / Background: A patient is at the end-of-life [EOL] when the general condition is impaired, further treatment will not improve the condition and any deterioration risks death. Palliative care is used to achieve best quality of life [QOL] at the EOL and not to hasten or delay death. Palliative care aims to prevent and alleviate suffering and promote QOL for patients and their families. The nurse's responsibility is to alleviate suffering, promote QOL and a dignified death. Aim: The aim is to describe the nurses’ experiences of meeting patients at end-of-life. Method: Qualitative literature review with thematic analysis method. Results: A main theme was identified: 'Challenges in the professional role' with three sub-themes: 'emotional strain', 'meaningful professional and personal development' and 'the importance of support, collaboration and coping strategies'. Conclusion: The nurses experienced EOL care as emotionally and psychologically draining. Encounters were described as meaningful, rewarding and challenging which led to personal and professional development. They experienced personal suffering, reflected on existential issues and had to balance between being emotionally present, emotionally distant and dealing with their own reflections on life and death. The importance of coping strategies and supportive colleagues was also highlighted.

The global market for wind energy is expanding rapidly, and in the last decade, Sweden has constructed thousands of wind turbines. The high installation pace suggests that a similarly rapid decommissioning rate is to be anticipated in the near future, notwithstanding the small number of turbines that have been retired thus far. There will be serious questions about the viability of wind power as a clean energy option if the decommissioned material by unfunctional turbines is not managed in a proper manner. The purpose of this research is to provide the distribution of Swedish installed wind turbine with the aspect of age, brand & model, hub height & rotor diameter, and nameplate capacity and also a reliable estimate of the total amount of decommissioned material that will be produced by wind turbines in Sweden over the next two decades. The results will represent to current characteristic of an industry to benefit the operation & maintenance activity and wind industry market research. Moreover, this will also help the waste management sector prepare for the inevitable increase in decommissioned material. The estimates are based on the installation dates, rotor diameter and other pertinent data included in vbk.lansstyrelsen.se, a Swedish national wind turbine map service. Applying the available data set with logarithmic function of rotor diameter and material fraction technique, the quantity of steel, iron, copper,aluminium, blade material, and electronics were generated. The material of each turbine is considered to be dismantled as wastes at 20 years after the installation date due to the industry average and comparison with empirical facts. As the results, the distributions show that most of Swedish wind turbines were installed between 2007 and 2016 and the most popular rated capacity ranged between 2 MW to 3 MW. Furthermore, the biggest market share belonged to Vestas, Enercon, and Siemens, respectively. The forecasted numbers reveal a large increase in decommissioned material weights year by year, and the blade material end-of-life management is the key concern when comparing the estimated number to Sweden's waste management capacity. Limitations associated with the suggested methodology and adopting data set are presented and discussed.

Complex continuing care (CCC) is a healthcare setting where many patients die. Previous research has demonstrated that patient deaths can be meaningful and challenging for nurses. However, little knowledge exists regarding how the unique features of CCC influence nurses’ experiences in managing patient deaths. The objective of this study was to explore nurses’ experiences when patients die and their perceptions of support surrounding these experiences. Using interpretive description methodology, 13 memorable patient death experiences were explored in semi-structured interviews with licensed nurses (n=12) and nursing leaders (n=1). Criterion and theoretical purposeful sampling were used to develop a rich understanding of nurses’ experiences when patients die. Concurrent data collection and analysis uncovered five key intersubjective themes which described nurses’ experiences with individual deaths and how nurses’ experiences change overtime which included: (a) Professionally experiencing patients’ deaths: 'Engaging your left brain;’ (b) Personally experiencing patients’ deaths: ‘I’m a human being too;’ (c) Seeking resolution in the experience: ‘It was a good resolution;’ (d) Integrating professional and personal experiences: ‘Applying what you learn in your nursing life into your personal life and vice versa,’ and; (e) Supporting One Another in a Culture of Acknowledging Patients’ Deaths and Nurses’ Experiences: ‘They expect us just to take it, the nursing profession is like that.’ These findings suggest that nurses need support to facilitate the interpersonal and intrapersonal aspects of their experiences with patient death. This support should be grounded in a unit culture which openly accepts patient death and acknowledges nurses’ experience. Just-in-time education, peer mentorship and targeted support may further facilitate nurses’ ability to find resolution when patients die and support their on-going journey towards integrating death experiences in their lives and practice. / Thesis / Master of Science (MSc) / Complex continuing care (CCC) is a healthcare setting where many people die. Patient deaths can be difficult and sad for nurses. The goal of this study was to learn more about nurses’ experiences when patients die in CCC. Nurses were asked to share memories of when patients died in CCC. This study found that patient deaths influence nurses personally and professionally. Nurses with fewer death experiences were uncomfortable caring for dying patients. Feeling understood and having their experience recognized were meaningful ways that nurses wanted to be supported. It was very important to nurses that the deceased person was respected and nurses worried about patients’ family members. This research shows that nurses with fewer death experiences would benefit from unique education and support. It is important to support nurses by creating a culture that acknowledges death in CCC and nurses’ responses to patients’ deaths.

Informal caregivers (CG) of persons with dementia can experience increased negative effects and symptoms of burden as the disease progresses, with long-term effects into bereavement. The purpose of this study was to describe staff and attendees’ perceptions of a unique CG psychoeducation program located in a Specialized Care Unit for persons with advanced dementia at end-of-life. This study used a qualitative descriptive design, which aimed to describe a natural experience. Sixteen individual interviews were conducted with current and bereaved CGs who jointly participated in the program, health care professionals (HCP) in the Specialized Care Unit and social work facilitators to understand experiences, perceived benefits and barriers of the program. Thematic content analysis was conducted with data collection following Hamilton Integrated Research Ethics Board approval. Final results indicate that the program was perceived positively, across all participant groups. Caregivers reported that the program contributed to improved emotional well-being, development of a close community, disease preparedness and empowerment. Participants also appreciated the open-ended, informal format of the program with continuity into bereavement. The study findings support the unique characteristics of this psychoeducation program compared to traditional education / support programs, which are closed to bereaved members and time-limited. This program model is translatable to multiple settings including long-term care. Moreover, study findings highlight the movement towards relationship-centered care for persons with dementia and their CGs. A future mixed-method study is warranted to measure quantitative outcomes, such as complicated grief, within CGs attending the program before and after bereavement. / Thesis / Master of Science (MSc) / Family caregivers of persons with dementia can become depressed, anxious and isolated over time from caregiving. These feelings often do not go away even after the person with dementia has died. In this study, caregivers of people with advanced dementia or who had died, described how they felt about a new support and education program in a special unit of the hospital. Findings showed that caregivers believed the program helped them become: more balanced and part of a supportive community, empowered and prepared for end-of-life and occasionally frustrated. Caregivers whose family member had died felt the program gave them continued support, a chance to help others, and a place to continuing learning. Nurses should try to include caregivers in caring for people with dementia, learn about the program, become more involved, encourage people to attend, and help to begin the program in other areas of the hospital and long-term care.

This scoping review contains a literature analysis regarding interventions used by health care workers to alleviate guilt in caregivers of patients during end-of-life care. During end-of-life care, many transitions and decisions are made that add to the burden of caregivers. Family caregivers experience many physical, financial, and emotional stressors during the journey of end-of-life care, and this can result in guilt. Feelings of guilt can lead to poorer health outcomes and coping in family caregivers and should be addressed by health providers. In this scoping review, a literature search was conducted using various key terms like "guilt," "hospice," "end-of-life care," "interventions," and "caregivers." The articles that fit the criteria were examined to find tested interventions to alleviate guilt in family caregivers of patients in end-of-life or hospice care. A total of 13 articles were analyzed and divided into three sections, interventions that directly influence guilt, interventions that indirectly influence guilt, and interventions recommended by caregivers and hospice workers. Main themes that emerged for tested and recommended interventions include shared decision making, increased communication with health care providers, increased education on disease process and available options, and an emphasis on caregiver self-care. This research is limited and can provide the framework for future interventions to be tested and applied to the care of family caregivers experiencing guilt while caring for or grieving their loved one.