No / Palliative care, since its inception over 60 years ago, has set the standard of how to care for people who are dying. Key features among these standards have been the professional development of clinical specialisms such as palliative medicine and palliative nursing; the essential addition of the multidisciplinary team to these two new specialisms that included social, spiritual and allied health workers—an outgrowth of the recognition that routine work with the dying, their carers, and the bereaved required more than solely clinical skills; and the unique partnership with communities that yielded the volunteer movement within palliative care. Professional, evidence-based symptom management and the importance of supportive care in its widest possible sense were and remain the cornerstones of the modern palliative care approach. However, the majority of people with terminal illnesses do not have access to palliative care teams, whose main focus of care remains patients with cancer. In the context outlined above this paper therefore poses two key questions: how can we provide an equitable level of care for all people irrespective of diagnosis and how can we increase the range and quality of non-medical/nursing supportive care in a context of diminishing resources? We argue that an important opportunity and solution can be found by adopting the principles of a public health approach to end-of-life care.

No / Communities play an increasingly significant role in their own health and social care, and evidence demonstrates the positive impact of this work on a range of health outcomes. Interest is building regarding the application of the principles of the new public health approach to those facing the end of life and their families and communities. To review the evidence relating to the impact of a new public health approach to end-of-life care, specifically as this applies to efforts to strengthen community action. Design: A systematic review employing narrative synthesis. Both meta-ethnography and the use of descriptive statistics supported analysis. Data sources: Eight databases (AMED, ASSIA, BiblioMap, CINAHL, Cochrane Reviews, EMBASE, MEDLINE and PsycINFO) were searched from the earliest record to March 2015 using set eligibility criteria. Results: Eight articles were included in the analysis. Three main themes emerged from the meta-ethnography: making a practical difference, individual learning and personal growth and developing community capacity. The quantitative findings mapped to the meta-ethnography and demonstrated that engaging communities can lead to improved outcomes for carers such as decreased fatigue or isolation, increase in size of caring networks and that wider social networks can influence factors such as place of death and involvement of palliative care services. Conclusion: Evidence exists for the impact of community engagement in end-of-life care. Impact assessment should be an integral part of future initiatives and policy makers should recognise that these approaches can influence complex issues such as carer support, community capacity, wellbeing and social isolation.

Yes / The majority of people with dementia in the UK die in care homes. The quality of end of life care in these environments is often suboptimal. The aim of the present study was to explore the context, mechanisms and outcomes for providing good palliative care to people with advanced dementia residing in UK care homes from the perspective of health and social care providers. Method: The design of the study was qualitative which involved purposive sampling of health care professionals to undertake interactive interviews within a realist framework. Interviews were completed between September 2012 and October 2013 and were thematically analysed and then conceptualised according to context, mechanisms and outcomes. The settings were private care homes and services provided by the National Health Service including memory clinics, mental health and commissioning services in London, United Kingdom. The participants included 14 health and social care professionals including health care assistants, care home managers, commissioners for older adults’ services and nursing staff. Results: Good palliative care for people with advanced dementia is underpinned by the prioritisation of psychosocial and spiritual care, developing relationships with family carers, addressing physical needs including symptom management and continuous, integrated care provided by a multidisciplinary team. Contextual factors that detract from good end of life care included: an emphasis on financial efficiency over person-centred care; a complex health and social care system, societal and family attitudes towards staff; staff training and experience, governance and bureaucratisation; complexity of dementia; advance care planning and staff characteristics. Mechanisms that influence the quality of end of life care include: level of health care professionals’ confidence, family uncertainty about end of life care, resources for improving end of life care and supporting families, and uncertainty about whether dementia specific palliative care is required. Conclusions: Contextual factors regarding the care home environment may be obdurate and tend to negatively impact on the quality of end of life dementia care. Local level mechanisms may be more amenable to improvement. However, systemic changes to the care home environment are necessary to promote consistent, equitable and sustainable high quality end of life dementia care across the UK care home sector

No / The number of children in the UK with life-limiting conditions and the demand for home-based palliative care is increasing. Children's hospices remain a dominant provider of palliative care. This study aimed to determine the approaches taken by children's hospices across the UK in meeting the planned and unplanned health needs of children and their families who receive palliative care at home. In addition, the survey aimed to identify the professional composition of community teams and the number of children and families supported by each service. An internet-based questionnaire survey was sent to all children's hospices in the UK, comprising ten questions exploring the size of the team, geographical areas covered, workforce composition, services offered and approaches to managing unplanned, out of hours care. Responses were received from 14 (26%) of the hospices. A total of 1,618 children and their families were being cared for by these hospices, of whom 825 received care at home. Registered nurses constituted the greatest proportion of staff and were employed by all teams. Care provided at home was broadly split into two categories: planned short breaks and responsive palliative nursing. The latter comprised advance care planning, anticipatory prescribing and active symptom control. Out of hours care was usually offered in the form of telephone support. Models of community-based care are evolving to include nurses practising at specialist and advanced levels, allowing more children with increasingly complex conditions to be cared for at home.

Yes / ackground Patient access to medicines in the community at end-of-life (pertaining to the last year of life) is vital for symptom control. Supply of such medicines is known to be problematic, but despite this, studies have failed to examine the issues affecting community pharmacy access to palliative medicines. Objective To identify community pharmacists' and pharmaceutical wholesalers'/distributors' views on supply chain processes and challenges in providing access to medicines during the last year of life, to characterise supply in this UK context. Methods Qualitative design, with telephone interviews analysed using Framework Analysis. Coding frames were developed iteratively with data analysed separately and then triangulated to examine differences in perspectives. Findings Thirty-two interviews (24 community pharmacists and 8 wholesalers/distributors) were conducted. To ensure appropriate palliative medicines were available despite occasional shortages, community pharmacists worked tirelessly. They navigated a challenging interface with wholesalers/distributors, the Drug Tariff to ensure reimbursement, and multiple systems. IT infrastructures and logistics provided by wholesalers/distributors were often helpful to supply into community pharmacies resulting in same or next day deliveries. However, the inability of manufacturers to predict operational issues or accurately forecast demand led wholesalers/distributors to encounter shortages with manufactured stock levels, reducing timely access to medicines. Conclusions The study identifies for the first time how palliative medicines supply into community pharmacy, can be improved. A conceptual model was developed, illustrating how influencing factors affect responsiveness and speed of medicines access for patients. Work is required to strengthen this supply chain via effective relationship-building and information-sharing, to prevent patients facing disruptions in access to palliative medicines at end-of-life.

Par une approche analytique, cette étude en éthique clinique a examiné la problématique de la demande d’assistance médicalisée pour mourir formulée dans le cadre des soins de fin de vie. Partant du fait que cette demande sollicite les soignants dans leur savoir et leur savoir-faire, surtout dans leur savoir-être, cette étude rend d’abord compte d’un fait : bon gré mal gré l’interdit de l’euthanasie par la loi et la déontologie médicale, ainsi que le débat contradictoire à son sujet qui dure déjà voici quelques décennies, il arrive de temps à autres que les soignants œuvrant en soins de fin de vie, soient confrontés à une demande d’assistance médicalisée pour mourir. Cette demande qui émane de certaines personnes en fin de vie et / ou de leurs proches, est souvent source de malaise pour les soignants à l’endroit de qui elle crée des défis majeurs et fait naître des dilemmes éthiques importants. Plus particulièrement, cette demande interroge toujours la finalité même des soins de fin de vie : est-ce que l’aide pour mourir fait partie de ces soins ? En réponse à cette question difficile, cette démarche réflexive de soignant chercheur en éthique montre qu’il est difficile de donner une réponse binaire en forme de oui / non ; il est difficile de donner une réponse d’application universalisable, et de définir une généralisable conduite à tenir devant une telle demande, car chaque cas est singulier et unique à son genre. Cette étude montre prioritairement que l’humanisation de la mort est à la fois un enjeu éthique important et un défi majeur pour notre société où la vie des individus est médicalisée de la naissance à la mort. En conséquence, parce que la demande d’assistance médicalisée pour mourir sollicite les soignants dans leur savoir et leur savoir-faire, cette étude montre toute l’importance de la réflexivité et de la créativité que doivent développer les soignants pour apporter une réponse constructive à chaque demande : une réponse humanisant le mourir et la mort elle-même, c’est-à-dire une réponse qui soit, sur le plan éthique, raisonnable et cohérente, une réponse qui soit sur le plan humain, porteuse de sens. D’où, outre l’axiologie, cette démarche réflexive montre que l’interdisciplinarité, la sémantique, l’herméneutique et les grilles d’analyse en éthique, constituent des outils réflexifs efficaces pouvant mieux aider les soignants dans leur démarche. Sur quelles bases éthiques, les soignants doivent-ils examiner une demande d’assistance médicalisée pour mourir, demande qui se présente toujours sous la forme d’un dilemme éthique? Cette question renvoie entre autre au fait que cette demande sollicite profondément les soignants dans leur savoir-être en relation des soins de fin de vie. Aussi bonnes les unes que les autres, qu’on soit pour ou contre l’euthanasie, plusieurs stratégies et méthodes d’analyse sont proposées aux soignants pour la résolution des conflits des valeurs et des dilemmes éthiques. Mais, ce n’est pas sur cette voie-là que cette étude invite les soignants. C’est plutôt par leur réflexivité et leur créativité, enrichies principalement par leur humanisme, leur expérience de vie, leur intuition, et secondairement par les différentes méthodes d’analyse, que selon chaque contexte, les soignants par le souci permanent de bien faire qui les caractérisent, trouveront toujours par eux-mêmes ce qui convient de faire dans l’ici et maintenant de chaque demande. C’est pourquoi, devant une demande d’assistance médicalisée pour mourir qui leur est adressée dans le cadre des soins de fin de vie, cette démarche éthique invite donc les soignants à être « des cliniciens créatifs, des praticiens réflexifs» . C’est pour cette raison, sur le plan proprement dit de la réflexion éthique, cette étude fait apparaître les repères de l’éthique humaniste de fin de vie comme bases axiologiques sur lesquels les soignants peuvent construire une démarche crédible pour répondre au mieux à cette demande. L’éthique humaniste de fin de vie située dans le sillage de l’humanisme médical , où l’humain précède le médical, renvoie au fait qu’en soins de fin de vie où émerge une demande d’aide à la mort, entre le demandeur de cette aide et le soignant, tout doit être basé sur une confiante relation d’homme à homme, même si du côté du soignant, son savoir être dans cette relation est aussi enrichi par sa compétence, ses connaissances et son expérience ou son savoir-faire. Basée sur l’humanité du soignant dans la démarche de soins, l’éthique humaniste de fin de vie en tant que pratique réflexive émerge de la créativité éthique du soignant lui-même et de l’équipe autour de lui ; et cette éthique se situe entre interrogation et transgression, et se définit comme une éthique « du vide-de-sens-à-remplir » dans un profond souci humain de bien faire. Car, exclue l’indifférence à la demande de l’assistance médicalisée pour mourir, son acceptation ou son refus par le soignant, doit porter sur l’humanisation de la mort. Cette dernière étant fondamentalement définie par rapport à ce qui déshumanise la fin de vie. / In an analytical approach, this clinical ethics study analyzes the issue of medical assistance request in dying in the context of end-of-life care. Runner of the fact that this request seeks the healthcare professionals in their knowledge and their know-how as well as in their knowledge-being in relation of the end-of-life care, this study gives first account of a fact: like it or not the prohibition of voluntary euthanasia by law and ethics, and the controversial debate about it in the last few decades, healthcare professionals involved in end-of-life care every so often are faced with a request of medical assistance to die. The request from some dying patients and / or their relatives often causes discomfort for the healthcare professionals to the point that it creates challenges and raises significant ethical dilemmas. Specifically, this request always challenges the very purpose of end-of-life care: Is medical assistance to dying part of the end-of-life care? In response to this difficult question, my reflexive ethics as medical researcher shows that: it is difficult to give a binary response yes / no. It is difficult to answer by a universalized application and define a generalized course of action, because each case is singular and unique to its kind. Accordingly, this study demonstrates the importance of reflexivity and creativity to be developed by the healthcare professionals to respond constructively to every request: a response humanizing dying and death itself. Hence, because the request of the assistance provided with medical care to die seeks the healthcare professionals in their knowledge and their know-how, in addition to axiology, this reflexive approach shows that interdisciplinarity, semantics, hermeneutics and analysis grids in ethics are effective reflexive tools that can better assist healthcare professionals in their approach. On what ethical basis, the healthcare professionals have to consider a request of medical assistance to dying, request that always presents itself as an ethical dilemma? This question sends back among others to the fact that this request seeks the healthcare professionals in their knowledge-being in relation of the end of life care. Several strategies and analysis methods, all equally good, are available to healthcare professionals for the resolution of ethical dilemmas. However, this is not the perspective this study invites healthcare professionals to discuss. Rather, it is through their reflexivity and creativity, enriched mainly by their humanity, life experience, intuition, and secondly helped by the different methods, that, according to each context, healthcare professionals in their ongoing effort to do right, that characterizes them, always find by themselves what is best to do here and now for each request. That is why, in front of a request of the assistance provided with medical care to die which is sent to them within the framework of the care of the end of life, this ethical approach thus invites the healthcare professionals to be “creative clinicians, reflexive practitioners " . Also, that is why, in terms of ethical reflection, this study exposes the framework of the humanistic ethics in end-of-life issues as axiological foundations on which health care providers can build their approach to best meet the request of medical assistance to die that they may receive in the context of end-of-life care. The humanistic ethics in end-of-life issues studied in the context of medical humanism , in which human precedes medical, refers to the fact that end-of-life care from which emerges a request for assisted death, between the one requesting such an assistance and the healthcare professional, everything must be based on a trusting human relationship between two persons, even if on the healthcare professional’s side, his personal and practical skills in this relationship are also enriched by his competence, knowledge and experience. Based on the humanity of the healthcare professionals in the medical process, humanistic ethics of end of life as a reflexive practice emerges from the ethical creativity of the healthcare professional himself and the team around him. This ethics is between query and transgression, and is defined as an ethics "vide-de-sens-à-remplir" in a deep human desire to do right. For, excluding indifference towards the request of medical assistance to dying, its acceptance or its rejection by the healthcare professionals must be a reasoned response and meaningful to the person who makes the request, whoever he may be, the dying patient or his relatives, and for the caregiver himself.

To end the use of a digital technology one must go througha process that research entitle information systems (IS)discontinuance. Prior research has developed phases andactivities that can be implemented in the IS discontinuanceprocess, but this knowledge is limited and has not beencompiled. This study purpose is therefore to create a modelof the IS discontinuance process and in it identify furtheractivities. To accomplish this, a real IS discontinuance hasbeen studied, who has had different circumstances andstakeholders than of previous studies. The discontinuanceprocess has occurred at a large organisation whomanufacture vehicles and the study has been conducted incollaboration with this organisation. The studied IS inquestion is an eLearning authoring tool. Information aboutthis discontinuance process has been collected throughsemi-structured personal interviews with five participantswho are employees at the organisation. The collected datahas been analysed and interpreted in comparison to atheoretical model of the IS discontinuance process, whichcontains phases and activities. The result of the analysis andinterpretation is an iterative model of the IS discontinuanceprocess with phases and activities, of which 34 are newfound activities. A big part of these activities can be relatedto the new circumstance and stakeholders within thestudied discontinuance process / Att sluta använda digitala teknologier sker genom en processsom forskningen benämner sominformationssystemsavveckling (IS-avveckling). Tidigareforskning har tagit fram faser och aktiviteter som kangenomföras i IS-avvecklingsprocessen, men denna kunskapär begränsad och har inte sammanställts. Denna studie syftarsåledes att skapa en modell av IS-avvecklingsprocessen och iden identifiera ytterligare aktiviteter. För att realisera dettahar en verklig IS-avvecklingsprocess studerats som haft ettannat förhållande och intressenter än i tidigare studier.Avvecklingen har skett hos en stor organisation somtillverkar fordon och studien har genomförts tillsammansmed dem. Avvecklingen harutförts på organisationens eLearning författarverktyg.Information om avvecklingen har samlats in genomsemistrukturerade personliga intervjuer med fem styckenrespondenter som är anställda hos organisationen. Deninsamlade datan har analyserats och tolkats i jämförelse meden framtagen teoretisk modell för IS-avvecklingsprocessensom innehåller faser och aktiviteter. Resultatet av analysenoch tolkningen blev en iterativ modellen för ISavvecklingsprocessen med faser och aktiviteter, varav 35stycken nya aktiviteter hittats. Stor del av dessa nyaaktiviteter kan kopplas till det nya förhållandet ochintressenterna i avvecklingen.

The solar industry is one of the fastest-growing energy industries in the global market. The reason is a combination of the falling prices of modules and inverters and increased conversion to fossil-free energy production. When a photovoltaic module reaches the end of its life it needs to be replaced and discarded, which can create a sustainability problem depending on how this is managed. Today, less than 10% of the global photovoltaic waste is recycled. Only the European Union has implemented photovoltaic waste regulations in the form of the WEEE Directive, which requires that 85% of the waste is collected and at least 80% of waste collected must be prepared for reuse or recycling. This master thesis examines the energy technical, economic, and political conditions for a Swedish photovoltaic recycling plant. This is done through a literary study that is enhanced with calculations of future potential waste volumes and their economic value. As an alternative to a Swedish plant, the energy consumption for transporting waste to existing recycling plants in Europe is evaluated. The photovoltaic technologies included in this work are silicon-based mono-and polycrystalline modules, cadmium tellurium (CdTe) and copper indium gallium selenide (CIGS). Based on the calculations and the literature study, the energy technical conditions are good and not a barrier for a potential facility, the political conditions are deficient, and regulations need further development. The economic conditions constitute the largest barrier as waste volumes are not large enough for a Swedish facility to be economically profitable until 2042. The energy consumption for transport to existing recycling plants in Europe was 22 MJ/module for silicon-based mono-and polycrystalline modules and 10 MJ/module for CdTe modules. Which is a good alternative to a Swedish plant as collection processes and recycling processes are already in place.

Für Brennstoffzellen wird in den kommenden Jahren ein erhebliches Marktwachstum prognostiziert. Aktuell besteht die Notwendigkeit die technischen und wirtschaftlichen Herausforderungen für einen Markthochlauf zu realisieren. Hierzu müssen neue hochratenfähige Fertigungstechnologien entwickelt werden, um die Produktions- und Stückkosten zu senken. Für das Stapeln von Brennstoffzellen-Stacks sollen zukünftig mehrere entwickelte Konzepte für das „Stacking im Fließverfahren“ betrachtet und hinsichtlich ihrer Machbarkeit und Wirtschaftlichkeit überprüft werden. Zusätzlich müssen hochratenfähige Prüfverfahren entwickelt werden, um eine Null-Fehler-Produktion der kostenintensiven Komponenten und Systeme zu gewährleisten. Hierbei sollen u.a. KI-basierte Technologien genutzt werden. Die Abhandlung zeigt den aktuellen Stand der Technik auf dem Gebiet des Stapelns und stellt innovative und zugleich wirtschaftliche technische Lösungsansätze vor, wie die Fertigungsprozesse zukünftig gestaltet werden können und welche technologischen Neuerungen dafür notwendig sein werden. Weiterhin steht die Demontage der Brennstoffzellen unter dem Aspekt einer optimalen Verwertung (Recycling) sowie insbesondere der Nachnutzung (ReUse) im Fokus der Betrachtungen. / Considerable market growth is forecast for fuel cells in the coming years. Currently, there is a need to realise the technical and economic challenges for a market ramp-up. To this end, new high-rate manufacturing technologies must be developed in order to reduce production and unit costs. For the stacking of fuel cell stacks, several developed concepts for 'stacking in a flow process' are to be considered in the future and examined with regard to their feasibility and economic efficiency. In addition, high-rate testing methods must be developed to ensure zero-defect production of the cost-intensive components and systems. Among other things, AI-based technologies are to be used here. The paper shows the current state of the art in the field of stacking and presents innovative and at the same time economical technical solution approaches, how the manufacturing processes can be designed in the future and which technological innovations will be necessary for this. Furthermore, the disassembly of the fuel cells under the aspect of optimal utilisation (recycling) as well as re-utilisation (ReUse) is the focus of the considerations.

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