Bakgrund: Vård i livets slut syftar till att förebygga och lindra lidande. Idag lever människor allt längre vilket resulterar i att behovet av palliativ vård och vård i livets slut ökar. Det kan upplevas som utmanande att vårda en döende patient eftersom denna vårdform fortfarande kan vara främmande för många sjuksköterskor. Syfte: Litteraturöversiktens syfte är att sammanställa forskningsbaserad kunskap om vad som kan påverka sjuksköterskans erfarenheter av vård i livets slut för patienten på en somatisk vårdavdelning.  Metod: Studien genomfördes som en litteraturöversikt som baserades på 15 vetenskapliga artiklar, varav tolv kvalitativa och tre kvantitativa. Artiklarna söktes fram via databaserna i PubMed och CINAHL. Resultat: Huvudresultatet som identifierades i studien var kompetens, utmaningar och vårdens resurser. Otillräcklig kompetens hos sjuksköterskor framkom, likaså att mer utbildning behövdes på grund av bristande kunskapen hos sjuksköterskor på somatiska vårdavdelningar när det gällde vård i livets slut. Sjuksköterskor som fått utbildning inom området upplevde det lättare och kände sig tryggare med att vårda döende patienter. Det framkom behov av att utveckla detta område i den grundläggande sjuksköterskeutbildningen. Kommunikation, som till exempel att bygga förtroende och sjuksköterskans förmåga att uttrycka sig, var viktiga faktorer. Sjuksköterskor tyckte att det var utmanande att få ett förtroende från patientens närstående.  Slutsats: Sjuksköterskans kunskap har i resultatet visats vara viktigt och behovet av utbildning och fortbildning har varit tydligt framträdande. Med den sjuksköterskebrist som råder behövs fler sjuksköterskor med rätt kunskap. Utbildning och praktiska erfarenheter kan bidra till att sjuksköterskor känner sig trygga i rollen att vårda döende patienter samt att kommunicera med dem och deras närstående. / Background: Palliative care and end-of-life care aims to prevent and relief suffering. Today people live longer which shows an increased care of dying patients. It can be expressed as challenging to care for a dying patient since this form of care still can be foreign to many nurses. Aim: The purpose of this literature review was to compile research-based knowledge of things that can affect the nurse's experiences of care in the end of life for the patient in a somatic hospital setting. Method: The study was conducted as a literature review which was based on twelve qualitative and three quantitative studies. The results were based on scientific articles that were found in databases such as PubMed and Cinahl.  Results: The main result that was identified in the study was competence, challenges and resources of care. Nurses had a lack of knowledge when caring for dying patients in a somatic hospital setting. The competence was inadequate and it appeared that there was a need of more education and the basic nursing education needs to be further developed in end of life care. Nurses who received education in end of life care were more safe caring for dying patients. Communication, for example building trust and the nurse’s ability to express themselves, were important factors. Nurses thought it was challenging to earn trust from the patient's relatives. Conclusion: The results have shown that the nurse's knowledge is important and the need for education and training has been clearly prominent. Today there is a lack of nurses and there is a need for more nurses with the right knowledge. Education and practical experience can help the nurses feeling safer in the role of caring for dying patients and communicating with them and their relatives.

A escassez de sistemas consolidados de reciclagem de veículos no Brasil e o grande volume de veículos em final de vida (VFVs) junto aos pátios do Departamento Estadual de Trânsito do Rio Grande do Sul - DETRAN/RS serviram de base para o desenvolvimento desta dissertação. Em face disso, o objetivo deste trabalho foi desenvolver um sistema de reciclagem de VFVs ambientalmente mais sustentável, a partir de exemplos globais de melhores práticas adotadas, atendendo à legislação vigente do país. Para tanto, a presente dissertação é composta por dois estudos fundamentados em revisões sistemáticas e em estudos de caso. Inicialmente, como resultado da primeira revisão sistemática, foi realizada a comparação de sistemas de gestão de reciclagem de veículos, identificados em 25 países. Essa comparação possibilitou ampliar o conhecimento de tecnologias e de procedimentos adotados em diferentes realidades, permitindo a proposição de oito políticas a serem adotadas em âmbito nacional, bem como três ações de melhoria ao atual sistema do DETRAN/RS. Em seguida, a segunda revisão sistemática permitiu a proposição de um sistema ambientalmente adequado para reciclagem de VFVs, que sirva de base para a futura padronização de processos de reciclagem, visando a potencial criação de centros especializados em reciclagem de veículos (CERVs). Diante do exposto, os resultados da pesquisa demonstraram que o tema da reciclagem de veículos está inserido num cenário mais amplo, necessitando da participação de todos os stakeholders envolvidos no processo, a exemplo: (i) das montadoras e fabricantes de peças, no desenvolvimento de tecnologias automotivas; (ii) dos entes federados, na criação de legislações mais rígidas e específicas, com foco na economia circular; e (iii) da sociedade na busca de produtos eco-amigáveis. Por fim, conclui-se que, associado às políticas e ações de melhoria sugeridas, a adoção do sistema ambientalmente adequado para reciclagem de VFVs proposto, poderá acelerar a criação de um ambiente favorável para o desenvolvimento e a consolidação da reciclagem no país. / The scarcity of consolidated vehicle recycling systems in Brazil and the huge amounts of endof- life vehicles (ELVs) at the Transit State Department of Rio Grande do Sul - DETRAN/RS courtyards served as the basis for the development of this Masters dissertation. Therefore, the objective of the work was to develop an environmentally more sustainable ELVs recycling system, based on global adopted best practices, without disregarding the country's current legislation. So, this dissertation is composed of two studies based on systematic reviews and on case studies. Initially, as a result of the first systematic review, a comparison of vehicle recycling management systems was carried out, identified in 25 countries. This comparison allowed the increasing of the knowledge about technologies and procedures adopted in different realities, making possible a proposal of educational policies to be adopted at national level, as well as three improvement actions for the current system of the DETRAN/RS. Subsequently, a second systematic review allowed a proposal for a suitable environmentally recycling system for the ELVs, which serves as the basis for a standardization of recycling processes, aiming the potential creation of specialized centers for such processes (CERVs). Considering this, the research results showed that the theme of product recycling is inserted in a broader scenario, requiring participation of all stakeholders involved in the process, such as: (i) the automakers and parts manufacturers, in the automotive technologies development; (ii) the federal entities, in the creation of more rigid and specific legislation, focusing on the circular economy; and (iii) the society in the search for eco-friendly products. Finally, it is concluded that, associated with the suggested policies and improvement actions, the adoption of the proposed environmentally appropriate system for the recycling of the ELVs, may accelerate the creation of a favorable way to the develop and consolidate the recycling in our country.

Bakgrund: Hjärtsvikt är en allvarlig sjukdom med hög mortalitet och förr eller senare uppstår behov av palliativ vård.  Syftet med studien var att beskriva omvårdnadsbehov samt omvårdnadsåtgärder vid hjärtsvikt i palliativt skede. Metod: Den metod som användes var systematisk litteraturstudie. Nio artiklar inkluderades. De granskades och huvudkategorier med underkategorier bildades. Resultat: De sex kategorier som framkom var; Brister i kommunikation, information och stöd; Existentiella; Dyspné; Fatigue och depression; Ångest och Minskad rörelseförmåga. Patienternas behov var symtomlindring, god omvårdnad och bättre kommunikation vid vård i livets slutskede. Konklusion: Distriktsköterskan fungerade som en länk åt patienten. Samarbete med andra professioner var önskvärt. Kunskap, information, symtomlindring och god vård spelade en viktig roll i omvårdnaden av patienter med hjärtsvikt. De resultat som framkom ger en vägvisning om vilka faktorer som spelar roll för omvårdnaden av patienter med hjärtsvikt i palliativt skede. / Background: Heart failure is a serious illness with high mortality and sooner or later arises the need for palliative care. The aim of this study was to describe the care needs and care measurses for patients with heart failure in a palliative stage. Method: the method used was a systematic literature study. Nine articles were included. They were reviewed then categories and subcathegories was formed. Results: The six categories that emerged were deficits in communication, information and support; Existential; Dyspnea; Fatigue and Depression; Anxiety and Reduced mobility. Patients’ needs where symptom relief, good care and better communication at the end of life. Conclusion: The districtnurse acts as a link to the patient. Cooperation with other professions is desirable. Knowledge, information, symptom relief and good care play an important role in the care of patients with heart failure. The result that emerged gives a guidance on which factors play an important role in care of patients with heart failure in the palliative phase.

A recuperação de produtos por meio das estratégias de fim de vida (EoL) é uma alternativa pró-ativa que visa diminuir os impactos ambientais e os resíduos decorrentes do descarte desses produtos. O objetivo deste trabalho é levantar as práticas ligadas às estratégias de fim de vida que podem auxiliar o processo de desenvolvimento de produtos (PDP) e verificar quais estão sendo aplicadas por algumas empresas que recuperam produtos na fase de pósconsumo. Para tanto, foi realizada uma revisão bibliográfica sistemática que identificou 87 práticas de estratégias de fim de vida e 64 práticas operacionais que podem ser usadas na integração da recuperação de produtos no PDP. De modo a verificar a aplicação das práticas operacionais, foram realizados quatro estudos de caso em empresas reconhecidas pela sua excelência em processos de remanufatura. Os resultados da pesquisa permitem verificar a baixa aplicação de práticas operacionais dentro dessas empresas no processo de desenvolvimento de produtos. Nos casos em que elas foram implantadas, observou-se que elas são uma mera conseqüência da melhoria continua dos processos. No entanto, as empresas já percebem a importância dessas práticas operacionais para a melhoria da gestão do ciclo de vida de seus produtos e das oportunidades relacionadas com os pilares da sustentabilidade (ambiental, econômico e social). Finalmente, conclui-se que há um paradoxo entre a teoria e a aplicação nas empresas com relação às práticas operacionais de fim de vida do produto, desde o PDP. Isto é ratificado pelo grande número de práticas existentes na literatura quando comparadas com a aplicação destas práticas operacionais nas empresas estudadas. / The recovery of products using end-of-life strategies (EoL) is a proactive alternative that aims to diminish environmental impacts and waste generated from the disposal of products. This research aims to compile practices based on the EoL strategy that are used by companies in the (PDP). Focus is given to companies that recover products after they have been disposed. To this end, a literature review was carried out, in which 87 EoL-like practices were identified. Additionally, this research identified 64 operational practices that integrate the PDP process with the recovery of products. Four case studies were conducted in companies renowned for their excellence in remanufacturing to assess the applicability of EoL-like practices. It was found a low degree of adoption of such practices in the companies researched, mainly in the PDP process. The practices implemented were a mere implication of the continuous improvement of processes. Nonetheless, it was observed that these companies realize the importance of EoL practices to improve the life-cycle management of their products, which may positively impact all facets of sustainability (environmental, economical and social). Finally, we conclude that there is a gap between theory and practice with respect to EoL practices used in the product development process, which is supported by the great variety of practices found in the literature as opposed to the use of operational practices in the companies studied.

Bakgrund: Döden är ett tabubelagt ämne för många. I sjuksköterskeprofessionen ingår det att kunna bemöta döende patienter och ge god vård i livets slut. Dock saknas det rekommendationer för vilka slags coping-strategier sjuksköterskan själv kan använda för att kunna hantera den krävande situationen. Syfte:  Syftet med studien var att belysa allmänsjuksköterskans coping-strategier i vårdarbetet vid livets slut. Metod: En litteraturstudie gjord av tio vetenskapliga artiklar som analyserats med hjälp av Lundman & Hällgren Graneheim (2017) kvalitativa innehållsanalys. Databasen CINAHL har använts. De tio artiklar som valdes kvalitetsgranskas enligt Fribergs (2017) granskningsmall. Resultat: Analysmaterialet mynnade ut i tre huvudkategorier: ”I sjuksköterskan huvud”, Coping som riktlinjer och Betydelsen av förkunskaper. Slutsats: Med rätt utbildningsmöjligheter och kompetens skapas en trygghet för sjuksköterskan då hen får rätt coping-strategier att tillämpa i arbetet vid livets slut. Nyckelord: Coping, Coping-strategies, Death, Dying, End of life, Experience, Nurses & Palliative care.

Cancer kan drabba alla, oavsett kön eller ålder. När sjukdomen ej längre är kurativ och döden blir förutsägbar så bedöms patienten vara i sent palliativt skede. Sjuksköterskor möter dessa patienter samt deras närstående vid olika instanser i vården där det krävs ett palliativt förhållningssätt och goda kunskaper kring en förebyggande omvårdnad i livets slutskede. Syftet var att beskriva sjuksköterskors upplevelser av att vårda patienter med cancer i livets slutskede. En litteraturöversikt enligt Fribergs metod genomfördes och baserades på tolv vetenskapliga artiklar, alla kvalitativa. Sökningarna gjordes i databaserna CINAHL Complete och PubMed. Utifrån resultatet i artiklarna identifierades likheter som resulterade i teman och subteman. Analys av artiklarna resulterade i fyra huvudteman, Tillhörighet, Meningsfullhet och personlig utveckling, Behov av stöd och Stress. Två subteman framkom även; Meningslöshet ochRädsla. Styrkor och svagheter i metoden såsom eventuell förförståelse och tillvägagångssätt diskuteras genom arbetet. I resultatdiskussionen är det tidigare forskning som berör sjuksköterskors upplevelser, författarnas egna reflektioner samt Watsons teori om mänsklig omsorg med två caritativa processer; ett kärleks och omsorgsfullt sinnelag – att bry sig om samt att vara autentiskt närvarande som ligger till grund för diskussionen. / Cancer can affect everyone regardless of gender or age. When the disease no longer is curable and death is inevitable the patient is then assessed to be in a late palliative stage. Nurses´ meet these patients and their close relatives at various care instances where a palliative approach and good knowledge about preventive care in the end of life is required.  The aim of this study was to illustrate nurses´experiences caring for patients with cancer at end of life.  A literature review according to the method of Friberg was conducted and based on twelve scientific articles, all qualitative. The articles were published between 2008 and 2018. The searches were completed in the CINAHL complete and PubMed databases. Similarities in the results of the articles were identified and categorized in to themes and sub themes. Analysis of the articles resulted in four main themes, Affiliation, Meaningfulness and personaldevelopment, Need of support and Stress. Two sub themes also emerged; Meaninglessness and Fear. Strenghts and weaknesses of the method such as preunderstanding and approach will be discussed and the basis of the result discussion will include; previous research regarding nurses` experiences, the authors’ reflections and Watsons theory of human care including two of the caritive processes; a loving and caring mind-caring and to be present autenticly.

Nursing Care for Terminal Patients in Intensive Care Units by Pervell Dunbar Project Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Nursing Practice Walden University August 2015 Although the goal of the ICU has always been to save lives, ICU now additionally provides end-of life (EOL) care. The objective of this project was to provide ICU nurses with a comprehensive awareness of physical, emotional, and spiritual EOL care issues of patients and their families in order to be better equipped to handle EOL care. The framework used was Jean Watson's Caring model (10 Caritas). A literature review revealed a poster previously used by a major health organization as a conversation starter to facilitate decision-making among ICU nurses, EOL patients, and their families related to EOL issues. The purpose of this quality improvement initiative was to introduce and implement an educational EOL tool that would engage patients and family members in meaningful and useful conversations with ICU nurses. Twenty seven ICU nurses were selected by the unit's director to attend a PowerPoint presentation on the use of the EOL educational poster. Four ICU nurses were chosen by the director to be champions for this project. After the presentation, there was a period for questions and answers, and the ICU nurses were requested to give feedback on the presentation. The result from the feedback revealed that EOL care is outside previous practice and may require extra education and support. These comments substantiated similar conclusions from other researchers as described in this paper. With an increase in EOL training for ICU nurses and the implementation of EOL teaching tools like the poster used in this study, ICU nurses may be better able to have conversations with EOL patients and families, thus improving patient care.

This is a cross-national qualitative study with the purpose of obtaining perspectives held by people with quadriplegia and leading figures in disability movements in the Netherlands and Australia on the issues of euthanasia and physician-assisted suicide (EPAS). A disability voice is not prominent in public debate on EPAS in Australia or the Netherlands, even though people with disabilities are often thought to be vulnerable in relation to EPAS policies. Disability perspectives are potentially valuable in illuminating issues in relation to euthanasia and physician-assisted suicide, because issues of dependence, independence, and individual autonomy play important roles in relation to both EPAS and to living with disability. The study's methodology uses a phenomenological approach and incorporates aspects of heuristics and grounded theory. Its conceptual framework incorporates MacIntyre's (1999) theory of acknowledged dependency and vulnerability; Habermas' (1989) theory of knowledge; and Festinger's (1959) theory of cognitive dissonance. The main sample of twenty people with quadriplegia (the grassroots sample) was interviewed in the Netherlands and in Australia.

Syftet med föreliggande litteraturstudie var att beskriva vanligt förekommande problem samt faktorer som påverkar beslutsfattandet i vården av personer med demens i livets slutskede inom slutenvården. Artikelsökningen i databaserna Cinahl och Medline via PubMed resulterade i inkludering av 15 vetenskapliga artiklar. Resultatet visade att problem med näringsintag och komplikationer som pneumoni, feber och smärta var vanligt förekommande för personer med demens i livets slutskede. Flera drabbades av trycksår och rörelsehinder som exempelvis sänggrindar och bälten användes ofta. Det fanns brister i kommunikationen mellan vårdpersonal och anhöriga. Vårdpersonalen hade dåliga kunskaper om demens som sjukdom med tillhörande symtombild. Sjukdomsutveckling av demens var svår att förutsäga vilket komplicerade planeringen för den sista tiden i livet. Målet för omvårdnaden vid livets slut var välbefinnande. En uppfattning om hur livskvalitén var för de demenssjuka hade stor betydelse för hur vårdpersonal och anhöriga beslutade om vården. Anhöriga värdesatte i sitt beslutsfattande om personer med demens hade skrivit ner sina egna önskemål, angående vård vid livets slut, innan de försämrats i sjukdomen. Synen på döden påverkade både vårdpersonalens och anhörigas vilja att planera för vård vid livets slut. Det är viktigt att reflektera över hur vården av personer med demens i livets slutskede ser ut och det underlättas av att det finns kunskap om vanligt förekommande problem och faktorer som påverkar beslutsfattandet i vården. / The aim of this study was to describe common problems and factors affecting decision making in the care of people with dementia in the final stages of life in residential homes. Search for articles in databases Cinahl and Medline via PubMed resulted in the inclusion of 15 scientific articles. The results showed that problems with nutritional intake and complications such as pneumonia, fever and pain were common for people with dementia in the final stages of life. Several suffered from pressure sores and physical disabilities such as bed rails and belts were often used. There were deficiencies in communication between health care professionals and relatives. Health care professionals had poor knowledge about dementia as a disease and its symptoms. Disease development of dementia was difficult to predict which made it difficult to plan for the final stages of life. The aim of nursing care at the end of life was well-being. An idea of how the quality of life was for the persons with dementia was important to how health care professionals and relatives decided on nursing care. In their decision-making relatives gave great importance if the persons with dementia had written down their wishes, regarding care at the end of life, before they deteriorated in the disease. The attitudes towards death affected both nursing staff and relatives wish to make plans for the end-of-life care.  It is important to reflect on how the care of people with dementia in the final stages of life is like and this is facilitated by the existence of knowledge about common problems and factors affecting decision making in nursing care.

Sammanfattning Syftet med litteraturstudien var att beskriva sjuksköterskors inställning till eutanasi. Metoden var en beskrivande litteraturstudie. Av 220 artiklar valdes 14 artiklar med kvalitativ eller kvantitativ ansats. Resultatet visade att eutanasi är en komplex fråga där olika etiska och moraliska aspekter spelar in. Sjuksköterskorna ansåg att eutanasi kunde vara etiskt försvarbart för värnandet av patientens autonomi, vid svår obotlig sjukdom, om alla andra behandlingsmetoder blivit uttömda samt om patienten själv tog upp förfrågan om eutanasi. Argument emot eutanasi var att sjuksköterskan har en livsbevarande roll, att risk för missbruk av eutanasi kan förekomma samt religiösa skäl. Yngre deltagare och de med lägre utbildning var mer positiva till eutanasi medan äldre sjuksköterskor och de med högre utbildning hade en mer negativ inställning. Inställningen till eutanasi skilde sig beroende på vart sjuksköterskorna arbetade t.ex. vid intensivvårds-, palliativ- eller pediatrisk vårdavdelning. De som arbetade inom pediatrisk och palliativ vård var i högre omfattning emot mot eutanasi. Sjuksköterskor som uppgavs sig vara religiösa var mer negativt inställda till eutanasi och till legalisering av eutanasi. I länder där eutanasi är legaliserat pågår diskussioner om sjuksköterskans roll inom eutanasivården och dess beslutsprocess. Slutsatsen är att frågor kring eutanasi är viktigt att undersöka, inte bara allmänhetens inställning utan även olika professioners reflektioner. Debatten kring eutanasi kommer att fortgå.   Nyckelord: eutanasi, sjuksköterskors inställningar, palliativ vård, beslut i livets slutskede / Abstract The aim of this literature review was to describe nurse’s attitudes towards euthanasia. The method used was a descriptive design. Of the 220 hits, 14 was chosen by CINAHL and PubMed (MedLine) and then analyzed. Both qualitative and quantitative aspects were included. The results showed that euthanasia is a complex issue where many ethical and moral aspects come in to play. The nurses felt that euthanasia was ethically acceptable for safeguarding patient autonomy, but also when patients’ suffered from incurable disease and severe pain therefore requested euthanasia. Arguments against euthanasia where directed towards the nurse’s role as lifesaver and preserver of life, the risk of misuse and religious beliefs. The study showed that younger nurses and those with lower formal education where more prone to the use of euthanasia than elderly nurses and those with higher education. Attitudes toward euthanasia differed depending on what type of ward the nurses worked in, for example at intensive care units, palliative care or pediatrics. Those who work in pediatric wards or with palliative care are those who more often oppose the use of euthanasia. Nurses who described themselves as religious often argued against the use of euthanasia and its legislation. In countries where euthanasia is legal there is an ongoing debate about nurses’ role in euthanasia and in its decision processing. The conclusion is that questions regarding euthanasia are important to investigate, not only by exploring the public’s attitudes but also by exploring the reflections of professionals. The debates will continue regarding euthanasia.  Keywords: Euthanasia, nurses’ attitudes, palliative care, end of life decisions