Despite (national) strategies/frameworks for care at the end of life, many patients do not die at their preferred location or under the form of care desired. This cross-country comparison study analyzed system-level characteristics - such as legislation, regulation and financing - that might influence service delivery in the care for terminally ill adults and their implications for outcomes and costs. Drawing on triangulated data from Canada, England, Germany and the United States of America and taking a 'most similar – most different' perspective, it was hypothesized that system-level factors might impede the broader use of (integrated) models of hospice and palliative care/the system-wide adoption of best practices. An embedded case study examined resource utilization and costs of shared care and its role as a potential best practice avenue. While similar with regard to leading causes of death, patient needs and potential avenues to care, different service models were employed – including hospice and palliative care. Generally offered alongside standard care along the disease continuum and across settings - and featuring common elements like physical, psycho-social and spiritual care - outcomes (e.g., access, utilization) varied. Legislative (e.g., jurisdictional), regulatory (including education and training) and financial issues were identified as barriers, as were public knowledge and perception ('giving up hope') challenges. Advance care planning, dedicated and stable funding, population aging and standards of practice/guidelines to care were seen as facilitators. Successful policy implementation requires concerted action to align system-level characteristics – with each alone being essential but not sufficient. Policies need to be monitored and fine-tuned, with a caveat toward their transferability between jurisdictions. The analysis of the shared-care approach in the rural Niagara-West setting revealed effective and efficient home-based hospice and palliative care – on par with per diem funding for long-term care homes and lower than average alternate level of care and hospital costs in Ontario, and in line with the Medicare Hospice Benefits in the United States of America. The thesis results provide a base for further analyses across jurisdictions and settings and might assist decision makers in the allocation of resources to meet the complex needs of hospice and palliative care populations.

This audio documentary explores the contemporary landscape of death and dying with specific focus on caregiving, the process of cultivating personal death value systems, and the importance of intergenerational exchange for fostering inquiry and acceptance of the aging process. The audio thesis is fluidly presented in three parts, with an accompanying annotation to be read after listening. For the sake of textual clarity, the annotation is separated into chapters. Chapter I explores hospice care and the complexities of the dying process, leading the listener to consider what it is like to work professionally in the field of end-of-life care. Chapter II explores implications of highly technological medical care and advancements in health sciences. Finally, Chapter III implicitly suggests through personal narrative that embodied experiences of caregiving and intergenerational exchange create spaces that subvert cultural and temporal fears of aging and the dying process.

Despite (national) strategies/frameworks for care at the end of life, many patients do not die at their preferred location or under the form of care desired. This cross-country comparison study analyzed system-level characteristics - such as legislation, regulation and financing - that might influence service delivery in the care for terminally ill adults and their implications for outcomes and costs. Drawing on triangulated data from Canada, England, Germany and the United States of America and taking a 'most similar – most different' perspective, it was hypothesized that system-level factors might impede the broader use of (integrated) models of hospice and palliative care/the system-wide adoption of best practices. An embedded case study examined resource utilization and costs of shared care and its role as a potential best practice avenue. While similar with regard to leading causes of death, patient needs and potential avenues to care, different service models were employed – including hospice and palliative care. Generally offered alongside standard care along the disease continuum and across settings - and featuring common elements like physical, psycho-social and spiritual care - outcomes (e.g., access, utilization) varied. Legislative (e.g., jurisdictional), regulatory (including education and training) and financial issues were identified as barriers, as were public knowledge and perception ('giving up hope') challenges. Advance care planning, dedicated and stable funding, population aging and standards of practice/guidelines to care were seen as facilitators. Successful policy implementation requires concerted action to align system-level characteristics – with each alone being essential but not sufficient. Policies need to be monitored and fine-tuned, with a caveat toward their transferability between jurisdictions. The analysis of the shared-care approach in the rural Niagara-West setting revealed effective and efficient home-based hospice and palliative care – on par with per diem funding for long-term care homes and lower than average alternate level of care and hospital costs in Ontario, and in line with the Medicare Hospice Benefits in the United States of America. The thesis results provide a base for further analyses across jurisdictions and settings and might assist decision makers in the allocation of resources to meet the complex needs of hospice and palliative care populations.

This audio documentary explores the contemporary landscape of death and dying with specific focus on caregiving, the process of cultivating personal death value systems, and the importance of intergenerational exchange for fostering inquiry and acceptance of the aging process. The audio thesis is fluidly presented in three parts, with an accompanying annotation to be read after listening. For the sake of textual clarity, the annotation is separated into chapters. Chapter I explores hospice care and the complexities of the dying process, leading the listener to consider what it is like to work professionally in the field of end-of-life care. Chapter II explores implications of highly technological medical care and advancements in health sciences. Finally, Chapter III implicitly suggests through personal narrative that embodied experiences of caregiving and intergenerational exchange create spaces that subvert cultural and temporal fears of aging and the dying process.

In the past few decades, globalization has led to a world economy with unbounded consumption. In addition to the consequential impoverishment of natural resources, this large consumption produces copious amounts of waste and requires high energy use. Proper end-of-life strategies can help to reduce the global impact of these inefficiencies. The objective of this thesis is to demonstrate, through life-cycles analyses of an automotive transfer case and a gear, the positive environmental impact of remanufacturing strategies compared to recycling and disposal end-of-life strategies. In this study, the energy consumption, the air emissions and the wastes resulting from the entire supply chain s engineering processes will be quantitatively evaluated through calculations and also industrial or governmental data. In disposal end-of-life strategies, the analysis will begin with the ore mining phase, will go through material refining and processing; and eventually end with the final parts machining. In recycling scenarios and remanufacturing scenarios, the analysis will begin with the used material collection, will go through material s reprocessing or refurbishing and will finally end with the new or renewed parts machining. This study will show the significant impact of high energy consumption processes such as electrolysis of aluminum and metal melting. It will also show how shipping and collection phases can dramatically change or annihilate the advantage of sustainable reuse scenarios depending on the sorting strategies adopted in the supply chain. To conclude, the goal of this research is to demonstrate how remanufacturing strategies can reduce the energy consumption, air emissions and waste. This thesis will also show how inappropriate supply chain management can negate the impact of these savings.

Bakgrund: I Afrika är behovet av palliativ vård stort efter utbredning av HIV, samt cancer och andra sjukdomar. Den palliativa vården avser att öka livskvalitet en hos patienter och närstående, lindra lidande och behandla smärta. World Health Organization startade ett projekt för att utveckla palliativ vård i Afrika, ett projekt som önskar utveckla synen på palliativ vård, integrera den i vårdprogram och förbättra möjligheten till läkemedelstillgångar och utbildning. Sjuksköterskan är en central figur inom den palliativa vården och relationen är betydelsefull för patienten. För sjuksköterskan är mötet med den palliativa patienten både smärtsamt och stressfullt, och väcker starka känslor. Syfte: Beskriva sjuksköterskors upplevelse av palliativ vård i Tanzania. Metod: En empirisk studie och datainsamling i form av semistrukturerade intervjuer genomfördes med åtta sjuksköterskor i Tanzania. Intervjuerna transkriberade s och analyserades sedan enligt kvalitativ innehållsanalys. Resultat: Resultatet presenteras i två huvudkategorier; Sjuksköterskans uppfattning av vårdandet och Utmaningar som sjuksköterskan möter i den palliativa vården. I dessa redovisas bland annat; betydelsen av relationer i vården, patientens behov, sjuksköterskans beskrivning av brister och hur tro kan påverka vården samt krav som ställs i mötet med patienter och närstående. Diskussion: Sjuksköterskornas reflektioner på relation och kommunikation di skuteras, tillsammans med synen på god relation och god vård. Sjuksköterskans invändningar på de anhöriga i vården kontra hur deras egen tro påverkar vården, samt reflektioner kring fokuseringen på fysiska symtom i relation till övriga behov gjordes. Studiens utförande diskuterades också. / Background: In Africa, the need for palliative care is high after the prevalence of HIV, cancer and other diseases. The aim of palliative care is to improve quality of life for patients and families, to relieve suffering and to treat pain. World Health Organizati on launched a project to develop palliative care in Africa, a project that wishes to d evelop the perception ofpalliative care, to integrate in treatmentprograms and improve access to medicine and education. The nurse is playing a major part in palliative care therefor their relationship becomes important for the patient. For the nurse the meeting with the palliative patient could be both painful and stressful, and create strong emotions. Purpose: To describe nurses experiences of palliative care in Tanzania. Method: An empirical study and datacollection in the form of semi-structured interviewswere conducted with eight nurses in Tanzania. The interviews were transcribed and then analyzed according to qualitative content analysis. Resultat: The results are presented in two main categories: Nurses perception of caring and Challenges that the nurse is facing in palliative care. These are, among others; the importance of relations, patient needs, nurse description of shortcomings in palliative care and how faith can affect the care, and also demands that is expected in contact with patients a nd relatives. Discussion: In the discussion nurses reflect on relations and communication together with their vision on good care. Nurses thoughts about the relatives and how their own beliefs affect the care, and reflections about focus on physical symto ms in relations to other needs were discussed. The study design was also discussed.

Les filières de valorisation de déchets ont été mises en place au cours des dernières années pour répondre à des pressions économiques, sociétales, environnementales et réglementaires. Pour que les produits en fin de vie soient valorisés au mieux, il faut que leur conception soit adaptée aux spécificités des différents acteurs de la filière. L’étape de prétraitement consiste en la séparation des différents composants et matières des déchets. C’est une étape essentielle pour la valorisation de produits complexes comme les DEEE (déchets d’équipements électriques et électroniques), qui sont l’objet de ces travaux. Nos recherches bibliographiques montrent que les méthodes de conception existantes pour la valorisation ne prennent en compte ni la diversité et la nature des pratiques de prétraitement ni les raisons qui poussent à réaliser chacune d’elles. Afin de comprendre l’expertise liée à ces pratiques, nous avons réalisé deux modèles.En premier lieu, un modèle macroscopique nous a permis d’identifier les grands facteurs qui affectent le fonctionnement des opérateurs de prétraitement. Il a été établi en deux étapes : la première étape consiste en la caractérisation des opérateurs de traitement ; la deuxième étape s’attache à la classification des opérateurs de traitement. Afin de développer ce modèle nous nous sommes appuyés sur deux études descriptives de la filière DEEE française. Une étude descriptive qualitative nous a permis d’identifier les raisons qui poussent les opérateurs à réaliser les différentes stratégies de fin de vie et les processus de prétraitement. Une analyse statistique en composantes principales (ACP), a été réalisée afin de développer une classification des opérateurs de prétraitement.Dans un deuxième temps, dans le but d’identifier quels sont les conséquences de certains choix de conception pour la fin de vie, nous avons développé une méthode d’analyse systématique et détaillée du traitement réalisé par un type spécifique d’opérateur de DEEE. Celle-ci nous a permis d’obtenir un modèle microscopique des activités. Afin de développer et d’appliquer la méthode, nous nous sommes focalisés sur le désassemblage manuel d’écrans plats en vue de leur recyclage. Nous avons obtenu des données quantitatives qui constituent des preuves solides pour soutenir le développement de recommandations d’éco-conception. Avec ce modèle nous pouvons développer des indicateurs et des règles de conception quantitatives utilisables en conception de produit.Les modèles macro et microscopiques sont des instruments d’acquisition des connaissances sur l’expertise de centres de traitement qui peuvent être adaptés pour une utilisation dans d’autres filières de valorisation de déchets. / Compliance schemes have been stablished in recent years to alleviate the burden of economical, societal, environmental and regulatory pressures. To ensure the best recovery of end-of-life products, their design has to meet the requirements of the different waste management operators. The pre-treatment phase consists on the separation of components and materials from waste. It is an essential step when recovering complex product such as waste electrical and electronic equipment (WEEE), which is the focus of this research work. The literature research shows that design for recovery methods do not take into account the diversity and nature of pre-treatment practices or the reasons behind them. In order to increase the understating related to these practices we have developed two models.The first one is a macroscopic model whose aim is to identify the main factors that influence the activity of pre-treatment operators. The development of the method involved two main steps: the characterization and the classification of pre-treatment operators. Two descriptive studies of the French WEEE compliance scheme have been carried out in order to develop the method. A qualitative descriptive study allowed us to identify the reasons why operators realize the different recovery strategies and pretreatment process. A descriptive statistical analysis, more specifically, a principal component analysis (PCA) was performed to develop a classification of the pretreatment operators.The second model that has been developed, a microscopic one, contains detailed information about the treatment operations carried out by one specific type of operator. The aim of this model is to identify what the best and worst design choices are in order to improve product’s pre-treatment. We have proposed a method for manual disassembly analysis to support the ecodesign of flat panel displays. The method enables to obtain quantitative data that provide solid evidence to support the development of eco-design guidelines. It also enables the development of disassembly indicators and recommendations to be used in product design.The macro and microscopic models are instruments of knowledge acquisition on pre-treatment practices that may be applicable to other compliance schemes.

Actuellement, les matériaux collectés à partir de produits en fin de vie sont recyclés en matière première pour être réutilisés dans un nouveau cycle de production. Cependant, la consommation énergétique des filières de recyclage reste importante. Le processus du recyclage fait aussi perdre la valeur ajoutée et l’énergie utilisée durant la fabrication de pièces originales. Aujourd’hui, les techniques de fabrication additive sont suffisamment performantes et permettent une fabrication de produits avec un matériau compatible avec l’usage. La prise en compte des performances de ces nouvelles techniques dans une stratégie soutenable peut ouvrir des pistes pour modifier les pièces et les réutiliser directement sans retourner au niveau de matière première. Cette thèse a pour objectif de développer une stratégie soutenable, qui permet de donner une nouvelle vie à une pièce en fin de vie (ou une pièce existante) en la transformant directement en une nouvelle pièce destinée à un autre produit. Afin de développer une telle stratégie, les travaux menés de la thèse visent à résoudre les verrous scientifiques suivants :Le premier verrou scientifique est lié à la faisabilité technologique : est-il possible de déposer de la matière sur une pièce existante en utilisant les techniques de fabrication additive pour obtenir la nouvelle pièce avec une bonne santé de matière ? Cette question a été résolue en réalisant une étude expérimentale sur l’observation de microstructures et de propriétés mécaniques des éprouvettes, qui sont fabriquées par ajout de nouvelles entités sur une pièce existante en EBM. Le deuxième verrou scientifique est lié à l’étude de la chaîne complète de fabrication d’un point de vue technologique. Comment concevoir des gammes de fabrication en combinant intelligemment des opérations additives et soustractives pour obtenir la pièce attendue à partir de la pièce existante ? Une méthode de conception des gammes de fabrication combinant les procédés additifs et soustractifs a été proposée en s’appuyant sur le concept d’entités de fabrication additive et soustractive. Le troisième verrou scientifique est lié à la soutenabilité et la stratégie présente-t-elle des avantages par rapport à la stratégie conventionnelle en termes de soutenabilité ? Une approche s’appuyant sur la méthode d’Analyse du Cycle de Vie (ACV) a aussi été développée pour évaluer des impacts environnementaux. Des critères permettant de qualifier le domaine de la stratégie proposée vis-à-vis de la stratégie conventionnelle ont été identifiés / Currently, materials collected from end-of-life (EoL) products are recycled into raw material for reusing in a new production cycle. However, energy consumptions of recycling sectors remain important. The added values and energy used in the manufacture of original parts are also lost during the material recycling process. Nowadays, additive manufacturing techniques are sufficiently efficient and allow the manufacture of products with a material compatible with the use. Taking into account the performances of these techniques in a sustainable strategy can open the ways to modify parts and reuse them directly without returning to the raw material level. This thesis aims to develop a sustainable strategy, which allows giving a new life to an EoL part (or an existing part) by transforming it directly into a new part intended for another product. In order to develop such a strategy, the works of the thesis aims to solve the following scientific issues : the first scientific issue is related to the technological feasibility : is it possible to deposit material on an existing part using additive manufacturing technologies to obtain the new part with good material health ? This question is solved by carrying out an experimental study on the observation of microstructures and mechanical properties of the samples, which are manufactured by adding new features into an existing part in EBM. The second scientific issue is related to the study of the complete manufacturing chain from a technological point of view. How to design the process planning for additive and subtractive manufacturing combination to manufacture the expected part from the existing part ? To solve this question, a methodology to design the process planning for combining these manufacturing processes has been proposed based on the concept of additive manufacturing and machining features.The third scientific issue is linked to the sustainability and does the new strategy have advantages in comparison to the conventional strategy in terms of sustainability ? An approach based on the Life Cycle Assessment (LCA) method has also been developed to assess environmental impacts. The criteria for qualifying the domain of the proposed strategy vis-a-vis the conventional strategy were also identified

Ces travaux de thèse portent sur la photodégradation de retardateurs de flamme bromés  (RFB) : décabromodiphényléther (BDE -209), tétrabromobisphénol A (TBBPA), TBBPA bis (allyl) éther (TBBPA-BAE) et TBBPA bis (2,3-dibromopropyl) éther (TBBPA- DBPE) en milieu solide et dans des échantillons réels. Nous avons d’abord caractérisé par chromatographie en phase liquide-haute résolution couplée à la spectrométrie de masse (LC-HR-MS) le BDE-209 et ses produits de dégradation dans des échantillons de textiles issus de sièges auto des véhicules hors usage (VHUs) des années 90. Puis, nous avons mené des expériences prouvant que ces produits de dégradation étaient d’origine photochimique. Dans un deuxième temps, nous avons étudié l’effet du polystyrène sur la photodégradation du BDE-209, TBBPA et ses dérivés et l’effet de ces RFBs sur la photodégradation du polystyrène. Des analyses par différentes techniques spectroscopiques et chromatographiques (IR, ATR-FTIR, GC-MS, SEC) ont mis en évidence un net effet d’accélération réciproque. La SEC (chromatographie d’exclusion stérique) a révélé une augmentation drastique des coupures de chaîne du PS avec fragmentation. En outre, des photoproduits résultant de l'oxydation du PS et de sa bromation par Br· ont été observés pour la première fois. L’existence de ces sous-produits suggère un nouveau mécanisme de transformation de PS en présence de RFB. Certains de ces photoproduits migrent dans l’eau et l’air, pouvant causer une pollution environnementale. / The main objective of this PhD thesis was to evaluate the photodegradation of brominated flame retardants (BFRs): decabromodiphenyl ether (BDE-209), tetrabromobisphenol A (TBBPA), TBBPA bis (allyl) ether (TBBPA-BAE) and TBBPA bis(2,3-dibromopropyl) ether (TBBPA-DBPE) in solid medium and real samples. As a first step, we characterized by liquid chromatography high-resolution-mass spectrometry (LC-HR-MS) the BDE-209 and its degradation products in textile samples from car seats of end-of-life vehicles (ELVs) of the 1990s. Then we demonstrated that these products were formed by photodegradation. In a second step, we investigated the effect of polystyrene on the photodegradation of BDE-209, TBBPA and its derivatives and the effect of these RFBs on the photodegradation of polystyrene. Analyses carried out by chromatography and spectroscopy techniques (IR, ATR-FTIR, GC-MS, SEC) revealed significant and mutual acceleration effects. SEC (exclusion size chromatography) showed a drastic increase in chain breaks of PS. Morover, additional photoproducts that may result from PS oxidation and Br • bromination has been observed for the first time. The formation of these byproducts suggests a new PS transformation mechanism in the presence of BFR. Some of these photoproducts can migrate into water and air causing environmental pollution.

Introdução: Desde a década de 70, a limitação de suporte de vida vem sendo discutida como uma forma de oferecer uma morte digna a pacientes fora de possibilidades terapêuticas. A tomada de decisão de limitação terapêutica, quando não compartilhada por toda a equipe assistencial, pode se refletir em desconforto para os cuidadores, que devem executar a assistência conforme planejado, mesmo nem sempre concordando com as decisões tomadas. Esse desconforto pode ser reflexo de percepção de coerção, nem sempre manifesta. Objetivo: o objetivo da pesquisa foi avaliar a expressão de coerção de cuidadores frente à assitência a pacientes pediátricos terminais, em limitação de tratamento. Material e métodos: através de estudo transversal e prospectivo, foi avaliada a expressão de coerção dos enfermeiros, médicos e técnicos de enfermagem que assistiram pacientes terminais, no período de um ano, utilizando-se a Subescala de Voz da MacArthur Admission Experience Survey modificada, solicitando concordância ou discordância a 4 sentenças. Na análise estatística foram realizados os testes de qui-quadrado com correlação de Pearson e o teste de comparações múltiplas de proporções com correção de Bonferroni. Foram utilizados o sistema SPSS v.18 e WINPEPI v.10.11. O nível de significância estabelecido foi de 5% (P<0,05). Resultados: foram analisados 227 questionários de Expressão de Coerção, relativos à assistência de 17 pacientes pediátricos terminais, no período de 2009 e 2010. Houve expressão de coerção em 17% dos questionários dos médicos, 72% dos enfermeiros (p<0,00001) e 76% dos técnicos (p<0,00001). Não houve diferença significativa de Expressão de Coerção entre enfermeiros e técnicos de enfermagem. Com relação às sentenças, houve expressão de coerção em todas, em taxas variadas, nas diferentes categorias de cuidadores. Na sentença ―Tive oportunidade suficiente de dizer se concordava com a limitação terapêutica ou não-ressuscitação‖ houve diferença significativa entre médicos e enfermeiros (p=0,004) e entre médicos e técnicos (p<0,001). Na sentença ―Tive oportunidade de dizer o que queria a respeito da limitação terapêutica ou não-ressuscitação‖ houve diferença significativa entre médicos e enfermeiros (p=0,005 ) e entre médicos e técnicos (p<0,002). Não houve diferença entre as equipes nas demais sentenças. Conclusão: a pesquisa evidenciou expressão de coerção nas três categorias de cuidadores de pacientes pediátricos terminais em limitação de tratamento, sendo os médicos os que expressaram menor coerção. Dentre os itens de expressão de coerção, os relacionados à expressão de opinião foram os mais apontados, principalmente entre os enfermeiros e técnicos de enfermagem. / Introduction: Limitation of life support is considered a means of providing dignified death to patients who are beyond any therapeutic possibility. The decision to limit life support should be shared among patients, their relatives, and their care providers. Health professionals caring for terminally or intractably ill children under limited life support may feel coerced, particularly when they were not involved in decision making for end-of-life care. In order to understand the feelings of these care providers, it is important that this perceived coercion be expressed and measured with valid instruments. Objective: The objective of this study is to evaluate expression of perceived coercion by nurses, physicians, and nurse technicians during limitation of life support among terminal patients treated at the pediatric intensive care unit (PICU) of a tertiary hospital, quantify this expression of coercion, and compare it across the three aforementioned categories of caregivers. Methods: This prospective study used the three-item Voice subscale of the MacArthur Admission Experience Survey, modified by the addition of a fourth statement regarding ―validation,‖ to quantify expression of perceived coercion by the health professionals involved in the care of 17 patients who were under limitation of life support during the study period. The chi-square test with Pearson correlation and multiple comparisons with Bonferroni correction were used for statistical analysis. The significance level was set at 5%. Results: Overall, 10 nurses, 41 nurse technicians, and 23 physicians (65% of eligible healthcare providers) took part in the study. A total of 227 Coercion Expression questionnaires were completed, 121 by physicians, 50 by nurses, and 56 by nurse technicians, for a return rate of 65%, 61%, and 52% respectively. There was a significant difference in rate of return between physicians and nurse technicians (p=0.0258). Providers in all three categories expressed coercion to varying degrees. Analysis by Pearson's chi-squared test revealed that coercion was expressed significantly more by nurses and nurse technicians than by physicians (p<0.00001 for both comparisons). There was no significant difference between nurses and nurse technicians (p=0.7016). Coercion was reported for all items by caregivers in all three categories. There were significant differences between physicians and nurses and between physicians and nurse technicians in two of the three items concerning ―Voice‖ (p<0.005). There was no significant difference among providers for one of the ―Voice‖ items or for the ―Validation‖ item. Conclusion: This study revealed variable rates of coercion expression across three categories of healthcare providers involved in the end-of-life care of pediatric patients under limitation of life support, with physicians manifesting the least perceived coercion. Among the four items on coercion expression evaluated in this study, those related to expression of one‘s opinion—an essential element of decision-making—were the ones most commonly mentioned, particularly by nurses and nurse technicians.