The purpose of this quasi-experimental study was to assess the ongoing impact of the End-of-Life Nursing Education Consortium (ELNEC) training program on registered nurses’ death anxiety, concerns about dying, and knowledge of the dying process utilizing the principles of The Comfort Theory and Practice by Kolcaba (2003) at the institutional level. The research hypothesis was upon completion of the ELNEC training, registered nurses would have decreased death anxiety, less concerns about dying, and increased knowledge of the dying process. The Revised Death Anxiety Scale (RDAS) was used to measure death anxiety which is a 25 item self-report questionnaire. The Concerns about Dying Instrument (CAD) was used to measure death attitude or concerns about dying which includes three distinct but related areas for providers: general concern about death, spirituality, and concerns about working with dying patients. Participant's perceived knowledge of dying was measured using a self report 5-point Likert format with “0“ indicating no level of knowledge to “4“ reflecting complete knowledge of death and dying. Pre-tests of all dependent variables were administered to both a treatment and control group. Post-tests were administered two weeks after the two day ELNEC training, at 6 months, and finally at 12 months to both groups in order to study its lasting efficiency upon participants at one primary care medical center. Thirty eight participants completed all four questionnaires with 27 participants in the control group and 11 participants in the experimental group. Matched pair analysis with 11 participants in each group was conducted with statistical significance found for perceived knowledge about dying at post two weeks and 12 months (p= 0.01) for the intervention group. Death anxiety and concerns about dying were not found to be statistically significant at any testing interval, but mean scores of the treatment group revealed less death anxiety and concerns about dying. Recommendations included offering the ELNEC training on a routine basis to all registered nurses who care for dying patients. Additionally, clinicians and administrators were encouraged to seek out additional funding opportunities to plan more robust studies with larger samples, incentives, and research method triangulation addressing the qualitative aspects of palliative care. / Ph. D.

This dissertation examines the relationship among practices and policies of waste/ing and economic structures to make visible the implications of vehicle disposal policies for environmental policy and theory. Consequently, I attempt to build upon the small body of literature that is now critically engaging with waste production and resulting actions/inaction in the form of policies of management. In doing this I use waste as a lens to examine the interrelationships among environmental degradation and economic and political structures. Further, I examine these phenomena in relation to a physical object, the automobile, to add materiality to abstract notions of waste as it relates to both the political and the economic. Through vehicle recycling policies, I analyze how underlying economic structures in contemporary capitalism result in specific responses to the "problems" of waste as well as how the related responses, or "solutions" perpetuate an un-ecological industrial system which severely restricts the possibilities of making substantial change in the production of environmental harms. / Ph. D.

"Nothing endures but change" - Heraclitus. Buildings are designed and built to house a specific program for a set period of time. The end of a building's life marks a change in its use. In today's building practices, some building owners opt to demolish an entire building prior to constructing a new one. Unfortunately, this world-wide attitude results in the production of millions of tons of waste every year and is not an ecologically sustainable practice. However, as green building methods become more valued in today's society, building owners and designers are becoming more conscious of buildings' end lives. Construction methods are increasingly involving concepts of designing for disassembly, wherein parts and materials can be easily taken apart for reuse or recycling. Such practices are vital in minimizing the unnecessary production of construction waste. Everything on earth exhibits change. This thesis explores the development of a newly constructed building and its transformation at the end of its life into a new building. The project consists of two designs; the program of the first was predetermined while the program of the second was chosen by the committee at the concluding stage of the first design. This thesis seeks to develop a position on architectural design and construction methods that acknowledges the fact that buildings are not permanent objects and that they will, at some point in time, change. / Master of Architecture

No / Depression in patients receiving palliative and end-of-life care is difficult to distinguish from grief and sadness. However, there are some important distinctions and it is a clinical condition that is treatable and should not be considered a necessary or normal part of the dying process. This article examines the nature of depression and describes the stress vulnerability model of depression, linking it to recent developments in the neurobiology of depression. It also discusses how to distinguish depression from other symptoms that patients may be experiencing.

No / This article presents a review of key issues around caring for people in the last hours and days of life. The aim is that community nurses will be able to support patients and families, and to provide and explain decisions and interventions to promote comfort and dignity based on current evidence.

No / Laura Middleton-Green, lecturer and researcher in palliative and end of life care, writes about how attitudes to death influence care of the dying.

Yes / The prevalence of dementia is rising worldwide and many people will die with the disease. Symptoms towards the end of life may be inadequately managed and informal and professional carers poorly supported. There are few evidence-based interventions to improve end-of-life care in advanced dementia. To develop an integrated, whole systems, evidence-based intervention that is pragmatic and feasible to improve end-of-life care for people with advanced dementia and support those close to them. Design: A realist-based approach in which qualitative and quantitative data assisted the development of statements. These were incorporated into the RAND/UCLA appropriateness method to achieve consensus on intervention components. Components were mapped to underlying theory of whole systems change and the intervention described in a detailed manual. Setting/participants: Data were collected from people with dementia, carers and health and social care professionals in England, from expert opinion and existing literature. Professional stakeholders in all four countries of the United Kingdom contributed to the RAND/UCLA appropriateness method process. Results: A total of 29 statements were agreed and mapped to individual, group, organisational and economic/political levels of healthcare systems. The resulting main intervention components are as follows: (1) influencing local service organisation through facilitation of integrated multi-disciplinary care, (2) providing training and support for formal and informal carers and (3) influencing local healthcare commissioning and priorities of service providers. Conclusion: Use of in-depth data, consensus methods and theoretical understanding of the intervention components produced an evidence-based intervention for further testing in end-of-life care in advanced dementia.

No

Yes

Bakgrund: Cancer kan uppstå i diverse delar av kroppen. Cancervården använder sig av två faser. Den kurativa fasen där målet är att patienten ska bli botad samt den palliativa fasen där vårdinriktningen är palliativ och sjukdomen inte längre går att bota. Patienter med cancer kan leva flera år i en tidig palliativ fas där behandlings målet är att fördröja sjukdomsförloppet. Därefter träder den sena palliativa fasen in där fokusering på välbefinnande och smärtlindring är huvudändamål. Det är i skiftet mellan de olika faserna som brytpunktssamtalet främst äger rum. Sjuksköterskor kan ha en betydande roll i processen kring brytpunktssamtal. Syfte: Syftet med denna litteraturstudie var att undersöka och sammanställa sjuksköterskors upplevelser och erfarenheter av brytpunktsamtal hos patienter med cancer Metod: En litteraturstudie med systematisk översikt. Tio artiklar med kvalitativ ansats kvalitégranskades och sammanställdes genom innehållsanalys. Resultat: Resultatet identifierades till tre huvudteman; Upplevelser och erfarenheter kring samverkan med patient och läkare, relationer i anknytning till brytpunktssamtal och sjuksköterskans upplevelser av hopp. Sjuksköterskor upplevde att samverkan med läkare samt tydlig kommunikation med patient var av vikt. Relationen till patienter och närstående var en faktor som sjuksköterskor upplevde fanns med i brytpunktssamtalet. Hopp var en känsla som identifierades hos sjuksköterskor under brytpunktssamtal. Konklusion: Sjuksköterskor kan i samband med brytpunktssamtal med både för och nackdelar hamna i kläm mellan patienter och läkare. Sjuksköterskor är i behov av tydlig information i anknytning till brytpunktssamtal för att kunna bistå patienter och samverka inom det multidisciplinära teamet runt patienten. Sjuksköterskor oroar sig över att beröva hopp från patienter genom att diskutera och besvara frågor kring sämre prognoser. / Background: Cancer can occur in different areas of the human body. Cancer care consists of two different phases. The curative phase when the goal is to cure the patient and the palliative phase when cure is no longer possible and the goal changes to comfort care. Patients with cancer can live for several years in the early stages of palliative care when the goal is to prolong the patient’s life and slow down the progression of the disease. When prolonging life is no longer possible the late palliative phase sets in and the goal of care is to make the patient comfortable and to manage symptoms of the disease. It is in between these phases the discussion called breaking point takes place. Nurses have a meaningful role in the process around breaking point. Purpose: The purpose of this study is to explore and compile nurses’ experiences of discussion around breaking point with patients with cancer. Method: A systematic literature review. Ten articles with qualitative approach were graded and compiled through content analysis. Result: The results was identified into three main themes; Nurses experience of cooperation between physicians and patients, relationship within breaking point and the nurses experience of hope. Nurses experienced that cooperation with doctors and evident communication with patients was important. The relationship with patients and relatives was an element that was present during breaking point conversation according to nurses. Hope was an emotion that was identified among nurses during breaking point conversations. Conclusion: Nurses can in relation to the discussion around breaking point get stuck in the middle between patients and the physicians which has both advantages and disadvantages. Nurses can through their work with the patient establish a relationship that involves confidence between the patient and the nurse. This relationship can benefit everyone involved in the breaking point discussion. Nurses are concerned about depriving their patients of hope when talking about their worsening prognosis.