Advance care planning (ACP) is defined as a process of open communication and information sharing between the health care team, the patient, and his/her family to enable patient’s wishes for future care and medical treatment to be explored and supported. The purpose of this study was to investigate the knowledge, attitudes, and experiences of medical-surgical nurses working in Winnipeg, Manitoba in relation to ACP. This cross-sectional descriptive study involved the use of a questionnaire developed and used in Singapore and assessed for face validity by local experts. A sample of 218 registered nurses responded to the web-based survey. Nurses were found to have: a sound understanding of foundational ACP concepts; communal and also varied attitudes toward ACP; and reported variable levels of involvement in ACP with patients and families. The results of this study can be used to inform change within both the educational and clinical care settings. / October 2015

Physical and psychosocial symptoms in advanced chronic obstructive pulmonary disease (COPD) are cumulative and profound; global financial and human costs are huge. COPD in late stages runs an unpredictable downward course of increasing, potentially fatal exacerbations. Nevertheless many physicians avoid advance care planning in this context, a choice that tends to promote last minute crisis decision-making. To explore a more ethically sound proactive approach to end-of-life care decision-making I conducted a qualitative study informed by the question: “What is required for meaningful and effective advance care planning in the context of advanced COPD?” Fifteen participants (eight patients with advanced COPD plus seven intimate others) participated in two in-home advance care planning discussions that incorporated patient-centred care principles. Session transcripts were analyzed using "interpretive description." Despite initial wariness, participants were able to discuss their care-related hopes and preferences and reported that the process was a positive one. Interpretation of the positive feedback suggested participants experienced the process as a chance to: a) talk with an attentive clinician, b) learn, c) consider care-related goals and preferences, and, d) have intimate others hear about these goals/preferences. Interpretation of the process that led to this positive assessment is described in terms of a thematic network. The overarching global theme of this network was "advance care planning as collaborative care," which involved three organizing themes--partnering, negotiating ambiguity, and being a resource--and a cluster of basic themes related to each of these. The "collaborative care" approach is discussed as a guide to advance care planning in advanced COPD. Like other advance care planning models, the study approach included a skilled clinician facilitator, provision of targeted information, and attention to readiness. There were four new elements: focus on caring, engaging hope, facilitator reflective praxis, and contextual sensitivity. While potentially enhancing the "care" dimension in advance care planning, the study approach may incidentally improve resource allocation and satisfaction with outcomes. Done well it may enhance decision-making and care planning, and, just as importantly, be experienced as care itself at a time and by those often neglected in this regard.

The continental margin in the area west of Shetland was subjected to repeated and extensive ice sheet advances during the Late Pleistocene. Seabed imagery, seismic survey and borehole core data show the Late Devensian ice sheets expanded across the continental shelf three times, two of these advances reaching the shelf edge. On the inner shelf, where present-day water depths are generally less than 100m, only thin sediments from the last retreat phase and exposed rock surfaces remain, all other deposits from earlier phases having been removed by the last advance. On the mid to outer shelf elements of all three phases are preserved, including lodgement and deformation tills, melt-out and water-lain till sheets, in-filled hollows left by stagnant ice decaying in situ and a series of large recessional and terminal moraines. In addition, there is evidence of shallow troughs and overdeepend basins which indicate preferential ice-drainage pathways across the shelf which were formerly occupied by ice streams. At the shelf edge, a thick wedge of glacigenic sediment forms a transition from the till sheets and moraines of the shelf to debris flows composed of glacigenic sediments on the upper slope. Shelf-edge moraines show an architecture indicating floating ice in modern water depths over approximately 180m, suggesting the West Shetland ice sheet was no more than about 250m thick. The upper and middle slope is dominated by glacigenic debris flows which are focused in the slope areas below the proposed ice stream discharges at the shelf edge. The mid-to-lower slope has been subjected to contour current activity which has re-worked much of the glacigenic sediment in this position. The lower slope and floor of the Faroe-Shetland Channel are marked by either large debris flow lobes of glacigenic sediment or thin glacimarine muds deposited from suspension. A conceptual model of the glacigenic development of a passive continental margin based upon the West Shetland example shows the deposited sequence for both advance and retreat phases of a glacial cycle, and the actual preserved sequence which might be expected in the rock record. The model also shows that ice sheet buoyancy, thickness, and to a lesser extent, basin subsidence, are the most important factors in the deposition and preservation of a glacially-influenced marine sequence.

Professional paper (M Nursing)--Montana State University--Bozeman, 2009. / Typescript. Chairperson, Graduate Committee: Elizabeth S. Kinion. Includes bibliographical references (leaves 28-34).

Thesis (M.A.)--Catholic Theological Union at Chicago, 1998. / Vita. Includes bibliographical references (leaves 117-124).

Thesis (Ph. D.)--University of Washington, 2005. / Vita. Includes bibliographical references (leaves 110-120).

Thesis (Ph. D.)--University of Rhode Island, 2004. / Typescript. Includes bibliographical references (leaves 171-187).

Background: - Living wills have long been associated with end-of- life care. This study explored the promotion and use of living wills amongst general practitioners and frail care nursing coordinators directly involved in the care of the elderly in Howick, Kwa-Zulu Natal. The study also explored their views regarding the proforma living will disseminated by the Living Will Society. Participants: - Seven general practitioners and three frail care nursing coordinators, making ten in total. Design: - Qualitative in-depth interviews and analysis, using the Framework method. Results:- Both doctors and nursing staff understood the concept of living wills and acknowledged their varied benefits to patient, family and staff. They were concerned about the lack of legal status. They felt that the proforma document from the Living Will Society was simple and clear. Despite identifying the low level of use of living wills, they felt that third party organisations and individuals should promote living wills Conclusion: - GPs and frail care nurse coordinators were knowledgeable of living wills in general and the Living Will Society proforma document in particular. They valued the contribution that living wills can make in the care of the elderly, benefitting patients, their families, health care workers and even the health system. They also valued the proforma living will document from the Living Will Society for its clarity and simplicity. However, both GPs and frail care nursing coordinators viewed the living will process as patient- driven and their main role was as custodians and not advocates of the living will.

Master of Science / Department of Animal Sciences and Industry / James S. Drouillard / Ruminal characteristics and feedlot performance were measured for steers adapted to a high-grain diet using a traditional 22-d step-up program (Control) and for steers adapted over 10 d with the aid of M. elsdenii NCIMB 41125 fresh culture administered as an oral gavage (Fresh), an oral gavage of rehydrated lyophilized culture (Rehyd), or Rehyd combined with lyophilized culture powder administered daily as a ration top-dress (Rehyd+Daily). Yearling steers (n = 435; initial BW = 408 ± 5 kg) were blocked by weight and randomly allocated to 64 concrete surfaced pens with 7 steers/pen and 16 pens/treatment. Step-up diets contained 40, 30, and 20% corn silage, and were followed by a finishing diet containing 10% corn silage and 90% concentrate. Ruminal fluid was obtained from a subset of steers by rumenocentesis 26 h after their first feeding, and inoculated into culture tubes containing lactate medium to determine differences in capacity for lactate metabolism over 24 h. A radiofrequency pH bolus was placed in the reticulorumen of 32 steers, that measured ruminal pH every 10 min for 124 d. Steers were fed once daily ad libitum for 156 d, then weighed, and transported 450 km to a commercial abattoir for harvest. HCW and incidence of liver abscesses were determined at harvest and carcass traits were evaluated after 36 h of refrigeration. No differences were detected for feedlot performance (P > 0.20), liver abscesses (P = 0.45), or carcass traits (P > 0.20). Capacity for lactate utilization was increased with all forms of M. elsdenii, as evidenced by increases in optical density (absorbance) of M. elsdenii cultures, disappearance of lactate, and increase in butyrate production (P < 0.01). Steers on Rehyd and Rehyd+Daily treatments spent less time between pH thresholds of 5.6 > pH > 5.2 (P < 0.01); 5.2 > pH > 5.0 (P < 0.01); and pH < 5.0 (P < 0.01) than Controls throughout the finishing period. In conclusion, steers dosed with M. elsdenii can be stepped up to finishing diets in 10 d with no adverse effects on performance. Ruminal fluid containing fresh cultures or freeze-dried and rehydrated cultures of M. elsdenii NCIMB 41125 were equally effective in metabolizing lactic acid. Lyophilized M. elsdenii resulted in less time below important pH thresholds, but no further benefit of daily administration was realized in this experiment.

Network virtualization allows operators to host multiple client services over their base physical infrastructures. Today, this technique is being used to support a wide range of applications in cloud computing services, content distribution, large data backup, etc. Accordingly, many different algorithms have also been developed to achieve efficient mapping of client virtual network (VN) requests over physical topologies consisting of networking infrastructures and datacenter compute/storage resources. However as applications continue to expand, there is a growing need to implement scheduling capabilities for virtual network demands in order to improve network resource utilization and guarantee quality of service (QoS) support. Now the topic of advance reservation (AR) has been studied for the case of scheduling point-to-point connection demands. Namely, many different algorithms have been developed to support various reservation models and objectives. Nevertheless, few studies have looked at scheduling more complex "topology-level'' demands, including virtual network services. Moreover, as cloud servers expand, many providers want to ensure user quality support at future instants in time, e.g., for special events, sporting venues, conference meetings, etc. In the light of above, this dissertation presents one of the first studies on advance reservation of virtual network services. First, the fixed virtual overlay network scheduling problem is addressed as a special case of the more generalized virtual network scheduling problem and a related optimization presented. Next, the complete virtual network scheduling problem is studied and a range of heuristic and meta-heuristic solutions are proposed. Finally, some novel flexible advance reservation models are developed to improve service setup and network resource utilization. The performance of these various solutions is evaluated using various methodologies (discrete event simulation and optimization tools) and comparisons made with some existing strategies.