The number of elderly in the U.S. (i.e., individuals age 65 years or older) is growing at a rapid rate. While the current proportion of elderly persons living in U.S. is estimated to be little over 14%, it will soon reach up to 20% in next 10 years. In addition, it is anticipated that the elderly population will soon outnumber the younger generations, for the first time in U.S. history. With the rapid shift we are witnessing in the U.S. population, the World Health Organization (WHO) informs that the leading cause of death in U.S. has also shifted: from infections to chronic illnesses. The majority of elderly individuals will suffer from at least one chronic illness, and many will live longer than ever, with complex multiple healthcare needs. The demands for specialized end of life (EoL) care among frail elderly will continue to rise, and it is among the top research priorities to identify best practices in EoL care and understand how best to facilitate patient-centered care in healthcare settings. In order to increase awareness in the importance of quality care provided to those who are near EoL, the Institute of Medicine (IOM; now the National Academy of Medicine) recommended a nation-wide implementation of an advance care planning tool, the POLST (Physician Orders for Life-Sustaining Treatment). Designed specifically for frail individuals living with serious illnesses, the POLST program is used to elicit care preferences and deliver goal-concordant care. Making patients’ specific care wishes actionable and transferrable, it aims to preserve one’s autonomy, and to allow them to die with dignity. This dissertation aims to evaluate the POLST program, from its effectiveness, dissemination, to outcomes associated with its maturity status. The first chapter provides background information on the aging population the importance of advance care planning among frail elderly persons. The POLST program is introduced and I lay out the three research aims and the significance of each topic. Chapter 2 contains a systematic review of scientific evidence on the concordance between documented care wishes and actual care delivered to the POLST users. It explains specific care interventions that yielded high concordant care, as well as ones that had mixed results. In chapter 3, an environmental scan of a state-specific POLST program across all U.S. states and Washington D.C. is presented; the scan examined maturity status, specific care options mentioned/ absent as well as descriptive statistics on the association between presence of infection/pain-related care options and the POLST program maturity status. In chapter 4, a quantitative analysis aimed at examining the impacts of the POLST program maturity status on a patient-level outcome (i.e., nursing home death) is presented. In it, multiple large datasets were used to generate a representative sample of the U.S. nursing home population. I then applied multivariate logistic regression modeling to estimate associations. Lastly, chapter 5 synthesizes the findings of this dissertation as well as strengths and limitations. It then shares recommendations for policy, clinical practice and future research.

This paper reviews literature on the topic of death anxiety and therapy. The author conducted a study examining potential clients' perceptions of two different therapeutic approaches for working with terminally ill clients with death anxiety. A review of literature relevant to this topic indicates that death anxiety is correlated with many psychological problems; however, there are no clinical studies focused primarily on the treatment of death anxiety among clients with a terminal illness. In this study, potential clients were randomly assigned to watched either a short video of a cognitive behavioral therapy session or a short video of an acceptance and commitment therapy session focused on treating a terminal ill person's death anxiety. After watching the video, potential clients rated the session impact of the therapy approach using the Session Evaluation Questionnaire. In addition, participant's views of seeking psychotherapy were assessed with the Attitudes Toward Seeking Professional Psychology Help measure. No differences in ratings of session impact were found between participants who viewed the cognitive behavioral therapy session and the acceptance and commitment therapy session. However, participants' attitudes toward seeking therapy were positively associated with their views of the therapist and session depth. Consistent with past literature, women reported more death anxiety than men. In regards to potential clients' views of session impact variables, their view of postsession positivity was positively related to their view of session smoothness. Additionally, a positive correlation was found between potential clients' views of the therapist and session depth. Implications and conclusions are discussed.

California Quail were exposed to fixed-interval schedules whose values ranged from FI 90 to FI 180. Post-reinforcement pause lengths and terminal rates were recorded and grouped into relative frequency distributions. The relative post-reinforcement pause length was found to be an increasing function of FI value such that at larger FI values a proportionally greater period of time was taken up by the post-reinforcement pause. Terminal rate (rate during the final 20% of the interval) was a decreasing function of FI value. The large amounts of variability in terminal rates observed indicated that terminal rate in fixed-interval schedules is not constant from interval to interval as is often reported in the literature. For a given subject, when overall rate of response for a session was plotted as a function of mean pause length for that session, no consistent relationship was found. Among the subjects there were two to three-fold differences in overall rate on FI 90, the only value to which all subjects were exposed. Differences among subjects in mean overall rates were correlated with differences in mean pause lengths, however. Thus, a subject's performance on a fixed-interval schedule could be characterized in terms of pause length and overall rate although rate in any given session was not necessarily correlated with mean pause length for that session, Differences between subjects in mean overall rates were also correlated with differences in mean terminal rates.

This work evaluates Medicare Hospice Benefit (MHB) eligibility standards that are referenced throughout this work as either "Medicare prognostic criteria," or "Local Medical Review Policies." Following the Chapter 1 overview of prognosis in end-stage disease, association between the Medicare clinical predictors and survival outcomes in dementing, cardiovascular and cerebrovascular illnesses are described in Chapter 2. Chapter 3 examines the prognostic belief systems of multidisciplinary hospice personnel. Chapter 4 seeks to improve the predictive performance of the Medicare prognostic criteria for dementia. The fifth and final chapter critiques the Medicare prognostic criteria from conceptual, methodological, and applied perspectives and suggests related research and policy directions. The Chapter 2 sample comprised 453 medical records of terminally ill persons; Chapter 4 sample, 187 medical records. Thirty-seven hospice personnel comprised the respondent sample in the Chapter 3 study. Chapter 2 assesses the scientific validity of federally sanctioned Medicare "severe illness/end-stage illness" demarcations in three non-cancer disease catregories. Calculation of measures of predictive validity revealed striking and consistent imbalances of false negative and false positive errors across the three diagnostic categories studied, suggesting inequitable distribution of the costs and benefits of regulatory reform among public health payers, consumers and providers. Chapter 3 qualitatively examines the belief systems of experienced hospice personnel regarding physical and non-physical time-to-death influences in end-stage disease. Non-physical survival influences were believed by these expert informants to have more survival impact in non-cancer as opposed to cancer end-stage diseases, and at remote as compared to imminent death proximities. Chapter 3 highlights the enormous complexity of time-to-death influences as well as the importance of non-physical influences on duration of survival in end-stage disease. Chapter 4 demonstrates that dropping one of the three prognostic criteria for dementia (the medical complications criteria) may improve predictive validity. This finding demonstrates that, in dementing illnesses at least, functional debility may better identify 6-month survival prognosis and thus hospice eligibility, than the composite Medicare prognostic criteria. The merit of parsimony in objective definitions of terminality is implied. Chapter 5 critiques the Medicare prognostic criteria, and suggests policy alternatives that are both prognostically- and non-prognostically-based. Peripheral findings of this work and suggestions for future end-of-life research conclude the dissertation.

Under terminal water deficit, the impact of stem carbohydrate remobilization has greater significance because post-anthesis assimilation is limited, and grain growth depends on translocation of carbohydrate reserves. The working hypothesis of this thesis is that increases in stem carbohydrates facilitate tolerance to terminal drought in wheat. The goals of this thesis are to examine this hypothesis using physiological and genetic tools; identify genes that are related to QTL for stem carbohydrate; work with wheat and barley breeders to integrate findings into the breeding program of the Department of Agricultural and Food Western Australia. The physiological data of three drought experiments (two years in a glasshouse and one year in the field) suggested the maximum level of stem water soluble carbohydrate (WSC) is not consistently related to grain weight, especially, under water deficit. The patterns of WSC accumulation after anthesis differed depending on variety and suggested that WSC degradation and translocation have different genetic determinants. Most of the carbohydrates in stem WSC in wheat are fructans. Because 1-FEH gene was an important gene in fructan degradation, the three copies of this gene (1-FEH w1, 1-FEH w2 and 1-FEH w3) were isolated from the respective genomes of bread wheat. In addition, the genes were mapped to chromosome locations and coincided with QTL for grain weight. The results of gene expression studies show that 1-FEH w3 had significantly higher levels in the stem and sheath which negatively corresponded to the level of stem WSC in two wheat varieties in both water-deficit and well-watered treatments. Strikingly, the 1-FEH w3 appeared to be activated by water deficit in Westonia but not in Kauz. The results suggest that stem WSC level is not, on its own, a reliable criterion to identify potential grain yield in wheat exposed to water deficit during grain filling. The expression of 1-FEH w3 may provide a better indicator when linked to instantaneous water use efficiency, osmotic potential and green leaf retention, and this requires validation in field grown plants. In view of the location of the contribution to grain filling of stem WSC, this is a potential candidate gene contributing to grain filling. The numerous differences of intron sequences of 1-FEH genes would provide more opportunities to find markers associated with the QTL. A new FEH gene was partially isolated from Chinese Spring and the sequence was closely related to 1-FEH genes. This gene, FEH w4, was mapped to 6AS using Chinese Spring deletion bin lines. The polymorphism of this gene was found between different bread varieties using PCRs and RFLPs, and this allowed the gene to be mapped to two populations of Hanxuan 10 × Lumai 14 and Cranbrook × Halberd. In the population of Hanxuan 10 × Lumai 14, it was close to SSR marker xgwm334 and wmc297 where the QTL of thousand grain weight and grain filling efficiency were located. This result indicated this gene might be another possible candidate gene for grain weight and grain filling in wheat.

Le Sud-est de la Côte d'Ivoire connaît depuis un demi-siècle une baisse exponentielle de sa surface forestière, liée à la déforestation et à l'impact du changement climatique. Les précipitations ont régressé de 15% entre 1937 et 2005 et la température de l'air connaît une légère augmentation de 0,08°C/10 ans. Pour comprendre le mécanisme de la recharge des aquifères, montrer l'impact du changement du climat et du couvert végétal sur les eaux et étudier la minéralisation des eaux de fractures du socle, 3 méthodes sont utilisées : la géochimie, la minéralogie et la télédétection. L'étude d'une image Landsat ETM+ a montré que l'aquifère du socle possède des paramètres géométriques favorables à un écoulement d'eau N-S. La minéralisation des nappes diminue d'amont en aval suivie d'une forte acidification des eaux, dues à un phénomène de dilution et de mise en solution du CO2 du sol. Sur le plan géochimique, l'étude révèle que l'enrichissement des nappes en Na+ et Ca2+ par rapport à K+ et Mg2+ est principalement lié à l'hydrolyse de l'albite pour le Na+ et de l'amphibole et de l'épidote pour le Ca2+. L'évolution du couvert végétal, depuis la période tardi-glaciaire, est marquée d'une augmentation de la teneur en 13C des eaux relativement vieilles (15 000 ans B.P) aux eaux récentes (~ 300-100 ans). La même tendance est constatée sur les teneurs en 18O et 2H des eaux du socle, témoignant ainsi des conditions particulièrement froides au début de la période post-glaciaire par rapport à celles d'aujourd'hui. Cette étude a montré que les eaux souterraines captives du socle sous le CT, ont enregistré les conditions paléoclimatiques de la Côte d'Ivoire des 15 000 dernières années.

Définition du projet: "CYCLADES", un réseau d'ordinateurs ; le traitement par lots dans un réseau hétérogène ; définition d'un serveur de traitement par lot pour le réseau CYCLADES ; définition d'un poste d'accès banalisé. Différents éléments de la réalisation : étude de la mise en œuvre ; outils pour le développement et la mise au point ; évaluation de la solution adaptée.

<p> </p><p> </p><p> </p><p><strong>Purpose</strong>: The Essay is written on behalf of a company called ”Uppdragsgivaren”. The purpose is to connect theory with the result of the survey and thereby find the critical factors for an optimal placement of the cargo holders in the company’s terminal.</p><p> </p><p> </p><p> </p><p><strong>Method:</strong> A qualitative case study has been carried out. The theory collection is completed with the result from the survey, which include the information “Uppdragsgivaren“ provides and the result from the survey. The survey is completed with telephone interviews. The survey is sent to seven persons working on similar company as “Uppdragsgivaren”. The study has a combination between the positivistic and hermeneutic view. The result is treated deductive. Theory and empirical are connected and among several theories one is chosen and will be tested on the company. Recommendations are given to “Uppdragsgivaren” and so are suggestions on further studies.</p><p> </p><p><strong>Result:</strong> The test shows that one part of the model is possible for “Uppdragsgivaren” to use when they want to optimize the cargo holder terminal. Part one of the tested model is independent from frequency and volume, and is therefore not applicable. Part two is applicable and the cargo holders can be arranged based on their volume. The result is thus that the most frequent cargo holder shall be placed on the most accessible area.</p><p> </p>

This dissertation will support full ethical endorsement of terminal sedation for those most urgently in crisis and need of beneficence, those who are dying and in the final hours or days and suffering. To clarify the practice I first detail ethical differences between euthanasia, physician assisted suicide and terminal sedation. Moreover, I identify new areas where harms and benefits need to be evaluated as affecting not only patients, but also families and caregivers. I evaluate the current practice to allow the development of ethical guidelines and greater consensus on deciding the hard cases. This work may also serve to assist those looking to enlarge the practice in the future with ETS for those with debilitating diseases or disability, but they are not my primary goal. Below is the standard I propose for moral allowability for the use of terminal sedation. I will refer to it often in the pages that follow simply as my standard . Terminal sedation is the appropriate and intentional use of medications (benzodiazepines and/or narcotics) to produce ongoing, deep unconsciousness upon 1) a terminal patient’s (or surrogates) request due to 2) suffering intractable pain or other distressing clinical symptoms intolerable to the patient when 3) death is expected within hours or days (less than two weeks) due to the terminal illness, injury, or disease. I offer two versions of initial guidelines for development of hospital policy. The first version outlines minimal guidelines that ought to be utilized to allow TS for patients who fit my standard. The minimal guideline is based upon the recommendations of the American Medical Association with some modifications. The guideline is admittedly restrictive in hopes of gaining wider societal support for a currently controversial practice. Secondly, I offer more moderate guidelines for policy that could become a standard in the future. It maintains the restrictive focus of the minimal guidelines and offers additional education and support to others which has yet to be broadly provided. The moderate guidelines would mark an important step forward for allowing more choices in dying and offering additional supports to those involved with dying patients.

Le monde des transports et de la mobilité nécessite une restructuration induite par la hausse sans cesse croissante des échanges. L’engorgement des routes, l’augmentation de l’insécurité, la hausse perpétuelle du trafic et des nuisances environnementales poussent les différentes instances à réfléchir et à agir. Dans cette optique, la Commission européenne a lancé les programmes Marco Polo I et II dont l’objectif est de transférer une partie du trafic de marchandise de la route vers des modes de transports plus respectueux de l’environnement. Cette étude s’inscrit dans ce cadre en essayant d’évaluer l’opportunité de développer le transport combiné rail-route. Plus précisément, elle propose de localiser de manière judicieuse des terminaux dédiés au transbordement de fret continental, afin de permettre l’expédition de marchandises sur longues distances avec des volumes suffisamment grands pour que le transport combiné soit compétitif. La répartition des flux sur le réseau est un élément essentiel, car l’une des principales raison d’être des terminaux considérés est de consolider les flux. C’est pourquoi une approche innovante basée sur les flux de transport est proposé. C’est en se basant sur une modélisation des flux qu’il est alors possible d’identifier les localisations optimales des terminaux et de minimiser ainsi les coûts totaux du système. La méthode développée permet également d’analyser les variations des aires de marché des terminaux en fonction de l’offre et de la demande de transport, ainsi que de mesurer les impacts sur la répartition modales.