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Supportive care (SC) is a multidimensional and person-centred approach to managing advanced CKD that engages the person and their caregivers in shared decision making from the outset. Rather than focusing on disease-specific therapies, SC is a collection of adjuvant interventions and adaptations to conventional treatments that can be used to improve the individual's quality of life. Recognizing that frailty, multi-morbidity and polypharmacy are more common among older people with advanced chronic kidney disease (CKD) and that people in this group tend to prioritize quality of life over survival as a goal of care, SC represents an important adjunct to disease-specific therapies in CKD management. This review provides an overview of SC in the older person with advanced CKD.Lay Summary Older people with advanced chronic kidney disease (CKD) are more likely to experience frailty and multiple other medical problems (comorbidity). This can result in impaired quality of life and reduced survival compared with younger adults with the same diagnosis. The benefits to be derived from kidney-specific treatments such as dialysis and transplantation are also less well-defined in older adults. Supportive care (SC) involves honest communication with the person about their disease, the treatments available to them and prognosis. Through shared decision making, the person and their doctor will try determine what is important to the person and address those aspects of disease that are contributing most to the person's suffering now, while also making plans for the future. This article provides an overview of SC principles in the older adult with advanced CKD.

Light quality is an important determinant in the plant's response to biotic stress. A low red: far-red ratio perception enhances plant susceptibility to pathogens. Increasing red wavelengths in the light spectrum may thus enhance the tolerance to pathogens. In this study, strawberry plants were exposed to increasing periods of red light replacing the full-spectrum white light in a 16 h photoperiod for, respectively, 5, 10 and 15 days. After the light pre-treatment, leaf resistance to three Botrytis isolates was evaluated. A diurnal rhythm of 6 h red light followed by 10 h white light during 15 days improved leaf resistance to all Botrytis isolates. Further finetuning of the light treatments showed that ten days of this light treatment followed by 5 days of 16 h white light could be the optimized light recipe to enhance leaf resistance to different Botrytis isolates in strawberry.

Background: Survival of patients with colon and rectal cancer has improved in all Nordic countries during the past decades. The aim of this study was to further assess survival trends in patients with colon and rectal cancer in the Nordic countries by age at diagnosis and to present additional survival measures. Methods: Data on colon and rectal cancer cases diagnosed in the Nordic countries between 1990 and 2016 were obtained from the NORDCAN database. Relative survival was estimated using flexible parametric models. Both age-standardized and age-specific measures for women and men were estimated from the models, as well as reference-adjusted crude probabilities of death and life-years lost. Results: The five-year age-standardized relative survival of colon and rectal cancer patients continued to improve for women and men in all Nordic countries, from around 50% in 1990 to about 70% at the end of the study period. In general, survival was similar across age and sex. The largest improvement was seen for Danish men and women with rectal cancer, from 41% to 69% and from 43% to 71%, respectively. The age-standardized and reference-adjusted five-year crude probability of death in colon cancer ranged from 30% to 36% across countries, and for rectal cancer from 20% to 33%. The average number of age-standardized and reference-adjusted life-years lost ranged between six and nine years. Conclusion: There were substantial improvements in colon and rectal cancer survival in all Nordic countries 1990-2016. Of special note is that the previously observed survival disadvantage in Denmark is no longer present. (C) 2022 The Author(s). Published by Elsevier Ltd.

Background Due to the rising number of acutely hospitalised older people in the coming years, there is increased interest in tailoring care to the individual goals and preferences of patients in order to reach patient-centered care. Aims This study aimed to investigate the goals of older hospitalised patients and the extent to which these goals were reached during hospitalisation. Methods A single centre prospective cohort study was performed in the Netherlands between December 2017 and January 2018. Participants aged 70 years or older were included. In the first three days of hospitalisation, a semi-structured interview was conducted to assess the patient goals regarding the hospital admission. One to two weeks after discharge patients were asked to which extent the recent hospitalisation had contributed to reaching their goals. Results One-hundred-and-four patients were included and for 86 patients follow-up was completed. The main goals reported at hospital admission were "remaining alive" (72.1%), "feeling better" (71.2%) and "improving condition"(65,4%). Hospitalisation seemed to have a positive contribution to reaching the goals "remaining alive", "knowing what is wrong", "feeling better", "reducing pain" and "controlling disease". Hospitalisation seemed to contribute little to reaching the goals in the categories "enjoying life", "independency and freedom", "improving daily functioning", "hobbies and work" and "social functioning". Conclusions It is important for healthcare professionals to know the goals of their patients. The majority of these goals were not achieved at hospital discharge. It is important to be aware of this, so sufficient aftercare can be arranged, and patients can be prepared. This article is protected by copyright. All rights reserved.

Background: The delivery of palliative care interventions is not widely integrated in chronic heart failure care as the recognition of palliative care needs is perceived as difficult. Tools may facilitate healthcare professionals to identify patients with palliative care needs in advanced chronic heart failure. Aim: To identify tools to help healthcare professionals recognize palliative care needs in patients with advanced chronic heart failure. Design: This systematic review was registered in the PROSPERO database (CRD42019131896). Evidence of tools’ development, evaluation, feasibility, and implementation was sought and described. Data sources: Electronic searches to identify references of tools published until June 2019 were conducted in MEDLINE, CINAHL, and EMBASE. Hand-searching of references and citations was undertaken. Based on the identified tools, a second electronic search until September 2019 was performed to check whether all evidence about these tools in the context of chronic heart failure was included. Results: Nineteen studies described a total of seven tools. The tools varied in purpose, intended user and properties. The tools have been validated to a limited extent in the context of chronic heart failure and palliative care. Different health care professionals applied the tools in various settings at different moments of the care process. Guidance and instruction about how to apply the tool revealed to be relevant but may be not enough for uptake. Spiritual care needs were perceived as difficult to assess. Conclusion: Seven tools were identified which showed different and limited levels of validity in the context of palliative care and chronic heart failure.

Background Colorectal cancer (CRC) incidence in Finland has risen steadily. Given development in cancer treatments in recent decades, disease-specific data on the long-term prognosis of patients may be obsolete. Thus, this study aimed to report 5-year disease-specific survival (DSS) and relative survival based on tumour spread and site among CRC patients diagnosed between 1991 and 2015 in Finland. Material and methods We conducted a population-based registry study among 59 465 CRC patients identified from the Finnish Cancer Registry. Results The 5-year DSS for all CRC patients was 56.7% [95% confidence interval (CI) 56.3–57.1%] for 1991 through 2015. Tumour site-specific survival has improved for the period 2006–2015 versus 1991–2005 for right-sided colon cancer from 54.8% (95% CI 53.8–55.8%) to 59.9% (95% CI 58.7–61.1%), for left-sided colon cancer from 54.1% (95% CI 52.9–55.3%) to 61.0% (95% CI 59.8–62.2%) and for rectal cancer from 53.6% (95% CI 52.2–55.0%) to 62.3% (95% CI 61.3–63.3%). The 5-year relative survival for the period 2006 through 2015 was 93.6% for localised disease (stage I); 84.2% for locally advanced tumour invading adjacent structures (stage II); 68.2% for regional disease with regional lymph node metastases (stage III); and 14.0% for metastatic disease (stage IV). Conclusions This study confirms that survival for CRC has improved in recent decades in Finland, mirroring observations from other Western countries. However, the classification of tumour spread within the Finnish Cancer Registry differs slightly from the TNM classification, thereby limiting the generalisability of these results.

The purported study explored Online Travel Agencies (OTA) influence on consumers brand relationships towards hotels and provided convenient and easy purchase decisions for South African Millennial consumers who travel or intend to travel. Empirical and theoretical investigation in in low and high-end hotel groups was executed, explored the research problem aimed at filling the gap. Hypotheses were quantitatively tested using Structural Equation Modelling (SEM), Confirmatory Factor Analysis (CFA) tested reliability and validity. A quantitative methodology philosophy was used, and random sampling employed to selected respondents among the millennials and Amos and SPSS 25 obtained CFA and path model to determine best model fit. Findings indicated that there is a positive relationship between hotel brand loyalty and repurchase intentions. However, consumer may be attitudinally loyal and may need marketing incentives to ensure that the consumer become behaviourally loyal to ensure visitation to the hotel brand. Originality and value of the research is in the study proving significant insight into the travel industry and in its ability to provide marketers an understanding of customer satisfaction and retention, fresh contemporary evidence supported by reliable information contributing to body of knowledge giving lieu-way into further research on brand relationships in low & high-end hotels.

According to the World Health Organization, palliative care must be available for everyone with life-threatening diseases. However, in daily practice the primary focus worldwide is on cancer patients. The aim of the article was to generate a national position statement as the first step in implementing palliative care in severe heart disease with focus on advanced heart failure, including tools to identify the need for and timing of palliative care and how palliative care could be organized in Denmark. A task force was formed in the Danish Society of Cardiology Heart Failure Working Group, and the position statement was prepared in collaboration with members from a broad group of specialties, including palliative medicine. Because of major gaps in evidence, the position statement was based on small and low-quality studies and clinical practice statements. This position statement was aligned with the European Society of Cardiology recommendation, focusing on relieving suffering from the early disease stages parallel to standard care and supplementing life-prolonging treatment. The statement delivers practical guidance on clinical aspects and managing symptoms during the three stages of advanced heart disease. Furthermore, the statement describes the importance of communication and topics to be broached, including deactivating implantable cardioverter defibrillators. The statement recommends a targeted effort on organizational strategies using high-quality assessment tools and emphasizes multidisciplinary and intersectoral collaboration. Danish cardiologists supported by allied professionals acknowledge the importance of palliative care in advanced heart disease. This national position statement intended to inform and influence policy and practice and can hopefully inspire other countries to take action toward implementing palliative care in advanced heart disease.

The Arab Spring marks a puzzling shift in the sanction politics of the Arab League: for the first time, the Arab League suspended member states for matters of internal affairs by majority vote. This article argues that survival politics can explain the changing sanction politics of the Arab League. To re-legitimize rule during this unprecedented moment, member states selectively supported some protest movements to signal their understanding of public demands for change without committing to domestic reform. Contrasting case studies of the Arab League’s suspension of Libya and Syria and its simultaneous support for military intervention against protestors in Bahrain illustrate how concerns for regime legitimation and a short-lived alliance between Saudi Arabia and Qatar contributed to the sanctioning decisions. The Arab League can thus be considered a case of negative democracy protection, where regional sanctions are employed to selectively preserve authoritarian rule.

Aims: This study aimed to find out how place of death varied between countries with different health and social service systems. This was done by investigating typical groups (concerning age, sex and end-of-life trajectory) of older people dying in different places in Finland and Norway. Methods: The data were derived from national registers. All those who died in Finland or Norway at the age of ⩾70 years in 2011 were included. Place of death was analysed by age, sex, end-of-life trajectory and degree of urbanisation of the municipality of residence. Two-proportion z-tests were performed to test the differences between the countries. Multinomial logistic regression analyses were performed separately for both countries to find the factors associated with place of death. Results: The data consisted of 68,433 individuals. Deaths occurred most commonly in health centres in Finland and in nursing homes in Norway. Deaths in hospital were more common in Norway than they were in Finland. In both countries, deaths in hospital were more common among younger people and men. Deaths in nursing homes were commonest among frail older people, while most of those who had a terminal illness died in health centres in Finland and in nursing homes in Norway. Conclusions: Both Finland and Norway have a relatively low share of hospital deaths among older people. Both countries have developed alternatives to end-of-life care in hospital, allowing for spending the last days or weeks of life closer to home. In Finland, health centres play a key role in end-of-life care, while in Norway nursing homes serve this role. Aims: This study aimed to find out how place of death varied between countries with different health and social service systems. This was done by investigating typical groups (concerning age, sex and end-of-life trajectory) of older people dying in different places in Finland and Norway. Methods: The data were derived from national registers. All those who died in Finland or Norway at the age of ⩾70 years in 2011 were included. Place of death was analysed by age, sex, end-of-life trajectory and degree of urbanisation of the municipality of residence. Two-proportion z-tests were performed to test the differences between the countries. Multinomial logistic regression analyses were performed separately for both countries to find the factors associated with place of death. Results: The data consisted of 68,433 individuals. Deaths occurred most commonly in health centres in Finland and in nursing homes in Norway. Deaths in hospital were more common in Norway than they were in Finland. In both countries, deaths in hospital were more common among younger people and men. Deaths in nursing homes were commonest among frail older people, while most of those who had a terminal illness died in health centres in Finland and in nursing homes in Norway. Conclusions: Both Finland and Norway have a relatively low share of hospital deaths among older people. Both countries have developed alternatives to end-of-life care in hospital, allowing for spending the last days or weeks of life closer to home. In Finland, health centres play a key role in end-of-life care, while in Norway nursing homes serve this role.

Introduction. Insufficient cultural competences among health care professionals (HCPs) working with ethnic minorities may result in poorer quality of care. This study aimed to develop a cultural intervention for HCPs. Method. The intervention was designed using the Behavior Change Wheel. The development phase contained empirical studies of patients with HIV and African background, literature review, observations from a migrant health clinic, and transcultural care theory. Results. Systematic development will facilitate an intervention tailored to focus on nurses’ sensitivity and awareness, and aims to give them tools to identify narratives about patients’ life situation and self-management as well as provide effective, compassionate, and culturally competent care. Discussion. Higher cultural competence among nurses may improve their support of patients to manage their disease.

Euthanasia was first legalized in the Netherlands and Belgium in 2001 and 2002, respectively. Currently they are among the few countries that also allow euthanasia on the basis of dementia, which is still considered controversial, both from a scientific and societal perspective. To date, euthanasia in dementia constitutes a small proportion of all Dutch and Belgian euthanasia cases. However, instances are rising due to a growing awareness among the general public about the possibilities of a self-chosen end-of-life and the willingness among medical professionals to perform euthanasia in individuals diagnosed with dementia. In both countries euthanasia is allowed under strict conditions in patients with dementia and decisional capacity regarding euthanasia, while in the Netherlands an advance euthanasia directive can also replace an oral request for euthanasia in those with late-stage dementia. Judging euthanasia requests from patients with dementia is complex and the assessment of the due care criteria (especially those related to decisional capacity and unbearable suffering) requires caution and great care. In this narrative review, we reflect on the legal regulation, clinical guidelines and societal debate regarding euthanasia in dementia in the Netherlands and Belgium. By discussing the 20 years of experience with the ethical dilemmas and controversial aspects surrounding this delicate topic, we hope to inform the preparation or implementation of new legislation on euthanasia in dementia in other countries.

Background Although advance care planning (ACP) has been widely recommended to support patient and family engagement in understanding the patient’s values, preferences and goals of care, there are only a few models in paediatric oncology that capture ACP as a process of behaviour change. We aimed to develop and test the acceptability and feasibility of BOOST pACP (Benefits of Obtaining Ownership Systematically Together in paediatric Advance Care Planning) – an intervention to improve ACP in adolescents with cancer, their parents and paediatric oncologists. Methods Several methods informed the intervention development process: 1) Problem identification: interviews with 11 healthcare professionals working in paediatric oncology; 2) Identification of evidence: literature review of existing pACP tools and barriers and facilitators in performing pACP; 3) Logic model and 4) Intervention design: collaborative expert meetings with researchers and professionals in pACP; 5a) Acceptability test of the materials: interviews with nine healthcare professionals, four adolescents and young adults with cancer and six parents; 5b) Feasibility test of core intervention components with three families, including interviews about their experiences. Results The BOOST pACP intervention was iteratively developed and adapted, based on feedback from families, healthcare professionals, and pACP experts (e.g., components were changed, deleted, and added; formulation of themes and associated questions were amended to enhance acceptability). The core components of the BOOST pACP intervention include: four ACP conversation sessions with the adolescent and/or parent(s) provided by a trained facilitator, structured by interactive conversation cards covering different ACP themes, followed by a transfer of information from the intervention facilitator to the paediatric oncologist. Core intervention components were deemed feasible by all participating families. Conclusion The BOOST pACP intervention was developed by close involvement of both adolescent patients and their parents, healthcare professionals and pACP experts. The final intervention and supporting materials are considered appropriate and feasible. Its effectiveness in improving parent-adolescent communication on ACP themes is currently being tested in a multi-centre randomised controlled trial. Researchers aiming to develop a complex psychosocial intervention for a vulnerable target group could use the step-by-step approach described in this paper.

In 2009, the European Association for Palliative Care (EAPC) developed a framework on palliative sedation, acknowledging this practice as an important and ethically acceptable intervention of last resort for terminally ill patients experiencing refractory symptoms. Before and after that, other guidelines on palliative sedation have been developed in Europe with variations in terminology and concepts. As part of the Palliative Sedation project (Horizon 2020 Funding No. 825700), a revision of the EAPC framework is planned. The aim of this article is to analyze the most frequently used palliative sedation guidelines as reported by experts from eight European countries to inform the discussion of the new framework. The three most reported documents per country were identified through an online survey among 124 clinical experts in December 2019. Those meeting guideline criteria were selected. Their content was assessed against the EAPC framework on palliative sedation. The quality of their methodology was evaluated with the Appraisal Guideline Research and Evaluation (AGREE) II instrument. Nine guidelines were included. All recognize palliative sedation as a last-resort treatment for refractory symptoms, but the criterion of refractoriness remains a matter of debate. Most guidelines recognize psychological or existential distress as (part of) an indication and some make specific recommendations for such cases. All agree that the assessment should be multiprofessional, but they diverge on the expertise required by the attending physician/team. Regarding decisions on hydration and nutrition, it is proposed that these should be independent of those for palliative sedation, but there is no clear consensus on the decision-making process. Several weaknesses were highlighted, particularly in areas of rigor of development and applicability. The identified points of debate and methodological weaknesses should be considered in any update or revision of the guidelines analyzed to improve the quality of their content and the applicability of their recommendations. ispartof: JOURNAL OF PALLIATIVE MEDICINE vol:25 issue:11 pages:1721-1731 ispartof: location:United States status: published

New records of the Endangered Catagonus wagneri (Rusconi, 1930) are reported in Campo Grande Community of peasants, northwestern Santiago del Estero, Argentina. The new records were obtained through camera traps as well as the finding of a skull and footprints. We conducted interviews confirmed the historical presence of the species. The records indicate the presence of C. wagneri in the North Biological Corridor, expanding this species’ distribution in Santiago del Estero province, providing initial evidence of potential connection between northern and southern populations.

We show that sub-spreading events i.e., transmission events in which an infection propagates to few or no individuals, can be surprisingly important for defining the lifetime of an infectious disease epidemic and hence its waiting time to elimination or fade-out, measured from the time-point of its last observed case. While limiting super-spreading promotes more effective control when cases are growing, we find that when incidence is waning, curbing sub-spreading is more important for achieving reliable elimination of the epidemic. Controlling super-spreading in this low-transmissibility phase offers diminishing returns over non-selective, population-wide measures. By restricting sub-spreading we efficiently dampen remaining variations among the reproduction numbers of infectious events, which minimises the risk of premature and late end-of-epidemic declarations. Because case-ascertainment or reporting rates can be modelled in exactly the same way as control policies, we concurrently show that the under-reporting of sub-spreading events during waning phases will engender overconfident assessments of epidemic elimination. While controlling sub-spreading may not be easily realised, the likely neglecting of these events by surveillance systems could result in unexpectedly risky end-of-epidemic declarations. Super-spreading controls the size of the epidemic peak but sub-spreading mediates the variability of its tail.

Background: Advance care planning (ACP) is not well implemented in hospital. Implementation theory stresses the importance of knowing what hospitalised palliative patients and their families experience as barriers or as facilitators in the uptake of ACP with their treating physician. Aims: This study aimed to gain an in-depth understanding of what hospitalised palliative patients and their families experienced as barriers or facilitators for having ACP conversations. Methods: We used a tape-assisted recall procedure to conduct 29 videotaped interviews with hospitalised patients and their families. We used content analysis based on grounded theory principles. Results: Four major fields of tension were discovered: not knowing what to expect from the treating physician; not being sure the treating physician can be a trusted partner; daring to speak about ACP; and staying loyal to one's own wishes. Conclusions: Patients and families need physicians who are accessible and can be trusted ACP partners throughout the disease process.

Background: To avoid aggressive treatments at the end-of-life and to provide palliative care (PC), physicians need to terminate futile anti-cancer treatments and define the palliative goal of the treatment in time. This single center study assesses the practices used to make the decision that leads to treatment with a palliative goal, i.e., the PC decision and its effect on anti-cancer treatments at the end of life. Material and methods: Patients with a cancer diagnosis treated in tertiary hospital during 1st January 2013 - 31st December 2014 and deceased by the end of 2014 were identified in the hospital database (N = 2737). Of these patients, 992 were randomly selected for this study. The PC decision was screened from patient records, i.e., termination of cancer-specific treatments and a focus on symptom-centered PC. Results: The PC decision was defined in 82% of the patients during the last year of life (49% >30 days and 33%

Background: The European Association for Palliative Care White Paper defined optimal palliative care in dementia based on evidence and expert consensus. Yet, we know little on how to achieve this for people with dementia living and dying at home. Aims: To examine evidence on home palliative care interventions in dementia, in terms of their effectiveness on end-of-life care outcomes, factors influencing implementation, the extent to which they address the European Association for Palliative Care palliative care domains and evidence gaps. Design: A systematic review of home palliative care interventions in dementia. Data sources: The review adhered to the PRISMA guidelines and the protocol was registered with PROSPERO (CRD42018093607). We searched four electronic databases up to April 2018 (PubMed, Scopus, Cochrane library and CINAHL) and conducted lateral searches. Results: We retrieved eight relevant studies, none of which was of high quality. The evidence, albeit of generally weak quality, showed the potential benefits of the interventions in improving end-of-life care outcomes, for example, behavioural disturbances. The interventions most commonly focused on optimal symptom management, continuity of care and psychosocial support. Other European Association for Palliative Care domains identified as important in palliative care for people with dementia, for example, prognostication of dying or avoidance of burdensome interventions were under-reported. No direct evidence on facilitators and barriers to implementation was found. Conclusions: The review highlights the paucity of high-quality dementia-specific research in this area and recommends key areas for future work, for example, the need for process evaluation to identify facilitators and barriers to implementing interventions.

Purpose The present study explores transition experiences during courses of incurable cancer from the perspective of bereaved spouses. Method Ten bereaved spouses participated in individual semi-structured interviews conducted in participants' private homes. The study takes a phenomenological-hermeneutic approach and data was analysed inspired by the French philosopher Paul Ricoeur's theory of interpretation. Findings Two main themes were identified. The first one: “Being present when the life of their loved one is ending” consisted of three subthemes: “Challenged by suffering”, “Transitions during the final days” and “Moving on in life”. The second main theme: “Meaningful transitions in palliative care” consisted of two subthemes: “Changing direction towards palliative care” and “Transitions in palliative care”. Conclusion Bereaved spouses experienced meaningful transitions when the life of their loved one was ending and related to receiving palliative care . Spouses were challenged by witnessing their loved one's suffering and experienced a deviation in the quality of professional palliative care offered in the system of healthcare.

RationaleAdvance care planning (ACP) is uncommon in patients with chronic obstructive pulmonary disease (COPD).ObjectivesTo assess whether a nurse-led ACP-intervention can improve quality of patient-physician end-of-life care communication in patients with COPD. Furthermore, the influence of an ACP-intervention on symptoms of anxiety and depression in patients and loved ones was studied. Finally, quality of death and dying was assessed in patients who died during 2-year follow-up.MethodsA multicentre cluster randomised-controlled trial in patients with advanced COPD was performed. The intervention group received an 1.5 hours structured nurse-led ACP-session. Outcomes were: quality of patient-physician end-of-life care communication, prevalence of ACP-discussions 6 months after baseline, symptoms of anxiety and depression in patients and loved ones and quality of death and dying.Results165 patients were enrolled (89 intervention; 76 control). The improvement of quality of patient-physician end-of-life care communication was significantly higher in the intervention group compared with the control group (p0.05). The quality of death and dying was comparable between both groups (p=0.17).ConclusionOne nurse-led ACP-intervention session improves patient-physician end-of-life care communication without causing psychosocial distress in both patients and loved ones.

The spiritual dimension is considered to be a central component of palliative care. However, healthcare professionals have difficulties incorporating the spiritual dimension into their everyday practice. We propose a new approach by looking beyond the mere functionality of care practices. Rituals and ritualized practices can serve to express and communicate meanings and values. This article explores how ritualized practices have the ability to open up space for the spiritual dimension of care in the context of palliative care.

The respiratory system is one of the major components of the speech production system. Any alteration in breathing can result in changes in speech. Specific breathing characteristics, such as breathing rate and tidal volume, can indicate a person's pathological condition. More recently, neural network-based methods have started emerging for predicting the breathing signal from the speech signal. The neural networks are trained and evaluated with different objective measures, such as mean squared error (MSE) and Pearson's correlation. This paper investigates whether there is a systematic relationship between the different objective measures used for training and evaluating the neural network models and the end-goal, i.e. estimation of breathing parameters such as, breathing rate and tidal volume. Our investigations on two different data sets with two different neural network-based approaches show that there is no clear systematic relationship. In other words, obtaining a high Pearson's correlation on the evaluation set does not necessarily mean better breathing parameter estimation. Thus, indicating the need for developing other objective evaluation measures.

Background: The use of analgesics and sedatives to alleviate pain and discomfort is common in end-of-life care in neonates and infants. However, to what extent those drugs are used in that context with the specific aim of bringing the infant in a state of continuous deep sedation (CDS) is currently unknown. Methods: We performed a nationwide mortality follow-back survey based on all deaths under the age of 1 over a period of 16 months in Flanders, Belgium. Data on CDS were linked to sociodemographic information from death certificates. Physicians completed an anonymous questionnaire. Questions measured whether CDS preceded death, and which clinical characteristics were associated with the sedation (e.g., type of drugs used and the duration of sedation). Results: The response rate was 83% (229/276). In 39% of all deceased neonates and infants, death was preceded by CDS. Physicians used a combination of morphine and benzodiazepines in 53%, or morphine alone in 45% of all sedation cases in order to continuously and deeply sedate the infant. In 89% of cases, death occurred within 1 week after sedation was begun, and in 92% of cases, artificial nutrition and hydration were administered until death. In 49% of cases there was no intention to hasten death, and in 40% of cases, the possibility of hastening was taken into account. Conclusions: CDS precedes about 2 in 5 neonatal and infant deaths. Guidelines for CDS in this age group are non-existent and it is unclear whether the same recommendations as in the adult population apply and can be considered a good practice.

Background: International oncology societies recommend early palliative care. Specific models to integrate early palliative care efficiently into clinical practice are debated. The authors designed a study to look at the quantitative and qualitative outcomes of an early palliative care intervention in oncological care to decrease stress and improve quality of life. Aims: To compare a single structured early palliative care intervention added to a usual oncology care in terms of distress and health-related quality of life at baseline compared to 6 months after enrollment. Design: This multicenter randomized controlled trial (NCT01983956) enrolled adult patients with advanced cancer. Participants were either randomly assigned to usual oncology care alone or usual care plus a structured early palliative care intervention. Setting/participants: One hundred fifty adult patients with a variety of advanced cancer diagnoses were randomized. Seventy-four participants were in the intervention and 76 participants in the control group. The primary outcome was the change in patient distress assessed by the National Comprehensive Cancer Network distress thermometer at 6 months. Health-related quality of life, the secondary outcome, was assessed by the Functional Assessment of Cancer Therapy–General Questionnaire. Results: The results showed no significant effect of the early palliative care intervention neither on patient distress nor on health-related quality of life. Conclusion: The addition of an early intervention to usual care for patients with advanced cancer did not improve distress or quality of life. Thus, patients may need more intensive early palliative care with continuous professional support to identify and address their palliative needs early.

Background: Whether Intensive Care Unit (ICU) clinicians display unconscious bias towards cancer patients is unknown. The aim of this study was to compare the outcomes of critically ill patients with and without perceptions of excessive care (PECs) by ICU clinicians in patients with and without cancer. Methods: This study is a sub-analysis of the large multicentre DISPROPRICUS study. Clinicians of 56 ICUs in Europe and the United States completed a daily questionnaire about the appropriateness of care during a 28-day period. We compared the cumulative incidence of patients with concordant PECs, treatment limitation decisions (TLDs) and death between patients with uncontrolled and controlled cancer, and patients without cancer. Results: Of the 1641 patients, 117 (7.1%) had uncontrolled cancer and 270 (16.4%) had controlled cancer. The cumulative incidence of concordant PECs in patients with uncontrolled and controlled cancer versus patients without cancer was 20.5%, 8.1%, and 9.1% (p < 0.001 and p = 0.62, respectively). In patients with concordant PECs, we found no evidence for a difference in time from admission until death (HR 1.02, 95% CI 0.60–1.72 and HR 0.87, 95% CI 0.49–1.54) and TLDs (HR 0.81, 95% CI 0.33–1.99 and HR 0.70, 95% CI 0.27–1.81) across subgroups. In patients without concordant PECs, we found differences between the time from admission until death (HR 2.23, 95% CI 1.58–3.15 and 1.66, 95% CI 1.28–2.15), without a corresponding increase in time until TLDs (NA, p = 0.3 and 0.7) across subgroups. Conclusions: The absence of a difference in time from admission until TLDs and death in patients with concordant PECs makes bias by ICU clinicians towards cancer patients unlikely. However, the differences between the time from admission until death, without a corresponding increase in time until TLDs, suggest prognostic unawareness, uncertainty or optimism in ICU clinicians who did not provide PECs, more specifically in patients with uncontrolled cancer. This study highlights the need to improve intra- and interdisciplinary ethical reflection and subsequent decision-making at the ICU., SCOPUS: ar.j, info:eu-repo/semantics/published

ObjectivesTo explore intercountry and intracountry differences in physician opinions about continuous use of sedatives (CUS), and factors associated with their approval of CUS.SettingsSecondary analysis of a questionnaire study.ParticipantsPalliative care physicians in Germany (N=273), Italy (N=198), Japan (N=334) and the UK (N=111).Primary and secondary outcome measuresPhysician approval for CUS in four situations, intention and treatment goal, how to use sedatives and beliefs about CUS.ResultsThere were no significant intercountry or intracountry differences in the degree of agreement with statements that (1) CUS is not necessary as suffering can always be relieved with other measures (mostly disagree); (2) intention of CUS is to alleviate suffering and (3) shortening the dying process is not intended. However, there were significant intercountry differences in agreement with statements that (1) CUS is acceptable for patients with longer survival or psychoexistential suffering; (2) decrease in consciousness is intended and (3) choice of neuroleptics or opioids. Acceptability of CUS for patients with longer survival or psychoexistential suffering and whether decrease in consciousness is intended also showed wide intracountry differences. Also, the proportion of physicians who agreed versus disagreed with the statement that CUS may not alleviate suffering adequately even in unresponsive patients, was approximately equal. Regression analyses revealed that both physician-related and country-related factors were independently associated with physicians’ approval of CUS.ConclusionVariations in use of sedatives is due to both physician- and country-related factors, but palliative care physicians consistently agree on the value of sedatives to aid symptom control. Future research should focus on (1) whether sedatives should be used in patients with longer survival or with primarily psychoexistential suffering, (2) understanding physicians’ intentions and treatment goals, (3) efficacy of different drugs and (4) understanding the actual experiences of patients receiving CUS.

Context. Long-term care facility (LTCF) residents have unmet needs in end-of-life and symptom care. Objectives. This study examines the effects of an end-of-life care staff training intervention on LTCF residents' pain, symptoms, and psychological well-being and their proxies' satisfaction with care. Methods. We report findings from a single-blind, cluster randomized controlled trial featuring 324 residents with end-of-life care needs in 20 LTCF wards in Helsinki. The training intervention included four 4-hour educational workshops on palliative care principles (advance care planning, adverse effects of hospitalizations, symptom management, communication, supporting proxies, challenging situations). Training was provided to all members of staff in small groups. Education was based on constructive learning methods and included participants' own resident cases, role-plays, and small-group discussions. During a 12-month follow-up we assessed residents' symptoms with the Edmonton Symptom Assessment Scale (ESAS), pain with the PAINAD instrument and psychological well-being using a PWB questionnaire. Proxies' satisfaction with care was assessed using the SWC-EOLD. Results. The change in ESAS symptom scores from baseline to 6 months favored the intervention group compared with the control group. However, the finding was diluted at 12 months. PAINAD, PWB, and SWC-EOLD scores remained unaffected by the intervention. All follow-up analyses were adjusted for age, gender, do-not-resuscitate order, need for help, and clustering. Conclusion. Our rigorous randomized controlled trial on palliative care training intervention demonstrated mild effects on residents' symptoms and no robust effects on psychological well-being or on proxies' satisfaction with care. (C) 2021 The Authors. Published by Elsevier Inc. on behalf of American Academy of Hospice and Palliative Medicine.

Respiration is an essential and primary mechanism for speech production. We first inhale and then produce speech while exhaling. When we run out of breath, we stop speaking and inhale. Though this process is involuntary, speech production involves a systematic outflow of air during exhalation characterized by linguistic content and prosodic factors of the utterance. Thus speech and respiration are closely related, and modeling this relationship makes sensing respiratory dynamics directly from the speech plausible, however is not well explored. In this article, we conduct a comprehensive study to explore techniques for sensing breathing signal and breathing parameters from speech using deep learning architectures and address the challenges involved in establishing the practical purpose of this technology. Estimating the breathing pattern from the speech would give us information about the respiratory parameters, thus enabling us to understand the respiratory health using one's speech. (C) 2021 The Authors. Published by Elsevier Ltd.

Background Since the introduction of the concept of advance care planning (ACP), many studies have been conducted exploring beneficial effects. These studies show a heterogeneity in clinical endpoints, which reflects diversity of goals connected to ACP. This study aims to get insight in the range of underlying goals that comprise the legitimacy of ACP. Methods Systematic literature search in PubMed, EMBASE, PsychInfo, CINAHL and Cochrane Library. Articles on normative aspects of ACP were included, based on title and abstract. Due to the quantity of inclusions, of which many had similar content, purposive sampling was used to select articles for full text document analysis. Analysis stopped once saturation was reached. Results In total, 6497 unique articles were found of which 183 were included. Saturation was reached after document analysis of 55 articles (30%); this yielded 141 codes concerning goals of ACP and also 70 codes about objections against ACP, which shed light on the underlying goals of ACP as well. We identified five underlying goals: respecting individual patient autonomy, improving quality of care, strengthening relationships, preparing for end-of-life, reducing overtreatment. Conclusions Five distinctive underlying goals of ACP were identified, each with corresponding objections that need to be considered. Specifying underlying goals of ACP may direct the debate on definitions, methods and preferred outcomes of ACP. This study was funded by the Netherlands Organisation for Health Research and Development, grant 839120002.

ObjectivesMost research on starting palliative care focuses on the role of healthcare services and professional carers. However, patients and their family carers may also play a role. Especially opportunities for starting palliative care might exist among family carers. This study focused on family carers by identifying their behaviours and underlying determinants that might contribute to starting palliative care.MethodsA qualitative study with 16 family carers of deceased persons who used palliative care was conducted using semistructured, face-to-face interviews. Constant comparison analysis was used to identify groups of behaviours that influenced starting palliative care and related determinants. The behavioural determinants were matched with concepts in existing behavioural theories. A preliminary behavioural model was developed.ResultsMost reported behaviours regarding starting palliative care were related to communicating with the seriously ill person, other family members and professional carers; seeking information and helping the seriously ill person process information from professional carers; and organising and coordinating care. Determinants facilitating and hindering these behaviours included awareness (eg, of poor health), knowledge (eg, concerning palliative care), attitudes (eg, negative connotations of palliative care) and social influences (eg, important others’ opinions about palliative care).ConclusionsThis study identified relevant family carers’ behaviours and related determinants that can contribute to starting palliative care. As these determinants are changeable, the palliative care behavioural model that resulted from this study can serve as a basis for the development of behavioural interventions aiming at supporting family carers in performing behaviours that might contribute to starting palliative care.

Neodymium and dysprosium can be efficiently separated by solvent extraction, using the neutral extractant Cyanex 923, if the conventional aqueous feed phase is largely replaced by the green polar organic solvent polyethylene glycol 200 (PEG 200). While pure aqueous and pure PEG 200 solutions in the presence of LiCl or HCl were not able to separate the two rare earth elements, high separation factors were observed when extraction was performed from PEG 200 chloride solutions with addition of small amounts of water. This addition of water bridges the gap between traditional hydrometallurgy and novel solvometallurgy and overcomes the challenges faced in both methods. The effect of different variables was investigated: water content, chloride concentration, type of chloride salt, Cyanex 923 concentration, scrubbing agent. A Job plot revealed the extraction stoichiometry is DyCl3·4L, where L is Cyanex 923. The McCabe-Thiele diagram for dysprosium extraction showed that complete extraction of this metal can be achieved by a 3-stage counter-current solvent extraction process, leaving neodymium behind in the raffinate. Finally, a conceptual flow sheet for the separation of neodymium and dysprosium including extraction, scrubbing, stripping, and regeneration steps was presented. The nonaqueous solvent extraction process presented in this paper can contribute to efficient recycling of rare earths from end-of-life neodymium-iron-boron (NdFeB) magnets., Nonaqueous solvent extraction can be integrated in conventional hydrometallurgical flow sheets to provide a sustainable process for the separation of Nd and Dy.

We update the constraints on the location of the nearest ultrahigh energy cosmic ray (UHECR) source. By analyzing recent data from the Pierre Auger Observatory using state-of-the-art CR propagation models, we reaffirm the need of local sources with a distance less than 25-100 Mpc, depending on mass composition. A new fast semianalytical method for the propagation of UHECR in environments with turbulent magnetic fields is developed. The onset of an enhancement and a low-energy magnetic horizon of cosmic rays from sources located within a particular distance range is demonstrated. We investigate the distance to the nearest source, taking into account these magnetic field effects. The results obtained highlight the robustness of our constrained distances to the nearest source.

ObjectiveMost previous studies on advance care planning (ACP) have focused on patients with specific diseases and only a few on frail ageing individuals. We therefore decided to examine the perspective of geriatric patients on ACP. Our research questions include if, when, with whom and with which content geriatric patients wish to have ACP conversations.DesignParticipants were interviewed either in the hospital or in their own home. The interviewer followed a semistructured interview guide. Interviews were transcribed and analysed using the systemic text condensation method.SettingGeriatric department in a regional hospital in a rural area in Region Zealand, Denmark.ParticipantsWe included 11 geriatric patients aged above 65 who had been referred for geriatric inpatient or outpatient assessment. Participants were clinically judged by experienced geriatricians to have sufficient physical and mental capacity to take part in an interview.ResultsThis study’s main finding is that geriatric patients have varying preferences and feelings towards ACP. Some expressed concerns about ACP, especially regarding personal fear to talk about end-of-life (EOL) decisions, and whether a busy healthcare system has the resources to conduct ACP. Proper timing of ACP seemed unrelated to specific age but related to perception of health situation. The health professional involved should be well trained and a person the participant could trust. Most participants wanted family members to participate. Concerning content, participants mentioned quality of life, fear of losing their spouse, earlier experience with death, and practical concerns regarding funeral and will.ConclusionAmong geriatric patients, feelings towards ACP are mixed. Even participants who were generally positive towards the concept uttered concerns about the circumstances when talking about EOL topics. Health professionals therefore should approach ACP discussions with caution. Further studies aiming to develop guidelines describing the proper way to introduce and perform ACP in this patient group are needed.

Objectives Unrelieved pain is present in a majority of terminal cancer patients. However, the treatment of pain in palliative and hospice care is affected by the lack of validated pain assessment. The goal of this study was to evaluate differences in pain evaluation between terminal cancer patients and physicians and evaluate the pain levels as a survival biomarker. Materials and methods Patients were evaluated every 7 days for a total of 4 assessments. Physicians evaluated patients' pain on an numeric rating scale (NRS) scale after clinical examination, after which the patients completed NRS, Quality of Life Questionnaire Core 15 Pal (QLQ-C15-PAL), and Edmonton Symptom Assessment System (ESAS) questionnaires. Results On average, physicians minimally underestimated the pain level in patients (3.47 vs. 3.94 on an NRS scale). Pain was overestimated in 28% and underestimated in 46% of the patients. However, half of all underestimation was clinically meaningful, compared with 28% of the overestimation. For patients with an NRS score of ≥7, pain underestimation was both clinically and statistically significant (5.56 vs. 8.17). Pain ratings exhibited a very small correlation to survival (up to r=-0.22), limiting their use as a survival biomarker. Discussion Although physicians can accurately assess mild pain in terminal cancer patients in the hospice setting, the underestimation of pain is still clinically significant in almost a quarter of patients, and especially pronounced in patients with higher levels of pain and in female patients. Hence, validated pain assessment is a necessity in hospice care, with the choice of pain evaluation tool dependent on patient and physician preference.

Objectives: Pain is a highly prevalent problem in older adults and dying patients. Opioids are the main analgesic for moderate to severe pain in these patients. Different properties of various opioids can make them more or less suitable for this specific population. We therefore aim to explore opioid prescribing behavior in a group of physicians specialized in long-term geriatric care and to identify factors that are taken into account when selecting a specific opioid for treatment of pain in older patients and patients in the dying phase.Design: A cross-sectional study using an online questionnaire.Setting and Participants: All members of the Dutch Association of Elderly Care Physicians and Social Geriatricians (Verenso) on the mailing list of the weekly digital newsletter were invited to participate between November and December 2017.Measures: Preferences in opioids for the treatment of pain in nondying and dying older patients were recorded, as were the factors that were considered for these preferences.Results: 142 members completed the questionnaire (9%). Opioids of first choice were oxycodone (61%) for nondying and morphine (90%) for dying older patients. The second choice in both cases was fentanyl (56% for nondying and 31% in dying older patients). Personal experience was the main consideration in opioid prescribing (74%-98%). In daily practice, recommendations in guidelines are only considered by 8% to 9% and renal function by 0% to 1% of the respondents.Conclusions/Implications: Oxycodone is the opioid of first choice for physicians in long-term geriatric care in the Netherlands when prescribing for nondying older patients. In contrast, morphine is preferred for dying patients. Fentanyl as a second choice is mainly reserved for situations of stable pain. Prescribers base their choices almost exclusively on personal experience and are barely influenced by guidelines. Further research should therefore focus on clinical relevance for, and implementation in, daily practice. (C) 2018 AMDA - The Society for Post-Acute and Long-Term Care Medicine.

Ability of the DNA double helix to transport electrons is its critical feature, underlying a number of important biological and biotechnological processes. Here, we show that electron transfer (ET) from the gold electrode to the DNA-bound methylene blue (MB) mediated by the DNA base-pair pi-stack is less efficient in (dGdC)-rich duplexes compared to pure (dAdT) DNA. The ET rate constant k(s) extrapolated to the DNA surface coverage Gamma(DNA) -> 0 is 121 +/- 8 s(-1) for (dAdT)(25), being almost twofold higher than 67 3 s(-1) shown for (dGdC)(20), consistent with the electric-field-disturbed submolecular structure of the (dGdC)(20) duplex earlier shown at electrified interfaces. DNA-mediated ET occurs both to MB intercalated and thus perfectly a pi-stacked into the (dGdC)20 duplex and to MB solely groove-bound to (dAdT)(25). For both (dGdC)(20) and (dAdT)(25), ET is less efficient than ET in DNA duplexes of a mixed dA, dT, dG, dC composition. The results suggest new interpretations of the biological ET processes that may occur in dsDNA of different compositions at polarized interfaces.

Background Advance Care Planning (ACP) communication is difficult to implement in hospital. Possibly this has to do with the fact that the concept is not well tuned to the needs of hospital professionals or that they experience implementation barriers in practice. Aims The aim of this study was to investigate what is valued in having ACP conversations by hospital professionals (physicians, nurses, psychologists and social workers) and what they experience as barriers and facilitating factors for having ACP conversations with patients. Methods A Delphi study consisting of two rounds with respectively 21 and 19 multidisciplinary experts from seven European countries was organised. Data were analysed using content analysis and descriptive statistics. Results Participants agreed that ACP is valued mostly because it is seen to improve transmural continuation of care, emotional processing of the loss of a patient, and serenity at the end of life. Reported barriers are patient characteristics blocking patient-centred communication and a lack of knowledge to have these conversations. An important facilitator is multidisciplinary cooperation. Conclusions There is consensus by experts from different settings and countries suggesting that these results can theoretically be applied to hospital settings in Europe. This study reveals that hospital professionals value ACP in hospital practice, but that they encounter several barriers to its implementation.

For a person to enter a Dutch hospice as resident, a clearly articulated deadline is needed: a life expectancy of three months or less. This paper argues that this institutional timeframe of a singular, clocktimed period of more or less linearly approaching death (the end of time), affords life to unfold in hospice as a relatively clockless multitude of temporal orderings enacted by staff and residents (the time of the end). Based on a period of ethnographic fieldwork in hospices and focusgroup interviews with hospice staff, I analyse how temporal orderings manifest and intersect in different ways. The quality of these intersections presence end-of-life normativities in ways that may be instructive when designing and reflecting on end-of-life care.

A small proportion of older people in the Netherlands want to end their lives because they feel their lives to be ‘completed’ and no longer worth living. Currently, there is heated debate over whether or not these people should have the right to euthanasia. Drawing on previous research, we conduct a heuristic analysis of views and experiences of three different ‘parties’ involved in this debate, namely, the older people, their relatives and friends and medical professionals. The views of these three groups tend to be divergent and conflicting, posing a difficult dilemma to decision-makers.

In this article, I restate the interpretation of Aristotle’s Ph. 2.5, 196b17– 21, which I presented for the first time in my book I fondamenti della causalità naturale (2006). According to my reading, both the things that are due to deliberation and those that are not (Arist. Ph. 196b17–18) fall within the group of beings which come to be not for the sake of anything (Arist. Ph. 196b17). In his recent book, Aristotle’s Concept of Chance (Albany 2012), John Dudley found my interpretation laudable and original but rejected it, opting for the traditional interpretation. As he did not provide sufficient reasons for this, I deem it appropriate to discuss more broadly and in greater detail my interpretation in order to demonstrate that it is correct theoretically, linguistically and grammatically. I also discuss a reading of Neoplatonic commentators which seems to me very useful: when commenting on Aristotle, they start with a very prejudicial interpretation which comes from Alexander and which probably determined all later interpretations of the passage. According to this interpretation, beings which come to be not for the sake of anything (Arist. Ph. 196b17) are beings that have no teleology of any kind. Yet this exegetic position faces a series of difficulties which can easily be solved if one assumes, as I do, that these beings have a certain end albeit not an intrinsic one.

Introduction: Spinal muscular atrophy type 1 (SMA-1) is a progressive and fatal disease that leads to ethical problems for Paediatric professionals. Our objective was to determine the ethical options of Paediatric Intensive Care Unit (PICU) paediatricians as regards a child with SMA-1 and respiratory failure. Material and methods: A cross-sectional descriptive study was conducted using an anonymous questionnaire sent to PICUs in Spain (which can be accessed through the Spanish Society of Paediatric Critical Care web page). Results: Of the 124 responses analysed, 70% were from women, 51% younger than 40 years, 54% from a PICU with more than 10 beds, 69% with prior experience in such cases, and 53% with religious beliefs. In the last patient cared for, most paediatricians opted for non-invasive mechanical ventilation (NIV) and limitation of therapeutic effort (LTE) in case of NIV failure. Confronted with a future hypothetical case, half of paediatricians would opt for the same plan (NIV + LTE), and 74% would support the family's decision, even in case of disagreement. Age, prior experience and sex were not related to the preferred options. Paediatricians with religious beliefs were less in favour of initial LTE. Less than two-thirds (63%) scored the quality of life of a child with SMA-1 and invasive mechanical ventilation as very poor. Conclusions: Faced with child with SMA-1 and respiratory failure, most paediatricians are in favour of initiating NIV and LTE when such support is insufficient, but they would accept the family's decision, even in case of disagreement. Resumen: Introducción: La atrofia muscular espinal tipo 1 (AME-1) es una enfermedad progresiva e incurable que plantea problemas éticos entre los profesionales de Pediatría. Nuestro objetivo ha sido conocer las opciones éticas de los pediatras de UCIP ante los pacientes con AME-1 y fracaso respiratorio. Material y métodos: Estudio descriptivo transversal, mediante una encuesta anónima enviada a las UCIP de España y accesible en la web de la Sociedad Española de Cuidados Intensivos Pediátricos. Resultados: Analizamos 124 respuestas (70% mujeres, 51% menores de 40 años, 54% de UCIP con más de 10 camas, 69% con experiencia previa con estos niños y 53% con creencias religiosas). En el último caso atendido, la mayoría de los pediatras optó por la ventilación no invasiva (VNI), realizando después limitación del esfuerzo terapéutico (LET). Ante un hipotético caso futuro, la mitad de los pediatras apoyarían la misma opción (VNI + LET) y el 74% apoyaría la decisión de la familia, aunque no coincidiera con la suya. No se observaron diferencias según la edad, la experiencia previa o el sexo. Los pediatras con creencias religiosas son menos partidarios de la LET inicial. El 63% considera que la calidad de vida de un niño con AME-1 y ventilación invasiva es muy mala. Conclusiones: Ante un niño con AME-1 y fracaso respiratorio, la mayoría de los pediatras de UCIP están a favor de iniciar la VNI y realizar LET cuando dicho soporte no sea suficiente, pero apoyarían la decisión de la familia aunque no estuvieran de acuerdo con ella.

The essay approaches the problem of a possible differentiation between the death of the animal and that of the human being. Stepping beyond the Cartesian sharp dichotomy of the human and animal life, we follow the line of such philosophers as Montaigne, Spinoza, and Hume, who were radically critical towards the unwarranted claims of anthropocentric phantasies. Interpreting poetic texts of Emily Dickinson and Ted Hughes we demonstrate that reflecting upon animality we can get a new insight into the place and meaning of death in our lives as well as into foundations of our speech.

Background: In the last two decades, nursing authors have published ethical analyses of palliative sedation—an end-of-life care practice that also receives significant attention in the broader medical and bioethics literature. This nursing literature is important, because it contributes to disciplinary understandings about nursing values and responsibilities in end-of-life care. Research aim: The purpose of this project is to review existing nursing ethics literature about palliative sedation, and to analyze how nurses’ moral identities are portrayed within this literature. Research design: We reviewed discussion papers, written by nurses about the ethics of palliative sedation, which were cited in MEDLINE, CINAHL, Nursing and Allied Health, or Philosopher’s Index (search date March 2018). Twenty-one papers met selection criteria. We performed a comprehensive review and analysis (using the Qualitative Analysis Guide of Leuven), of the values, responsibilities, and relationships reflected in authors’ portrayal of the nursing role. Findings: Two different tones are apparent in the extant nursing ethics literature. One is educational, while the other is critically reflective. Irrespective of tone, all authors agree on the alleviation of suffering as a fundamental nursing responsibility. However, they differ in their analysis of this responsibility in relation to other values in end-of-life care, including those that depend on consciousness. Finally, authors emphasize the importance of subjective and experience-based understandings of palliative sedation, which they argue as depending on nurses’ proximity to patients and families in end-of-life care. Discussion and conclusion: Based on our findings, we develop three recommendations for future writing by nurses about palliative sedation. These relate to the responsibility of recognizing how consciousness might matter in (some) peoples’ moral experiences of death and dying, to the importance of moral reflectiveness in nursing practice, and to the value of a relational approach in conceptualizing the nursing ethics of palliative sedation.

BackgroundUnbearable suffering is a key criterion in legally granting patients' euthanasia requests in Belgium yet a generally accepted definition of unbearable suffering remains elusive. The ability to understand and assess unbearable suffering is essential, particularly in patients with psychiatric conditions, as the underlying causes of these conditions are not always apparent. To enable research into when and why suffering experiences incite patients with psychiatric conditions to request euthanasia, and to help explore preventive and curative perspectives, the development of an assessment instrument is needed.AimsTo improve the cognitive validity of a large initial item pool used to assess the nature and extent of suffering in patients with psychiatric conditions.MethodCognitive validity was established via two rounds of cognitive interviews with patients with psychiatric conditions with (n = 9) and without (n = 5) euthanasia requests.ResultsDuring the first round of cognitive interviews, a variety of issues relating to content, form and language were reported and aspects that were missing were identified. During the second round, the items that had been amended were perceived as sufficiently easily to understand, sensitive to delicate nuances, comprehensive and easy to answer accurately. Neither research topic nor method were perceived as emotionally strenuous, but instead as positive, relevant, comforting and valuable.ConclusionsThis research resulted in an item pool that covers the concept of suffering more adequately and comprehensively. Further research endeavours should examine potential differences in suffering experiences over time and in patients with psychiatric conditions with and without euthanasia requests. The appreciation patients demonstrated regarding their ability to speak extensively and openly about their suffering and wish to die further supports the need to allow patients to speak freely and honestly during consultations.Declaration of interestsNone.

Background Chronic obstructive pulmonary disease (COPD) is a major cause of mortality. Patients with advanced disease often have a poor quality of life, such that guidelines recommend providing palliative care in their last year of life. Uptake and use of palliative care in advanced COPD is low; difficulty in predicting 1-year mortality is thought to be a major contributing factor. Methods We identified two primary care COPD cohorts using UK electronic healthcare records (Clinical Practice Research Datalink). The first cohort was randomised equally into training and test sets. An external dataset was drawn from a second cohort. A risk model to predict mortality within 12 months was derived from the training set using backwards elimination Cox regression. The model was given the acronym BARC based on putative prognostic factors including body mass index and blood results (B), age (A), respiratory variables (airflow obstruction, exacerbations, smoking) (R) and comorbidities (C). The BARC index predictive performance was validated in the test set and external dataset by assessing calibration and discrimination. The observed and expected probabilities of death were assessed for increasing quartiles of mortality risk (very low risk, low risk, moderate risk, high risk). The BARC index was compared to the established index scores body mass index, obstructive, dyspnoea and exacerbations (BODEx), dyspnoea, obstruction, smoking and exacerbations (DOSE) and age, dyspnoea and obstruction (ADO). Results Fifty-four thousand nine hundred ninety patients were eligible from the first cohort and 4931 from the second cohort. Eighteen variables were included in the BARC, including age, airflow obstruction, body mass index, smoking, exacerbations and comorbidities. The risk model had acceptable predictive performance (test set: C-index = 0.79, 95% CI 0.78–0.81, D-statistic = 1.87, 95% CI 1.77–1.96, calibration slope = 0.95, 95% CI 0.9–0.99; external dataset: C-index = 0.67, 95% CI 0.65–0.7, D-statistic = 0.98, 95% CI 0.8–1.2, calibration slope = 0.54, 95% CI 0.45–0.64) and acceptable accuracy predicting the probability of death (probability of death in 1 year, n high-risk group, test set: expected = 0.31, observed = 0.30; external dataset: expected = 0.22, observed = 0.27). The BARC compared favourably to existing index scores that can also be applied without specialist respiratory variables (area under the curve: BARC = 0.78, 95% CI 0.76–0.79; BODEx = 0.48, 95% CI 0.45–0.51; DOSE = 0.60, 95% CI 0.57–0.61; ADO = 0.68, 95% CI 0.66–0.69, external dataset: BARC = 0.70, 95% CI 0.67–0.72; BODEx = 0.41, 95% CI 0.38–0.45; DOSE = 0.52, 95% CI 0.49–0.55; ADO = 0.57, 95% CI 0.54–0.60). Conclusion The BARC index performed better than existing tools in predicting 1-year mortality. Critically, the risk score only requires routinely collected non-specialist information which, therefore, could help identify patients seen in primary care that may benefit from palliative care.

We prove that metric measure spaces with nonnegative Ricci curvature have at most two ends.

Background: Intradialytic hypotension (IDH) is considered to be a frequent complication of hemodialysis (HD) and is associated with symptom burden, increased incidence of access failure, cardiovascular events, and higher mortality. This systematic literature review aims to analyse studies that investigated the prevalence of IDH. A complicating factor herein is that many different definitions of IDH are used in literature. Methods: A systematic literature search from databases, Medline, Cinahl, EMBASE, and the Cochrane library to identify studies reporting on the actual prevalence of IDH was conducted. Studies were categorized by the type of definition used for the prevalence of IDH. A meta-analysis of the prevalence of IDH was performed. Results: In a meta-analysis comprising 4 studies including 1,694 patients and 4 studies including 13,189 patients, the prevalence of HD sessions complicated by IDH was 10.1 and 11.6% for the European Best Practice Guideline (EBPG) definition and the Nadir Conclusion: Our meta-analysis suggests that the prevalence of IDH is lower than 12% for both the EBPG and the Nadir

Background The need for palliative care is increasing. Since almost every junior doctor will come across palliative care patients, it is important to include palliative care in the undergraduate curriculum. The objective of this research is to gather undergraduate students’ views on palliative care in terms of its importance, their confidence in and knowledge of the domain. Methods Final-year medical students at four Dutch medical faculties were surveyed. The questionnaire measured their views on the education they had received, their self-reported confidence in dealing with palliative care patients and their knowledge of palliative care. Results Two hundred twenty-two medical students participated in this study. Students considered palliative care education relevant, especially training in patient-oriented care and communication with the patient. Students felt that several topics were inadequately covered in the curriculum. Overall, the students did not feel confident in providing palliative care (59.6%), especially in dealing with the spiritual aspect of palliative care (77%). The knowledge test shows that only 48% of the students answered more than half of the questions correctly. Conclusion The students in this study are nearly junior doctors who will soon have to care for palliative patients. Although they think that palliative care is important, in their opinion the curriculum did not cover many important aspects, a perception that is also in line with their lack of confidence and knowledge in this domain. Therefore, it is important to improve palliative care education in the medical curriculum.

Background Currently, there are no formalized measures for the quality of home based palliative care in Ontario. This study developed a set of potential quality indicators for seriously ill home care clients using a standardized assessment. Methods Secondary analysis of Resident Assessment Instrument for Home Care data for Ontario completed between 2006 and 2013 was used to develop quality indicators (QIs) thought to be relevant to the needs of older (65+) seriously ill clients. QIs were developed through a review of the literature and consultation with subject matter experts in palliative care. Serious illness was defined as a prognosis of less than 6 months to live or the presence of severe health instability. The rates of the QIs were stratified across Ontario’s geographic regions, and across four common life-limiting illnesses to observe variation. Results Within the sample, 14,312 clients were considered to be seriously ill and were more likely to experience negative health outcomes such as cognitive performance (OR = 2.77; 95% CI: 2.66–2.89) and pain (OR = 1.59; 95% CI: 1.53–1.64). Twenty subject matter experts were consulted and a list of seven QIs was developed. Indicators with the highest overall rates were prevalence of falls (50%) prevalence of daily pain (47%), and prevalence of caregiver distress (42%). The range in QI rates was largest across regions for prevalence of caregiver distress (21.5%), the prevalence of falls (16.6%), and the prevalence of social isolation (13.7%). Those with some form of dementia were most likely to have a caregiver that was distressed (52.6%) or to experience a fall (53.3%). Conclusion Home care clients in Ontario who are seriously ill are experiencing high rates of negative health outcomes, many of which are amenable to change. The RAI-HC can be a useful tool in identifying these clients in order to better understand their needs and abilities. These results contribute significantly to the process of creating and validating a standardized set of QIs that can be generated by organizations using the RAI-HC as part of normal clinical practice. ispartof: BMC Palliative Care vol:18 issue:3 ispartof: location:England status: Published online