End of life

Background: The development of a brief valid tool to screen for depression in patients with advanced cancer is important. This paper reports data on the psychometric properties of the Brief Edinburgh Depression Scale. Method: Two hundred and forty six patients who fulfilled the inclusion criteria completed the 10-item EDS and Present State Examination. Results: Factor extraction revealed 6 items from the ten item EDS. The most valid cut off for defining a case, using the PSE diagnosis as the "gold-standard", was a score of 6 out of 18 on the Brief Edinburgh Depression Scale which gave a sensitivity of 72% and specificity of 83% with a PPV of 65.1% and NPV of 87.1%. Conclusions: The six item EDS is a brief and sensitive method of screening for depression in advanced cancer patientsthis novel use of the Edinburgh depression scale may have a significant impact on the assessment and thus management of this distressing symptom.

Psychological suffering is one of the most significant and potentially remediable impediments to the dying process for terminally ill patients and their families. This article reviews several of the most common psychological disorders that arise in the context of terminal illness, including depression, anxiety, delirium, and suicidal ideation. Issues related to assessment, measurement, and differential diagnosis are reviewed.

As the collection of end-of-life (EOL) electrical and electronic products from households and businesses increases around the world, the search for economically and environmentally responsible and sustainable recovery and recycling processes intensifies ...

The purpose of the study was to assess the stability of expressed preferences for the use of life-sustaining treatments (LST) in severe illness conditions over two years. The two year longitudinal study included three structured interviews with a one-year interval (1994, 1995, and 1996). At baseline, 1138 Israeli elderly persons (70+) were interviewed, 802 and 638 were interviewed in the following stages. Stability over time was assessed on the basis of score dierences on two dierent indices that measured the wish to prolong life.

This work concerns studies related to strategic development of products in which bio-based plastics are or will be applied, referred to as bio-based products. The studies cover (1) current and potential benefits of bio-based products in extended value chains including activities after end-of-life of products, (2) value communication between stakeholders in extended value chains, and (3) creating an integrated development approach for optimized bio-based products. Most existing models for value chains were found to be one-way single-flow models to which iterations and interactions have been added to obtain realistic representations of best practices. Interviews of thirteen professionals clarified some barriers between the current implementation of bio-based plastics and the ideal sustainable value chain fulfilment. The most noticeable barriers included trustful information sharing, information and knowledge gaps, sub-optimum application of bio-based plastics, and the need for facilitating product design. The main designers' needs are increased integrated literacy related to bio-based materials, eco-effectiveness and a more effective communication competence in value chains. Based on all findings, six approaches of design tasks integration into value chains have been proposed. These approaches encourage designers to think and act widely across value chains and particularly help implement life cycle thinking to achieve profitable sustainability.

Today, over-consumption, pollution and resource depletion threaten sustainability. Waste management policies frequently fail to reduce consumption, prevent pollution, conserve resources and foster sustainable products. However, waste policies are changing to focus on lifecycle impacts of products from the cradle to the grave by extending the responsibilities of stakeholders to post-consumer management. Product stewardship and extended producer responsibility are two policies in use, with radically different results when compared for one consumer product, refrigerators. North America has enacted product stewardship policies that fail to require producers to take physical or financial responsibility for recycling or for environmentally sound disposal, so that releases of ozone depleting substances routinely occur, which contribute to the expanding the ozone hole. Conversely, Europe's Waste Electrical and Electronic Equipment (WEEE) Directive requires extended producer responsibili...

Background: Systematic and reliable epidemiological information at population level, preferably cross-national, is needed for an adequate planning of (end-of-life) health care policies, e.g. concerning place of death, but is currently lacking. This study illustrates opportunities and weaknesses of death certificate data to provide such information on place of death and associated factors in nine European countries (seven entire countries and five regions). Methods: We investigated the possibility and modality of all partners in this international comparative study (BE, DK, IT, NL, NO, SE, UK) to negotiate a dataset containing all deaths of one year with their national/regional administration of mortality statistics, and analysed the availability of information about place of death as well as a number of clinical, socio-demographic, residential and healthcare system factors. Results: All countries negotiated a dataset, but rules, procedures, and cost price to get the data varied strongly between countries. In total, about 1.1 million deaths were included. For four of the nine countries not all desired categories for place of death were available. Most desired clinical and socio-demographic information was available, be it sometimes via linkages with other population databases. Healthcare system factors could be made available by linking existing healthcare statistics to the residence of the deceased. Conclusion: Death certificate data provide information on place of death and on possibly associated factors and confounders in all studied countries. Hence, death certificate data provide a unique opportunity for cross-national studying and monitoring of place of death. However, modifications of certain aspects of death certificate registration and rules of data-protection are perhaps required to make international monitoring of place of death more feasible and accurate.

Owing to the growing emergence of the end-of-life electrical and electronic products with complex material structures and an ever-diminishing particle size of the valuable metals involved, development of eddy current separators (ECS) has been targeting selective separation of small non-ferrous metal particles smaller than 5 mm. Separability of various materials smaller than 5 ram, including fine copper wires, has been investigated using ECS with various design concepts. The present research work is divided into two parts, with Part focusing on the rotating type ECS which are today common in practice, and with Part II dedicated to the ECS with novel concepts such as wet ECS technology. In Part I, three rotating belted-drum ECS were employed, which are manufactured by Bakker Magnetics, the Netherlands, Huron Valley Steel Co., US, and Eriez Magnetics, UK respectively. It is found that the belted-drum ECS are effective for separating materials below 5 mm if the magnetic drum rotates in opposite direction to the conveyor belt. The separation principle, particularly the "backward phenomenon" of the rotating type ECS for small particles has been unravelled in the present study. Moreover, separation of AI from the 0-10 mm fraction of electronic scrap has been conducted. The results obtained demonstrate that the belted-drum ECS with appropriate design may be applicable for separation of small aluminum particles from electronic scrap.

The increasing demand for efficient management of used products after the end of their life cycle stems from the increasing awareness of modern society about possible threats against the environment. Used starter or lead Á/acid batteries contain lead up to 65%, which is also valuable after the end of their life cycle. Recycling of lead gives rise to some environmental problems associated with its collection, processing and recycling and, finally, entering the main (forward) supply chain. In this paper, the lead recovery from old batteries is examined using life cycle inventory analysis (LCIA). The reverse supply chain of used starter or lead Á/acid batteries is outlined and analyzed. A model for this product system is formulated, which is used to identify the lead emissions as well as all the environmental exchanges through materials balance. The proposed model formulation, which is appropriately adapted to the needs of the reverse supply chain, is used as a tool in a LCIA in order to identify those stages in the battery life cycle that give rise to the greatest environmental burdens. A similar analysis is also made for the case of disposal. The model may be used in order to assess all the associated impacts in an in-depth life cycle analysis (LCA). A preliminary comparison between the two end-of-life scenarios in terms of their environmental inputs and outputs is also attempted. Thus, based on several assumptions, an inventory analysis referring to the above chains has been conducted whose results have been summarized in an Inventory table, which produces comprehensive information about each life stage of the examined end-of-life scenarios.

The ARIES-AT power core was evolved with the overall objective of achieving high performance while maintaining attractive safety features, credible maintenance and fabrication processes, and reasonable design margins as a rough indication of reliability. The blanket and divertor designs are based on Pb-17Li as coolant and breeder, and low-activation SiC f /SiC as structural material. Flowing Pb-17Li in series through the divertor and blanket is appealing since it simplifies the coolant routing and minimize the number of cooling systems. However, Pb-17Li provides marginal heat transfer performance in particular in the presence of MHD effects and the divertor design had to be adapted to accommodate the peak design heat flux of 5 MW/m 2 . The blanket flow scheme enables operating Pb-17Li at a high outlet temperature (about 1100 • C) for high power cycle efficiency while maintaining SiC f /SiC at a substantially lower temperature consistent with allowable limits. Waste minimization and additional cost savings are achieved by radially subdividing the blanket into two zones: a replaceable first zone and a life of plant second zone. Maintenance methods have been investigated which allow for end-of-life replacement of individual components. This paper summarizes the results of the design study of the ARIES-AT power core focusing on the blanket and divertor and including a discussion of the key parameters influencing the design, such as the SiC f /SiC properties and the MHD effects, and a description of the design configuration, analysis results and reference operating parameters.

Background: With improvements in the care of critically ill, physicians are faced with obligations to provide quality end-of-life care. Barriers to this include inadequate understanding of the dying patient and withdrawal or limitation of care. The objectives of this study were to document the comprehensions of physicians and nurses regarding the recognition and practice of end-of-life care for critically ill patients placed on life support in the intensive care unit.

Previously we had speculated that the patient-proxy relationship existed on a contractual to covenantal continuum. In order to assess this hypothesis, and to better understand the moral obligations of the patient-proxy relationship, we surveyed 50 patient-proxy pairs as well as 52 individuals who had acted as proxies for someone who had died. Using structured vignettes representative of three distinct disease trajectories (cancer, acute stroke, and congestive heart failure), we assessed whether respondents believed that proxies should follow explicit instructions regarding life-sustaining therapy and act contractually or whether more discretionary or covenantal judgments were ethically permissible. Additional variables included the valence of initial patient instructions-for example, "to do nothing" or "to do everything"-as well as the quality of information available to the proxy. Responses were graded on a contractual to covenantal continuum using a modified Likert scale employing a prospectively scored survey instrument. Our data indicate that the patient-proxy relationship exists on a contractual to covenantal continuum and that variables such as disease trajectory, the clarity of prognosis, instructional valence, and the quality of patient instructions result in statistically significant differences in response. The use of interpretative or covenantal judgment was desired by patients and proxies when the prognosis was grim, even if initial instructions were to pursue more aggressive care. Nonetheless, there was a valence effect: patients and proxies intended that negative instructions to be left alone be heeded. These data suggest that the delegation of patient selfdetermination is morally complex. Advance care planning should take into account both the exercise of autonomy and the interpretative burdens assumed by the proxy. Patients and proxies think inductively and contextually. Neither group viewed deviation from patient

Conflicts about EoL decisionmaking are not uncommon. Limited research in the adult and pediatric intensive care setting has shown that background and physicians' conflict-resolving strategies vary considerably. Empirical research on decision-making conflicts in the NICU is not available.

Despite evidence that doctor±patient communication aects important patient outcomes, patient expectations are often not met. Communication is especially important in terminal illness, when the appropriate course of action may depend more on patient values than on medical dogma. We sought to describe the issues important to terminally ill patients receiving palliative care and to determine whether patient characteristics in¯uence the needs of these patients. We utilized a multimethod approach, ®rst conducting interviews with 22 terminally ill individuals, then using these data to develop a more structured instrument which was administered to a second population of 56 terminally ill patients. Patient needs and concerns were described and associations between patient characteristics and issues of importance were evaluated. Seven key issues were identi®ed in the initial interviews: change in functional status or activity level; role change; symptoms, especially pain; stress of the illness on family members; loss of control; ®nancial burden and con¯ict between wanting to know what is going on and fearing bad news. Overall, respondent needs were both disease-and illness-oriented. Few easily identi®able patient characteristics were associated with expressed concerns or needs, suggesting that physicians need to individually assess patient needs. Terminally ill patients receiving palliative care had needs that were broad in scope. Given that few patient characteristics predicted responses, and that the majority opinion may not accurately re¯ect that of an individual patient, health care providers must be aware of the diverse concerns among this population and individualize assessment of each patient's needs and expectations.

This article presents the results of an experimental activity aimed at investigating the technical feasibility and the environmental performance of using municipal solid waste incineration bottom ash to produce glass frit for ceramic glaze (glaze frit). The process includes an industrial pretreatment of bottom ash that renders the material suitable for use in glaze frit production and allows recovery of aluminum and iron. The environmental performance of this treatment option is assessed with the life cycle assessment (LCA) methodology. The goal of the LCA study is to assess and compare the environmental impacts of two scenarios of end of life of bottom ash from municipal solid waste incineration (MSWI): landfill disposal (conventional scenario) and bottom ash recovery for glaze frit production (innovative scenario). The main results of the laboratory tests, industrial simulations, and LCA study are presented and discussed, and the environmental advantages of recycling versus landfill disposal are highlighted.

Goals of work: Discussing end-of-life issues is of key importance to terminally ill cancer patients and their families, and a challenging topic for both health professionals and patients/carers. There is a lack of research evidence in the literature to guide clinical practice. The objective of this study was to explore the optimal content and phrasing of information when discussing the dying process and end-of-life issues with terminally ill cancer patients and their carers. Subjects and methods: We conducted focus groups and individual interviews with 19 palliative care patients and 24 carers from three palliative care services in Sydney, and 22 palliative care health professionals from around Australia. The focus groups and individual interviews were audiotaped and fully transcribed. Further focus groups and/ or individual interviews were conducted until no additional topics were raised. Participants' narratives were analysed using qualitative methodology. Main results: Distinct content areas emerged for discussing end-oflife issues: treatment decisions at the end-of-life; potential future symptoms; preferences for place of death; the process of dying; what needs to be done immediately after death; and existential issues. When discussing the process of dying participants recommended: exploring the persons' fears about dying and dispelling myths; describing the final days and the likely unconscious period; and the reduced need for food and fluids. Many participants identified the dilemma regarding whether to discuss potential complications around the time of death. Conclusions: This paper provides strategies, words and phrases which may inform discussions about the process of dying and end-of-life issues. Further research is needed to determine the generalizability of these findings.

Background: Death in the intensive care unit is often predictable. End of life management is often discussed and initiated when futility of care appears evident. Respect for patients wishes, dignity in death, and family involvement in the decision-making process is optimal. This goal may often be elusive. Purpose: Our purpose was to review the end of life processes and family involvement within our Unit. Methods: We conducted a chart audit of all deaths in our 10 bed Unit over a 12-month period, reviewing patient demographics, diagnosis on admission, patient acuity, expectation of death and not-for-resuscitation status. Discussions with the family, treatments withheld and withdrawn and extubation practices were documented. The presence of family or next-of-kin at the time of death, the time to death after withdrawal of therapy and family concerns were recorded. Results: There were 70 patients with a mean age of 69 years. Death was expected in 60 patients (86%) and not-for-resuscitation was documented in 58 cases (85%). Family discussions were held in 63 cases (90%) and treatment was withdrawn in 34 deaths (49%). After withdrawal of therapies, 31 patients (44%) died within 6 h. Ventilatory support was withdrawn in 24 cases (36%). Family members were present at the time of death in 46 cases (66%). Family concerns were documented about the end of life care in only 1 case (1.4%).

Advance health care directives and informed consent remain the cornerstones of patients' right to self-determination regarding medical care and preferences at the end-of-life. However, the effectiveness and clinical applicability of advance health care directives to decision-making on the use of life support systems at the end-of-life is questionable. The Uniform Anatomical Gift Act (UAGA) has been revised in 2006 to permit the use of life support systems at or near death for the purpose of maximizing procurement opportunities of organs medically suitable for transplantation. Some states have enacted the Revised UAGA (2006) and a few of those have included amendments while attempting to preserve the uniformity of the revised Act. Other states have introduced the Revised UAGA (2006) for legislation and remaining states are likely to follow soon. The Revised UAGA (2006) poses challenges to the Patient Self Determination Act (PSDA) embodied in advance health care directives and individual expression about the use of life support systems at the end-of-life. The challenges are predicated on the UAGA revising the default choice to presumption of donation intent and the use of life support systems to ensure medical suitability of organs for transplantation. The default choice trumps the expressed intent in an individual's advance health care directive to withhold and/or withdraw life support systems at the end-of-life. The Revised UAGA (2006) overrides advance directives on utilitarian grounds, which is a serious ethical challenge to society. The subtle progression of the Revised UAGA (2006) towards the presumption about how to dispose of one's organs at death can pave the way for an affirmative "duty to donate". There are at least two steps required to resolve these challenges. First, physicians and hospitals must fulfill their responsibilities to educate patients on the new legislations and document their preferences about the use of life support systems for organ donation at the end-of-life. Second, a broad based societal discussion must be initiated to decide if the Revised UAGA (2006) infringes on the PSDA and the individual's right of autonomy. The discussion should also address other ethical concerns raised by the Revised UAGA (2006), including the moral stance on 1) the interpretation of the refusal of life support systems as not applicable to organ donation and 2) the disregarding of the diversity of cultural beliefs about end-of-life in a pluralistic society.

In this paper we investigate recent initiatives with respect to extended producer responsibility in the aviation sector. We compare those with the existing practices in the automobile sector and the emerging regulations in the shipping sector. We describe the challenges and the lessons to be learned from the evolution and state of extended producer responsibility in these two industries.

This study reports on a preliminary uncontrolled study of a treatment for couples in which one partner is diagnosed with a terminal illness. In this study nine couples, in which one partner was diagnosed with a terminal illness and had less than 18 months to live, were offered eight sessions of couples therapy. Follow-up data were available for six couples. Two patients died during treatment and a third patient moved out of the area prior to completing the follow-up assessment. Significant decreases were seen in the patients' distress about dying and the frequency of partners' worry about their partner dying. Improvements were also seen in relationship quality. While the size of the study precludes generalizing these findings to a larger population, this study supports further exploration of couples therapy as a potentially useful adjunct to end of life care.

Extended producer responsibility is an important environmental policy expected to increase producer environmental innovation through source reduction, collection effort and recyclability. Using a model of vertical differentiation, we propose to test the effectiveness of the application of the extended producer responsibility (EPR) through two complementary measures: eco-tax and adhesion to eco-organization. We focus on the importance of funding modalities membership on the achievement of environmental objectives. Simulation results show the need of mix policy instruments in the field of packaging waste. Instruments efficiency should be evaluated with regard to environmental targets and should permit the total transfer of responsibility to producer.

For patients at the end of life, active automatic implantable cardioverter-defibrillators (AICDs) may no longer achieve the treatment goals present at the time of implantation. It is possible to deactivate AICDs in patients with terminal and life-limiting diagnoses, thereby preventing the pain and distress of nontherapeutic discharge. This article presents a moral argument for the right of such patients to have their AICDs deactivated. It then explains that hospice and home care agencies have an obligation to address AICD deactivation at a policy level and offers recommendations for doing so.

Optimizing the quality of medical care at the end of life has achieved national status as an important health care goal. Palliative care, a comprehensive approach to treating the physical, psychosocial and spiritual needs of patients and their families facing life-limiting illnesses, requires the coordinated efforts of a multidisciplinary group of caregivers. Understanding the basic principles of palliative care can aid emergency department staff in identifying patients who could benefit from palliative care services and in managing the challenging situations that arise when such patients present to the hospital for care.

... Ainsi, dans une étude italienne [26] en soins de longue durée, 20,5% des patients atteints de maladie d'Alzheimer en fin de vie ont eu une sonde d'alimentation ou une gastrotomie et 66,6 % une hydratation intraveineuse. ... [13] Kammoun S, Gold G, Herrmann F, et al. ...

a Maître de conférences en psychologie médicale, psychologue clinicienne, équipe de recherche en sciences humaines et sociales appliquée à la cancérologie -ERSSCa EE0602, département de sciences humaines et sociales, faculté de médecine de Nantes, Reçu le 20 septembre 2006 ; accepté le 31 mai 2008 Disponible sur Internet le 21 juillet 2008

Lo scopo di questo studio è stato quello di realizzare uno strumento per rilevare il sovraccarico del familiare che assiste al domicilio il proprio parente giunto alla fine della vita. È importante l'utilizzo di strumenti di lavoro che permettano agli operatori di documentare le problematiche riferite sia dai malati che dai familiari. Esistono in letteratura pluralità di strumenti che indagano sulla condizione psicofisica del malato, ma non ne sono stati rintracciati di specifici per la rilevazione del sovraccarico del familiare in ambito di Cure Palliative. La costruzione di una scheda strutturata di rilevazione dati serve a supportare e non a sostituire il setting comunicativo che si instaura e si ricerca tra operatore e caregiver. Lo strumento sperimentato ha messo in evidenza il profilo prevalente del caregiver: sesso femminile, età tra 60 e 70 anni, pensionata, unica responsabile dell'assistenza. Il dato maggiormente rappresentativo è che tutti i soggetti esaminati risultano essere sovraccaricati. L'équipe, a seguito dei risultati ottenuti dall'utilizzo del questionario, ha strutturato una semplice griglia organizzata per aree problematiche di sovraccarico e ha individuato i corrispondenti interventi. L'uso del questionario e la costruzione della griglia, organizzata in modo sistematico, hanno reso più efficace ed efficiente l'intervento dell'équipe, sia in termini di tempestività sia di appropriatezza dell'intervento. Parole chiave: caregiver, fine vita, sovraccarico, assistenza domiciliare.

Purpose This study compares environmental impacts of two primary packaging alternatives used for injectable drugs: the traditional method based on glass vials and the method developed by Aseptic Technologies based on polymer vials. A critical review by an external LCA expert was made. Methods The boundaries of the systems include the packaging production, the product assembly, the filling process, the distribution and the packaging end-of-life by incineration. The study was made in accordance with the international standards ISO 14040 and ISO 14044. Some data were obtained in the scientific literature or by interview with packaging producers. Ecoinvent databases were also used. The LCA study was made using two methodologies: IMPACT 2002+ and ReCiPe. Some sensibility analyses were performed on different points of uncertainty both on method and on systems (polymer vial body and transport conditions). Results and discussion Results show an environmental gain using a polymer vial over glass. The impact is reduced by 23% for global warming, 25% for primary energy and 32% for respiratory inorganics. For each production step, the environmental impact of both technologies is nearly the same except for the material production, the filling step and the transportation of the finished goods. The production of the polymer vials, made of fuel, leads to a more important environmental impact, especially concerning global warming and primary energy. On the contrary, the two others steps, i.e. filling and transport of the finished goods are more favourable for the polymer vials. This technology allows the elimination of preparation and sterilisation steps which are highly energy consuming and mandatory in the case of the glass vials filling which are supplied unclean and unsterile. The major source of energy consumption comes from water heating, in order to clean the glass vial components. In addition, the filling process, made with a needle through the cork followed by laser re-sealing, is strongly simplified with additional beneficial impact as reduction of energy consumption and pollutants emissions. The transportation step has shown a more positive impact especially when exported over long distance. The sensitivity analyses show that the hypotheses made in both scenarios are rather conservative. Conclusions The life cycle assessment methodology has been successfully applied to both systems of production, filling, distribution and end-of-life of vials for injectable drugs. For identical disclosers, the polymer vials system has lower environmental impacts than the glass vials system.

Responsible Life Cycle Management (LCM) of mines has received much attention in the South African legislation. However, there is currently a mis-alignment between the mining industry and the various government authorities pertaining to the issue of mine closure or end-of-life management. The main reasons for this are unclear and unformulated approaches to rehabilitation with a subsequent legacy of unsuccessful mine closures that have wrongly been issued by the government from a sustainability perspective; this has posed an excessive economical burden for the mining industry. In this paper, a Mine Closure Model (MCM) based on project management principles, including risk management and concurrent engineering, is proposed to manage the closure process and assist the governing body with the effective evaluation of closures and the issuance of certificates. Mine closure or rehabilitation objectives can be achieved whilst managing the resources (of industry) optimally and aligning the closure process to meet the end requirements of stakeholder groups.

Life cycle assessment is a technique to assess environmental aspects associated with a product or process by identifying energy, materials, and emissions over its life cycle. The energy analysis includes four stages of a life cycle: material production phase, manufacturing phase, use phase, and end-of-life phase. In this study, the life cycle energy of fiber-reinforced composites manufactured by using the pultrusion process was analyzed. For more widespread use of composites, it is critical to estimate how much energy is consumed during the lifetime of the composites compared to other materials. In particular, we evaluated a potential for composite materials to save energy in automotive applications. A hybrid model, which combines process analysis with economic input-output analysis, was used to capture both direct and indirect energy consumption of the pultrusion process in the material production and manufacturing stages.

OBJETIVO: Estudiar el proceso de evolucion en sus primeras etapas tras la perdida y determinar cuales son los factores de riesgo y proteccion previos a la muerte que permiten predecir el surgimiento de posibles complicaciones en los familiares/cuidadores de pacientes oncologicos. METODO: Se evaluaron 236 dolientes cuyos familiares eran pacientes oncologicos atendidos en servicios de cuidados paliativos de Valencia y Madrid y se realizo un seguimiento en 2 momentos temporales: 2 y 6 meses tras la muerte, evaluandose la presencia/ ausencia de complicaciones en el proceso de duelo mediante dos criterios diagnosticos (DSM e ICG). RESULTADOS: Se encontro una gran estabilidad de las puntuaciones en los indicadores de duelo entre 2 y 6 meses post mortem. Respecto a los indicadores de riesgo pre-mortem se han encontrado como discriminativos entre los dolientes con/sin complicaciones: dependencia afectiva, expresiones de rabia y culpa, vulnerabilidad psiquica previa (antecedentes psicopatolo...

The end-of-life and the death of someone close are never easy. No one can escape the experience. Everyone at the bedside will be watching the potential for her or his own future end-of-life experience and death. If symptoms are not well managed, the patient may suffer unnecessarily, the dying process may be prolonged unnecessarily, and the individuals who watch may be left with memories that the death was not good and fear that their own death will be similar. Because much end-of-life care and dying take place in hospitals and long-term care facilities, most people today have never witnessed death or seen a dead body outside of a funeral home. They have seen only dramatizations on television or in movies. Most observers project their own experiences on what they think the patient is feeling and do not realize that the patient's experience may be different. Along with end of life and death come many losses for the patient and family, such as loss of functional capabilities, body...

Each year in the United States, approximately 50,000 children die, mostly in hospitals, and many more confront life-threatening conditions. Most-if not allof these children and their families would benefit from timely, comprehensive, compassionate, continuous, and developmentally appropriate supportive care services, including a mixture of palliative, end-of-life, and bereavement care. Palliative care aims to relieve suffering and improve quality of life for patients with advanced illnesses and their families. Effective palliative care includes communicating with patients and family members, managing pain and other symptoms, providing psychosocial, spiritual, and bereavement support, and 0031-3955/05/$ -see front matter D

With the trend toward an older, sicker dialysis population in the USA, discussions of ethical issues surrounding dialysis have shifted from concerns about access to and availability of the therapy, to growing unease about non-initiation and treatment discontinuation. Recent studies report treatment withdrawal as the leading cause of death among elderly dialysis patients. Yet, the actual activities that move patients toward stopping treatment often remain obscure, even to clinicians and patients themselves. This paper explores that paradox, drawing on anthropological research among patients over age 70, their families, and clinicians in two California renal dialysis units. It concludes that many older patients sacrifice a sense of choice about dialysis in the present to maintain "choice" as both value and possibility for the future. Yet, patients desire more information and communication, provided earlier in their illness, about prognosis, how long they can expect to be on dialysis, and what the impact of the treatment will be on their daily lives. That, with time, there is a transition to be made from dialysis as "treatment" to end of life care could be better explained and managed to alleviate patients' confusion and unneeded isolation.

The purpose of this quasi-experimental study was to assess the ongoing impact of the End-of-Life Nursing Education Consortium (ELNEC) training program on registered nurses' death anxiety, concerns about dying, and knowledge of the dying process utilizing the principles of The Comfort Theory and Practice by at the institutional level. The research hypothesis was upon completion of the ELNEC training, registered nurses would have decreased death anxiety, less concerns about dying, and increased knowledge of the dying process. The Revised Death Anxiety Scale (RDAS) was used to measure death anxiety which is a 25 item self-report questionnaire. The Concerns about Dying Instrument (CAD) was used to measure death attitude or concerns about dying which includes three distinct but related areas for providers: general concern about death, spirituality, and concerns about working with dying patients. Participant's perceived knowledge of dying was measured using a self report 5-point Likert format with "0" indicating no level of knowledge to "4" reflecting complete knowledge of death and dying.

Background, aim, and scope The use of bio-based products as carrier bags, packaging materials, and many other applications has been increasingly replacing conventional polymer products. One of the main driving forces of bioplastic applications is the perceived depletion and scarcity of fossil fuels, especially petroleum. However, despite being introduced as an environmentally friendly alternative to plastics made from crude oil, the environmental benefits of bio-plastics remain debatable. This article serves to investigate whether or not bio-based materials are environmentally friendlier options compared to plastics and attempts to explain the rationale of the results. Materials and methods The production and disposal of both conventional plastic and bio-plastic carrier bags are investigated using life cycle assessment or LCA. A typical bio-based bag (made from polyhydroxyalkanoate or PHA) from the U.S. was selected to be compared with a locally produced polyethylene plastic (PP) bag in Singapore. In the LCA system, the raw materials for making polyethylene came from crude oil imported from Middle East and natural gas piped from Natuna gas field. The refinery and PP bag production processes are based in Singapore. Bio-bag production was entirely in the U.S., and the finished product was shipped to