Developing and using a structured, conversation-based intervention for clarifying values and preferences for end-of-life in the advance care planning-naïve Swedish context: Action research within the DöBra research program

Sweden has no systematic advance care planning (ACP), nor legal recognition of end-of-life proxies. We describe our experiences and reflections from a participatory action research process, aiming at developing and initially using a conversation-based, structured ACP approach among community-dwelling, older adults in Sweden. Eco-mapping and DöBra cards were used with 65 people to catalyze discussions on preferences for the end-of-life. We found great individual variation in both Eco-map depictions of social networks and prioritization of the 37 DöBra card items. The DöBra cards were concluded to be a viable tool for stimulating person-centered conversations on preferences for future end-of-life care.

Family members' experiences of care of the dying in residential care homes where the Liverpool Care Pathway was used

BACKGROUND

Residential care homes (RCHs) are increasingly becoming a common place of death for older people.

AIM

The aim of this study was to describe family members' experiences of care of the dying in RCHs where the Liverpool care pathway for the dying patient was used.

METHODS

This study had a descriptive qualitative study design. Fifteen (n=15) individual interviews were analysed using qualitative content analysis.

RESULTS

The analysis resulted in three themes: being confident in a familiar and warm atmosphere, being involved vs not being involved in end-of-life (EoL) care, and being consoled by witnessing the health professional's endeavour to relieve suffering.

SIGNIFICANCE OF RESULTS

The results indicated that taking part in a care plan seems to increase family members' feelings of involvement in EoL care. This study also highlights the family members' needs for increased possibilities for EoL discussions with the GP.

Navigating power dynamics in engaging communities in end-of-life issues - Lessons learned from developing community-based intergenerational arts initiatives about death and loss

Lack of community engagement in end-of-life issues and age-segregation in Swedish society motivated us to develop Studio DöBra, a community-based intergenerational arts initiative to support community engagement in end-of-life issues and develop intergenerational meeting places. Representatives from several community organizations formed a project group with first author MK, to develop Studio DöBra. Based on analysis of exploratory interviews with professionals involved in other, similar initiatives and data from Studio DöBra development, we discuss challenges related to power dynamics in developing initiatives to engage communities in end-of-life issues, and how these can inform the development of similar initiatives.

Translating the Patient Dignity Inventory

Background:

The Patient Dignity Inventory (PDI) is based on an empirically-driven dignity model that has been developed and used for clinically assessing the various sources of dignity-related distress. In a recent review, it received the highest score as a useful instrument in both practice and research in palliative care. The PDI has been adapted to and validated for use in various countries, but not yet Sweden.

Aims:

To translate the PDI into Swedish, including cultural adaptation for clinical use.

Methods:

A multi-step process of translation, negotiated consensus, expert group discussion (n=7: four invited experts and three researchers) and cognitive interviewing (n=7: persons with palliative care needs).

Findings:

Discussion, by the expert reviewers, of both linguistic and cultural issues regarding the content and readability of the translated Swedish version resulted in revisions of items and response alternatives, focusing mainly on semantic, conceptual, and experiential equivalence. A pilot version for cognitive interviews was produced. The analysis of data showed that most of the items were judged to be relevant by the persons with palliative care needs.

Conclusion:

The process of translation and adaptation added clarity and consistency. The Swedish version of the PDI can be used in assessing dignity-related distress. The next step will be to test this Swedish version for psychometric properties in a larger group of patients with palliative care needs before use in research.

Family members´ experiences of the end-of-life care environments in acute care settings - a photo-elicitation study

PURPOSE

This article explores experiences of the acute-care environment as a setting for end-of-life (EoL) care from the perspective of family members of a dying person.

METHOD

We used participant-produced photographs in conjunction with follow-up interviews with nine family members to persons at the EoL, cared for in two acute-care settings.

RESULTS

The interpretive description analysis process resulted in three constructed themes-Aesthetic and un-aesthetic impressions, Space for privacy and social relationships, and Need for guidance in crucial times. Aspects of importance in the physical setting related to aesthetics, particularly in regard to sensory experience, and to a need for enough privacy to facilitate the maintenance of social relationships. Interactions between the world of family members and that of professionals were described as intrinsically related to guidance about both the material and immaterial environment at crucial times.

CONCLUSION

The care environment, already recognized to have an impact in relation to patients, is concluded to also affect the participating family members in this study in a variety of ways.

Quality of life in men with metastatic prostate cancer in their final years before death - a retrospective analysis of prospective data

Background

Quality of Life (QoL) is the most important outcome for patients in palliative care along with symptom alleviation. Metastatic prostate cancer (mPC) is a life-threatening illness, and hence, a palliative care approach may be beneficial to this group. Over time, new life-prolonging treatments have been developed for men with mPC, but the possibility to prolong life should also be balanced against the men’s QoL, particularly because there are side effects involved with these treatments. The aim of this study was to evaluate QoL, functioning and symptoms in men with mPC during their final years before death.

Methods

This is a retrospective analysis of data from a long-term prospective study of men (n = 3885) with prostate cancer from two regions in Sweden. Validated questionnaires asking about participants’ QoL, functioning and symptoms were used to collect data. From the overall study, 190 men with mPC were identified. They were stratified into three groups, depending on the amount of time that had passed between the last questionnaire and their death; < 6 months, 6–18 months and > 18 months before death.

Results

Men with mPC generally rated their QoL poorly compared to established clinically significant threshold values. The group of men that were < 6 months before death rated their QoL, functioning and several symptoms significantly worse than the two other groups. Men that died after the year 2006 reported lower QoL and functioning and more pain and fatigue than those who died before 2006.

Conclusion

The results in this study indicate that men with mPC have unmet needs with regards to QoL and symptoms. A palliative care approach, alongside possible life-prolonging treatments, that focuses on QoL and symptom relief, may serve as an important frame to give the best support to these men in their final years of life.

Factors Associated With Symptom Relief in End-of-Life Care in Residential Care Homes: A National Register-Based Study

CONTEXT

Residential care homes (RCHs) are a common place of death. Previous studies have reported a high prevalence of symptoms such as pain and shortness of breath among residents in the last week of life.

OBJECTIVES

The aim of the study was to explore the presence of symptoms and symptom relief and identify factors associated with symptom relief of pain, nausea, anxiety, and shortness of breath among RCH residents in end-of-life care.

METHODS

The data consisted of all expected deaths at RCHs registered in the Swedish Register of Palliative Care (N = 22,855). Univariate and multiple logistic regression analyses were conducted.

RESULTS

Pain was reported as the most frequent symptom of the four symptoms (68.8%) and the one that most often had been totally relieved (84.7%) by care professionals. Factors associated with relief from at least one symptom were gender; age; time in the RCH; use of a validated pain or symptom assessment scale; documented end-of-life discussions with physicians for both the residents and family members; consultations with other units; diseases other than cancer as cause of death; presence of ulcers; assessment of oral health; and prescribed pro re nata injections for pain, nausea, and anxiety.

CONCLUSION

Our results indicate that use of a validated pain assessment scale, assessment of oral health, and prescribed pro re nata injections for pain, nausea, and anxiety might offer a way to improve symptom relief. These clinical tools and medications should be implemented in the care of the dying in RCHs, and controlled trials should be undertaken to prove the effect.

Not just things: the roles of objects at the end of life

While the study of objects in care contexts is an emerging research field, it is largely overlooked in end of life (EoL) care. In this study, we empirically and inductively explore the roles of objects at the EoL from the perspective of bereaved family members. Open individual interviews were conducted with 25 family members recruited from palliative in-patient and homecare units, as well as residential care facilities. After verbatim transcription, the interviews were analysed thematically. Based on these interviews, we conceptualise the roles of objects as relating to temporality, transformations of the everyday, and care. Through analysis we offer two main insights, the first relating to interdependency between objects and people, and the second to the recognition of objects as simultaneously flexible and stable in this interdependent relationship. The capacity and challenge of objects as part of EoL care lies in their ability to encompass various viewpoints and relationships simultaneously. This might provide valuable insights for staff caring for dying persons and their families. We propose that staff's ability to navigate objects in care practices could be meaningful in supporting the relationships between individuals in EoL situations.

Public awareness of palliative care in Sweden

Objective: The aim of this study was to investigate the awareness of palliative care (PC) in a general Swedish population. Design: We developed an e-survey based on a similar study conducted in Northern Ireland, consisting of 10 questions. Closed questions were primarily analyzed using descriptive statistics. Open questions were subject to inductive qualitative analysis. Subjects: The study utilized a population sample of 7684 persons aged 18–66, of which 2020 responded, stratified by gender, age and region. Results: Most participants reported ‘no’ (n = 827, 41%) or ‘some’ (n = 863, 43%) awareness of PC. Being female or older were associated with higher levels of awareness, as was a university-level education, working in a healthcare setting and having a friend or family member receiving PC. Most common sources of knowledge were the media, close friends and relatives receiving PC, as well as working in a healthcare setting. Aims of PC were most frequently identified as ‘care before death’, ‘pain relief’, ‘dignity’ and a ‘peaceful death’. The preferred place of care and death was one’s own home. The main barriers to raising awareness about PC were fear, shame and taboo, along with perceived lack of information and/or personal relevance. The term ‘palliative care’ was said to be unfamiliar by many. A number of strategies to enhance awareness and access to PC were suggested, largely reflecting the previously identified barriers. Conclusions: This survey found limited awareness of palliative care in an adult sample of the Swedish general public ≤ 66 years, and points to a more widespread disempowerment surrounding end-of-life issues.

Going public: reflections on developing the DöBra research program for health-promoting palliative care in Sweden

Introduction: Public health approaches to end-of-life (EoL) research and care are relatively rare in Sweden, and health-promoting palliative care (HPPC) remains a foreign concept for most. We recently consolidated our HPPC endeavors into a cohesive research program, DöBra, to promote constructive change and awareness to support better quality of life and death among the general population, in specific sub-groups, and in interventions directed to professional groups caring for dying individuals, their friends and families. Objectives: In this article, we aim to share ideas, experiences, and reflections from the early stages of this research program, particularly in relation to how we try to work with new 'publics', to contribute to the development of HPPC as a new research field. Methods and Results: We discuss some considerations which arise in the Swedish context, and present the underlying ideas and approaches used in the research program, with examples of their application. HPPC, based on ideas from new public health, is essential as an umbrella for the DöBra program. Action research, experience-based co-design, and knowledge exchange, all aim to bring together a variety of stakeholders to exchange ideas and expertise, and co-create experience-based evidence through knowledge generation, dissemination, and sharing. Discussion: In reflecting on what we have learned about publics and partnerships in EoL research to date, we question distinctions made between professionals and publics, concluding that including publics in public health research, means also including ourselves and making public many of the reflections, the mistakes, and the experiences we all have, to foster collective learning.

Opening the doors a crack wider: palliative care research data in the public domain

This report builds further on OPCARE9, an EU 7th framework project aiming to identify knowledge gaps in care provision in the last days of life. This study began with curiosity about new ways of generating research questions to meet future challenges in palliative care (PC) and how to better engage disciplines not generally included in PC research. We here describe an innovative methodological approach to generating data; put data relevant for PC research in the public domain; and raise issues about open access in PC research. We aimed to compile research questions from different disciplines, based on raw data consisting of approximately 1000 descriptions of non-pharmacological caregiving activities (NPCAs), generated through previous research. 53 researchers from different fields were sent the full list of NPCAs and asked to generate research questions from their disciplinary perspective. Responses were received from 32 researchers from 9 countries, generating approximately 170 research topics, questions, reflections and ideas, from a wide variety of perspectives, which are presented here. Through these data, issues related to death and dying are addressed in several ways, in line with a new public health approach. By engaging a broader group of disciplines and facilitating availability of data in the public domain, we hope to stimulate more open dialogue about a wider variety of issues related to death and dying. We also introduce an innovative methodological approach to data generation, which resulted in a response rate at least equivalent to that in our Delphi survey of professionals in OPCARE9.

Effectiveness of the Liverpool care pathway for the dying in residential care homes: An exploratory, controlled before-and-after study

BACKGROUND

Clinical pathways aim to ensure that individuals receive appropriate evidence-based care and interventions, with the Liverpool Care Pathway for the Dying Patient focusing on end of life. However, controlled studies of the Liverpool Care Pathway for the Dying Patient, particularly outside of cancer settings, are lacking.

AIM

To compare the effects of the Liverpool Care Pathway for the Dying Patient and usual care on patients' symptom distress and well-being during the last days of life, in residential care homes.

DESIGN

Exploratory, controlled before-and-after study. During a 15-month baseline, usual care was carried out in two areas. During the following 15-months, usual care continued in the control area, while residential care home staff implemented Liverpool Care Pathway for the Dying Patient use in the intervention area. The intervention was evaluated by family members completing retrospective symptom assessments after the patient's death, using the Edmonton Symptom Assessment System and Views of Informal Carers - Evaluation of Services.

SETTINGS/PARTICIPANTS

Patients who died at all 19 residential care homes in one municipality in Sweden.

RESULTS

Shortness of breath (estimate = -2.46; 95% confidence interval = -4.43 to -0.49) and nausea (estimate = -1.83; 95% confidence interval = -3.12 to -0.54) were significantly reduced in Edmonton Symptom Assessment System in patients in the intervention compared to the control area. A statistically significant improvement in shortness of breath was also found on the Views of Informal Carers - Evaluation of Services item (estimate = -0.47; 95% confidence interval = -0.85 to -0.08).

CONCLUSION

When implemented with adequate staff training and support, the Liverpool Care Pathway for the Dying Patient may be a useful tool for providing end-of-life care of elderly people at the end of life in non-cancer settings.

Room for Death--International museum-visitors' preferences regarding the end of their life

Just as pain medications aim to relieve physical suffering, supportive surrounding for death and dying may facilitate well-being and comfort. However, little has been written of the experience of or preferences for the surroundings in which death and dying take place. In this study, we aim to complement our research from perspectives of patients, family members and staff, with perspectives from an international sample of the general public. Data derives from a project teaming artists and craftspeople together to create prototypes of space for difficult conversations in end-of-life (EoL) settings. These prototypes were presented in a museum exhibition, "Room for Death", in Stockholm in 2012. As project consultants, palliative care researchers contributed a question to the public viewing the exhibition, to explore their reflections: "How would you like it to be around you when you are dying?" Five-hundred and twelve responses were obtained from visitors from 46 countries. While preliminary analysis pointed to many similarities in responses across countries, continued analysis with a phenomenographic approach allowed us to distinguish different foci related to how preferences for surroundings for EoL were conceptualized. Responses were categorized in the following inductively-derived categories: The familiar death, The 'larger-than life' death, The lone death, The mediated death, The calm and peaceful death, The sensuous death, The 'green' death, and The distanced death. The responses could relate to a single category or be composites uniting different categories in individual combinations, and provide insight into different facets of contemporary reflections about death and dying. Despite the selective sample, these data give reason to consider how underlying assumptions and care provision in established forms for end-of-life care may differ from people's preferences. This project can be seen as an example of innovative endeavors to promote public awareness of issues related to death and dying, within the framework of health-promoting palliative care.

PA33 Reflections from the intersection of palliative care and design

: This presentation is based on our reflections as two designers entering palliative care, one working with supportive environments for death and dying and one working with issues related to health-promoting palliative care. Death, dying and mourning are important universal conditions that raise existential thought and reflection. The focus of care is different here than in most other areas, as it is not about curing, and values go beyond medical perspectives. Thus, if we want to support meaningful experiences related to dying, it is necessary to look beyond institutional structures and disciplinary divisions. The practice of design has begun to move away from a primary concern with the commercial realm, to instead be used as a method to approach complexity to incrementally improve situations. A key aspect of this is to design with those concerned rather than for them. We argue that design related to contextual change requires an immersion within that context. An essential feature of design is making, and so, drawing on this disciplinary background, we iteratively try theories out, working towards minimising the gap between theory and practice. This approach, applied in a sensitive setting, has the potential to result in insights relevant in the particular situation, as well as offering transferable design methods. Convinced that the intersection of design and palliative care offers opportunities for both sectors, we will present concrete examples from our interdisciplinary research group, to talk about the opportunities and challenges of our work.

WA3 Room for death - international museum - visitors' preferences regarding the end of their life

BACKGROUND

Just as pain medications aim to relieve physical suffering, supportive surrounding for death and dying may facilitate well-being and comfort. However, little has been written of the experience of or preferences for settings for death and dying.

AIM

We investigate preferences for and reflections about settings for end-of-life (EoL) in an international sample of museum visitors.

METHODS

Data derive from a project teaming artists and craftspeople together to create prototypes of space for difficult conversations in EoL settings. These prototypes were presented in a museum exhibition, "Room for Death", in Stockholm in 2012. As project consultants, we contributed a question to the public viewing the exhibition: "How would you like it to be around you when you are dying?" and analysed responses with a phenomenographic approach.

RESULTS

Five-hundred twelve responses were obtained from visitors from 46 countries. Responses were categorised in the following inductively- derived categories of types of deaths: The "Familiar", "Larger-than life", "Lone", "Mediated" "Calm and peaceful", "Sensuous", "'Green'", and "Distanced" death. Responses could relate to one category or be composites uniting different categories in individual combinations.

CONCLUSION

These data provide insight into different facets of contemporary reflections about death and dying. Despite the selective sample, the findings give reason to consider how underlying assumptions and care provision in established forms for EoL care may differ from people's preferences. This project can be seen as an example of innovative endeavours to promote public awareness of issues related to death and dying, within the framework of health-promoting palliative care.

Reflections on using biographical approaches in end-of-life care: dignity therapy as example

The therapeutic potential of nonpharmacologic interventions using biographical approaches at the end of life (EoL) is being increasingly recognized, but less attention is paid to processes impeding realization of this potential. In this article, Swedish and Australian researchers reflect on and problematize experiences using one biographical approach, dignity therapy (DT), in EoL care in Sweden. We use this as an example, focusing on critical examination of the process of applying DT in practice, examining frictions experienced in recruiting participants, collecting the data, and creating a biography. We discuss issues regarding agency, which became evident in the recruitment process and choices made about participation, and the power differentials manifested in the interactive process of eliciting stories and crafting them into a final product. We also raise salient questions about how research and practice with biographical approaches in EoL care might better build on and further existing knowledge to better reflect the complexities of everyday life.

Challenging situations when administering palliative chemotherapy - a nursing perspective

Palliative chemotherapy treatments (PCT) are becoming more common for patients with incurable cancer; a basic challenge is to optimize tumour response while minimizing side-effects and harm. As registered nurses most often administer PCT, they are most likely to be confronted with difficult situations during PCT administration. This study explores challenging situations experienced by nurses when administering PCT to patients with incurable cancer.

METHODS

Registered nurses experienced in administering PCT were asked in interviews to recall PCT situations they found challenging. Inspired by the narrative tradition, stories were elicited and analysed using a structural and thematic narrative analysis.

RESULTS

A total of twenty-eight stories were narrated by seventeen nurses. Twenty of these were dilemmas that could be sorted into three storylines containing one to three dilemmatic situations each. The six dilemmatic situations broadly related to three interwoven areas: the uncertainty of the outcome when giving potent drugs to vulnerable patients; the difficulty of resisting giving PCT to patients who want it; and insufficient communication between nurses and physician.

CONCLUSION

Nurses who administer PCT are engaged in a complex task that can give rise to a number of dilemmatic situations. The findings may be interpreted as meaning that at least some situations might be preventable if the knowledge and insight of all team members - nurses, physicians, patients, and relatives - are jointly communicated and taken into account when deciding whether or not to give PCT. Forming palliative care teams early in the PCT trajectory, could be beneficial for staff and patients.

International palliative care experts' view on phenomena indicating the last hours and days of life

BACKGROUND

Providing the highest quality care for dying patients should be a core clinical proficiency and an integral part of comprehensive management, as fundamental as diagnosis and treatment. The aim of this study was to provide expert consensus on phenomena for identification and prediction of the last hours or days of a patient's life. This study is part of the OPCARE9 project, funded by the European Commission's Seventh Framework Programme.

METHOD

The phenomena associated with approaching death were generated using Delphi technique. The Delphi process was set up in three cycles to collate a set of useful and relevant phenomena that identify and predict the last hours and days of life. Each cycle included: (1) development of the questionnaire, (2) distribution of the Delphi questionnaire and (3) review and synthesis of findings.

RESULTS

The first Delphi cycle of 252 participants (health care professionals, volunteers, public) generated 194 different phenomena, perceptions and observations. In the second cycle, these phenomena were checked for their specific ability to diagnose the last hours/days of life. Fifty-eight phenomena achieved more than 80% expert consensus and were grouped into nine categories. In the third cycle, these 58 phenomena were ranked by a group of palliative care experts (78 professionals, including physicians, nurses, psycho-social-spiritual support; response rate 72%, see Table 1) in terms of clinical relevance to the prediction that a person will die within the next few hours/days. Twenty-one phenomena were determined to have "high relevance" by more than 50% of the experts. Based on these findings, the changes in the following categories (each consisting of up to three phenomena) were considered highly relevant to clinicians in identifying and predicting a patient's last hours/days of life: "breathing", "general deterioration", "consciousness/cognition", "skin", "intake of fluid, food, others", "emotional state" and "non-observations/expressed opinions/other".

CONCLUSION

Experts from different professional backgrounds identified a set of categories describing a structure within which clinical phenomena can be clinically assessed, in order to more accurately predict whether someone will die within the next days or hours. However, these phenomena need further specification for clinical use.

Four essential drugs needed for quality care of the dying: a Delphi-study based international expert consensus opinion

PURPOSE

The majority of dying patients do not have access to necessary drugs to alleviate their most common symptoms, despite evidence of drug efficacy. Our aim was to explore the degree of consensus about appropriate pharmacological treatment for common symptoms in the last days of life for patients with cancer, among physicians working in specialist palliative care.

MATERIAL AND METHODS

Within OPCARE9, a European Union seventh framework project aiming to optimize end-of-life cancer care, we conducted a Delphi survey among 135 palliative care clinicians in nine countries. Physicians were initially asked about first and second choice of drugs to alleviate anxiety, dyspnea, nausea and vomiting, pain, respiratory tract secretions (RTS), as well as terminal restlessness.

RESULTS

Based on a list of 35 drugs mentioned at least twice in the first round (n=93), a second Delphi round was performed to determine ≤ 5 essential drugs for symptom alleviation in the last 48 hours of life that should be available even outside specialist palliative care. There was ≥ 80% consensus among the participants (n=90) regarding morphine, midazolam, and haloperidol as essential drugs. For RTS, there was consensus about use of an antimuscarinic drug, with 9%-27% of the physicians each choosing one of four different drugs.

CONCLUSION

Based on this consensus opinion and other literature, we suggest four drugs that should be made available in all settings caring for dying patients with cancer, to decrease the gap between knowledge and practice: morphine (i.e., an opioid), midazolam (a benzodiazepine), haloperidol (a neuroleptic), and an antimuscarinic.

Complexity in non-pharmacological caregiving activities at the end of life: an international qualitative study

BACKGROUND

In late-stage palliative cancer care, relief of distress and optimized well-being become primary treatment goals. Great strides have been made in improving and researching pharmacological treatments for symptom relief; however, little systematic knowledge exists about the range of non-pharmacological caregiving activities (NPCAs) staff use in the last days of a patient's life.

METHODS AND FINDINGS

Within a European Commission Seventh Framework Programme project to optimize research and clinical care in the last days of life for patients with cancer, OPCARE9, we used a free-listing technique to identify the variety of NPCAs performed in the last days of life. Palliative care staff at 16 units in nine countries listed in detail NPCAs they performed over several weeks. In total, 914 statements were analyzed in relation to (a) the character of the statement and (b) the recipient of the NPCA. A substantial portion of NPCAs addressed bodily care and contact with patients and family members, with refraining from bodily care also described as a purposeful caregiving activity. Several forms for communication were described; information and advice was at one end of a continuum, and communicating through nonverbal presence and bodily contact at the other. Rituals surrounding death and dying included not only spiritual/religious issues, but also more subtle existential, legal, and professional rituals. An unexpected and hitherto under-researched area of focus was on creating an aesthetic, safe, and pleasing environment, both at home and in institutional care settings.

CONCLUSIONS

Based on these data, we argue that palliative care in the last days of life is multifaceted, with physical, psychological, social, spiritual, and existential care interwoven in caregiving activities. Providing for fundamental human needs close to death appears complex and sophisticated; it is necessary to better distinguish nuances in such caregiving to acknowledge, respect, and further develop end-of-life care.

Palliative chemotherapy during the last month of life

BACKGROUND

This study analyses the potential discriminative characteristics for patients with incurable cancer who received palliative chemotherapy during their last month of life.

PATIENTS AND METHODS

The study includes all patients with epithelial cancer treated with palliative chemotherapy who died in 2008 in northern Sweden. Demographic parameters and care utilization data were registered. Data were analyzed using nonparametric methods.

RESULTS

Of 374 included patients, 87 (23%) received chemotherapy during the last month of life. These patients had a significantly shorter survival time from first palliative treatment to death, were admitted more frequently to hospital, more often lacked a documented decision to cease treatment, and died less frequently at home.

CONCLUSIONS

The results indicate covariations between palliative chemotherapy treatments in the last month of life and unfavorable patient outcomes. As almost one of four patients with incurable cancer received their last round of palliative chemotherapy <31 days before death, there is a potential for improved routines.

Time and bodily changes in advanced prostate cancer: talk about time as death approaches

The disease trajectory of living with incurable cancer is characterized by increasing bodily deterioration and problems. In this paper, we have focused on the change in temporal awareness as manifested in the narrations of two men with hormone refractory prostate cancer and skeletal metastases as they approach death. The two men participated in in-depth research interviews during the last part of their lives, sharing a similar disease trajectory with increasing bodily change and decreasing physical function. Both died a lingering, cancer-related death. The first and last research interviews were analyzed using a discourse analytic method. Findings show that the temporal awareness in the interviews changes as the illness progresses and death approaches. In the last interviews, the present is flooded with bodily problems; the past and the future are hardly present except for the future beyond the men's own deaths. Pain, fatigue, nausea, and other symptoms figure largely in this change, and there is no time for much more than attending to bodily needs in a present that is dominated by problems. Here, the importance of alleviating bodily problems once again becomes paramount, and two questions are raised: Is the often reported withdrawal from life, when death is imminent, a physical necessity rather than a psychological one, and is it possible to free time from the time-consuming problems of the present by means of a more concentrated attempt to alleviate these problems?

Reclaiming Wellness-Living With Bodily Problems, As Narrated by Men With Advanced Prostate Cancer

Having advanced prostate cancer means living with considerable bodily problems, a living we know little about. Thus, the aim of this study was to illuminate meanings of living with bodily problems, as narrated by men with advanced metastasized hormone refractory prostate cancer. Eighteen participants were interviewed, and the text was analyzed using a phenomenological-hermeneutic approach. Findings show that meanings of living with bodily problems are to live in cyclical movements between experiencing wellness and experiencing illness. New, or changed, bodily problems mean losing wellness and experiences of being ill. Understanding and, to some extent, being in control of bodily problems, make it possible to reclaim wellness and to experience oneself as being well. Findings also show that pain and fatigue are the most prominent problems and that they have different meanings. Pain being a threat of dying in agony, whereas fatigue is more of an emissary of death. Reclaiming wellness versus adaptation and enduring versus suffering deriving from 2 different perspectives, the inside or life world perspective and the outside or professional perspective, are questions discussed in the article. One clinical implication for nursing is the risk of obstructing the patients' possibility of reclaiming wellness by focusing on symptoms and disease.

Meanings of the phenomenon of fatigue as narrated by 4 patients with cancer in palliative care

The disabling experience of fatigue suffered in connection with incurable cancer is an area within nursing that has generated only limited research interest. The need for a change in focus is presented in the literature: from treating the symptom itself to facilitating living with the fatigue caused by a life-threatening disease. This implies that helping to alleviate fatigue must start from the patients' own understanding and interpretation of this experience. Our study attempts to achieve this understanding through illuminating the meanings of fatigue as experienced by 4 patients with cancer in palliative care. The research interviews were analyzed using a phenomenological-hermeneutic approach inspired by the philosophy of Ricoeur. Our findings indicate a world in which one meaning of fatigue connected with incurable cancer is a lived bodily experience of approaching death. Comprehending fatigue in this way allows us to understand the paradoxes we found in the text, such as struggling in vain against fatigue, and hoping to overcome fatigue but expecting failure. The paradoxes represent a struggle between body and mind, between bodily experiences and intellectual understanding, and have important implications for how we communicate with patients about fatigue.

A study of Cr(VI) in ashes from fluidized bed combustion of municipal solid waste: leaching, secondary reactions and the applicability of some speciation methods

The use of the fluidized bed technique for the combustion of municipal solid waste is a rather new concept. This type of combustor produces ash residues with somewhat different properties than the residues generated from the traditional mass burn techniques. Therefore, chemical characterization and the investigation of toxic metals behavior during ash water reactions are necessary for the safe disposal of these residues. In the present work, the total elemental composition, mineralogy and leaching behavior of ashes from the combustion of municipal solid waste in a fluidized bed combustion boiler have been investigated. The cyclone ash and, in particular, the filter ash contained considerable amounts of soluble substances, thus giving leachates with high levels of Cl-, Na+, K+, Ca2 + and Al(IIl). On the other hand, the two ash fractions taken in the boiler, the bottom and hopper ashes, were much more stable with respect to the release of salts and heavy metals. Since Cr(VI) is mobile and toxic its release from combustion residues can pose environmental problem. Even though the total Cr contents were similar in all ashes studied, the bottom ash gave about a thousand times higher levels of Cr(VI) in test leachates than the hopper, cyclone and filter ashes. However, it was found that the leached amount of Cr(VI) from the bottom ash decreased significantly when bottom ash was mixed with the hopper ash. The most probable cause for this decrease is the coupled oxidation of Al(0) to Al(III) and reduction of dissolved Cr(VI) to Cr(III). This finding that the mixing of two ash streams from the same boiler could result in the immobilization of Cr may point at a simple stabilization method. Selective extraction of water soluble, exchangeable and sparingly soluble forms of Cr(VI) was also investigated. Extraction methods were evaluated for their suitability for ash matrixes. It was found that interferences due to the presence of reducing substances in some ash materials may occur.

Modified on-line monitoring of total gaseous mercury in flue gases using Semtech Hg 2000 analyzer

The Semtech Hg 2000 analyzer continuously monitors the Hg0 content in flue gas. An on-line measurement method of total gaseous mercury in flue gas developed in our laboratory is described, which uses the absorption cell of the Semtech Hg Analyzer connected to a converter that is located in a furnace heated up to 650 degrees C. The converter can be heated up to 800 degrees C by both the furnace and an extra heating of a Ni-Cr alloy heating wire. Both the absorption cell and the converter are made of quartz. All gaseous Hg2+ species in flue gas are thermally reduced to Hg0 by the converter and detected by the Semtech Hg 2000 analyzer. The thermal reduction efficiencies of different conversion materials, which were filled in the converter, such as quartz chips, granular MgO, Ni and CoO powder, were tested using different flue gas conditions. Studies have shown that HCI is the major factor to inhibit the thermal reduction of Hg2+ to Hg0, and in the converter and the absorption cell Hg0 will react readily with HCl to form HgCl2. Both MgO and Ni could be used in the converter to absorb HCl in the flue gas, but Ni has better absorption efficiency. By using an original Semtech and a modified one, both Hg0 and total gaseous Hg contents in flue gas could be monitored simultaneously and continuously.

Atmospheric mercury deposition in Guizhou, China

The atmospheric deposition of mercury including total gas phase mercury (TGM), gas phase divalent mercury (Hg2+), and gas phase monomethyl mercury (MMHg) was investigated. Samples were collected from central cities and nature reserve areas across the province. Techniques and equipment including moss bags, KCl-coated denuder and GARDIS-1A portable mercury vapor analyzer were employed for sample collection and analysis. The reliability of techniques and analytical methods used for the project was evaluated. The deposition of atmospheric mercury was reported in species in this important mercury polluted province for the first time. The spatial and temporal variability of mercury emissions were investigated and reported. Contribution of coal mercury emissions to the atmosphere mercury deposition of the province was also investigated.

Distribution equilibrium of mercury (II) chloride between water and air applied to flue gas scrubbing

In the literature, different values of the distribution coefficient KH for HgCl2 between water and air are present in a range that spans more than 3 orders of magnitude. In order to determine if a waste incineration scrubber solution could become saturated with regard to HgCl2, an accurate experimental determination of the distribution constant of HgCl2 at elevated temperatures is needed. In this work, the coefficient has been determined at four different temperatures between 10 and 50 degrees C. The Arrhenius expression obtained is 5.5 x 10(5) x exp[-(8060 +/- 2200)/T] with a corresponding enthalpy for the process HgCl2(aq)<==>HgCl2(g) of 67 +/- 20 kJ/mole. KH at 293 K was found to be approximately 5 x 10(-7) atm M-1, which is in almost perfect agreement with an earlier study. Applying the obtained KH values to waste incineration scrubber conditions shows that no major saturation effect will occur.

[47-percent 6-months-long survival for intensive care patients over 80]

All 112 patients aged 80 and above treated at the intensive care unit at the University Hospital in Lund, Sweden 1994-1995 were followed-up retrospectively in terms of six-month survival (SMS) and for survivors in terms of quality of life. Overall SMS was the same for both men and women--47%. Patients with the poorest SMS were those aged 90 and above with only one patient out of eleven surviving six months. Patients admitted for severe heart failure also showed a very poor outcome with SMS 27%. Patients were grouped in terms of living conditions prior to admission to the ICU, and a significant difference in six-month survival was noted between those living in their own homes (53%) prior to admission compared to those coming from a nursing home (25%). Patients surviving six months were interviewed by telephone regarding their living situation in March 1997. More than 50% of survivors were living in their own homes with external help no more than once a day. The average APACHE II score was 14.9 +/- 8.2. The average score for patients surviving six months was 13.4 +/- 5.9 and for those not surviving six months 16.8 +/- 5.1. No significant statistical difference in APACHE II scores between these two groups was shown.

Improved determination of gaseous divalent mercury in ambient air using KCl coated denuders

An improved method for the determination of gaseous divalent mercury (GDM) in ambient air using KCl coated denuders has been developed and tested. GDM collected in the KCl coated denuders can be quantitatively desorbed at 450 degrees C in 10 min. After being complete thermally reduced to Hg0 at 900 degrees C, all mercury released from the denuder is pre-concentrated on the analytical Au trap, and detected by cold vapor atomic fluorescence spectrometry (CVAFS). The absolute detection limit of the method is less than 3 pg. Preliminary data of GDM concentration in ambient air from different sampling stations show that GDM concentrations in the urban air of Göteborg are much higher than in rural air (Rörvik and Sasetta), which indicates the anthropogenic origin of GDM.

Measurements of fractionated gaseous mercury concentrations over northwestern and central Europe, 1995-99

Although it makes up only a few per cent. of total gaseous mercury (TGM) in the atmosphere, the fraction of oxidised (divalent) mercury plays a major role in the biogeochemical cycle of mercury due to its high affinity for water and surfaces. Quantitative knowledge of this fraction present in mixing ratios in the parts-per-10(15) (ppq) range is currently very scarce. This work is based on approximately 220 data for divalent gaseous mercury (DGM) collected during 1995-99 in ambient air. Over the course of the measurements, the sampling and analytical methods were modified and improved. This is described here in detail and includes transition from wet leaching and reduction procedures to thermo-reductive desorption, the use of annular as well as tubular denuders and adoption of an automated sampling system. The concentration of DGM exhibited a strong seasonal behaviour in contrast to atomic gaseous mercury, with low values in winter and maximum values in summer. The DGM/TGM ratios were frequently found to be below the detection limit (< or = 1%) and in the range 1-5%. A trend of diurnal DGM patterns was observed and implies photolytically induced sources. Scavenging of DGM during rain events was also noticed.

Atmospheric mercury deposition on Fanjing Mountain Nature Reserve, Guizhou, China

Fanjing Mountain Nature Reserve (FMNR) is surrounded with several Hg emission sources within distances of 100-200 km. At the two sites studied, Tongren and Danzai, Hg emission and deposition fluxes, Hg concentration in the air, soil and other samples are all several hundred times higher than at other relatively clean areas. Hg accumulation in soil and moss at FMNR varies with the sampling heights. Total Hg deposition to this area has been estimated to be 115 micrograms m-2 y-1 using moss bag technique. Dry deposition was determined to be about 5.2 micrograms m-2 month-1 during March to June, corresponding to more than 50% of the total deposition.