Modelling end-of-life care practices: Factors associated with critical care nurse engagement in care provision

Objective To identify factors associated with critical care nurses��� engagement in end-of-life care practices. Methods Multivariable regression modelling was undertaken on 392 responses to an online self-report survey of end-of-life care practices and factors influencing practice by Australian critical care nurses���. Univariate general linear models were built for six end-of-life care practice areas. Results Six statistically significant (p < 0.001) models were developed: Information sharing F(3, 377) = 40.53, adjusted R2 23.8%; Environmental modification F(5, 380) = 19.55, adjusted R2 19.4%; Emotional support F(10, 366) = 12.10, adjusted R2 22.8%; Patient and family centred decision making F(8, 362) = 17.61 adjusted R2 26.4%; Symptom management F(8, 376) = 7.10, adjusted R2 11.3%; and Spiritual support F(9, 367) = 14.66, adjusted R2 24.6%. Stronger agreement with values consistent with a palliative approach, and greater support for patient and family preferences were associated with higher levels of engagement in end-of-life care practices. Higher levels of preparedness and access to opportunities for knowledge acquisition were associated with engagement in the interpersonal practices of patient and family centred decision making and emotional support. Conclusion This study provides evidence for interventions to address factors associated with nurse engagement to increase participation in all end-of-life care practice areas.

Critical review on the stability of illicit drugs in sewers and wastewater samples

Wastewater-based epidemiology (WBE) applies advanced analytical methods to quantify drug residues in wastewater with the aim to estimate illicit drug use at the population level. Transformation processes during transport in sewers (chemical and biological reactors) and storage of wastewater samples before analysis are expected to change concentrations of different drugs to varying degrees. Ignoring transformation for drugs with low to medium stability will lead to an unknown degree of systematic under- or overestimation of drug use, which should be avoided. This review aims to summarize the current knowledge related to the stability of commonly investigated drugs and, furthermore, suggest a more effective approach to future experiments. From over 100 WBE studies, around 50 mentioned the importance of stability and 24 included tests in wastewater. Most focused on in-sample stability (i.e., sample preparation, preservation and storage) and some extrapolated to in-sewer stability (i.e., during transport in real sewers). While consistent results were reported for rather stable compounds (e.g., MDMA and methamphetamine), a varying range of stability under different or similar conditions was observed for other compounds (e.g., cocaine, amphetamine and morphine). Wastewater composition can vary considerably over time, and different conditions prevail in different sewer systems. In summary, this indicates that more systematic studies are needed to: i) cover the range of possible conditions in sewers and ii) compare results more objectively. To facilitate the latter, we propose a set of parameters that should be reported for in-sewer stability experiments. Finally, a best practice of sample collection, preservation, and preparation before analysis is suggested in order to minimize transformation during these steps.

Characterization of small GTPase Cdc42 from the ectomycorrhizal fungus Suillus bovinus and Agrobacterium tumefaciens-mediated transformation of fungi

Ectomycorrhizal formation between the host tree, Pinus sylvestris and fungal symbiont, Suillus bovinus was investigated at the molecular level by isolating genes regulating the organization of the actin cytoskeleton in the fungal partner S. bovinus. An Agrobacterium tumefaciens mediated transformation (ATMT) system was developed for the ectomycorrhizal fungi in order to assign specific functions to the cloned molecules. The developed ATMT system was also used to transform a plant pathogenic fungus, Helminthosporium turcicum, to hygromycin B resistance. Small GTPases Cdc42 and Rac1, the regulators of actin cytoskeleton in eukaryotes were isolated from S. bovinus. Sbcdc42 and Sbrac1, are both expressed in vegetative and in the symbiotic hyphae of S. bovinus . Using IIF microscopy, Cdc42 and actin were co-localized at the tips of vegetative hyphae and were visualized in association with the plasma membrane in swollen cells typical to the symbiotic hyphae. These results suggest that the small GTPases Cdc42 may play a significant role in the polarized growth of S. bovinus hyphae and regulate fungal morphogenesis during ectomycorrhiza formation through reorganization of the actin cytoskeleton. The functional equality of Cdc42 was tested in yeast complementation experiments using a Saccharomyces cerevisiae temperature sensitive mutant, cdc42-1ts. The genomic clone of CDC42 was isolated from S. bovinus genomic DNA via specific primers for Cdc42. The analogous S. cerevisiae cdc42 mutations, dominant active G12V and dominant negative D118A, were generated in the Sbcdc42 gene by in-vitro mutagenesis. The ectomycorrhizal fungi, S. bovinus, P. involutus and H. cylindroporum were transformed using ATMT and phleomycin as a selectable marker. PCR screeing suggested that the T-DNA was inserted in all the three fungal genomes but the fate of integration could not be proved by Southern blot analysis. An alternative Agrobacterium strain, AGL-1 and selection marker, hygromycin was used to transform our model fungus S. bovinus. PCR and Southern analysis suggested an improved efficiency of transformation. All the transformed fungal colonies selected for hygromycin gave positives in PCR and the Southerns showed multiple or single copy T-DNA integrations into the S. bovinus genome. Using the same Agrobacterium strain and the selectable marker, a maize pathogen, H. turcicum was also subjected to ATMT. The H. turcicum transformation data suggested the single copy T-DNA integrations into the genome of the screened transformants that further confirms wider applicability of the ATMT. The plasmids carrying the wild-type (pHGCDC42) and the mutated Sbcdc42 alleles (pHGGV; pHGDA) under Agaricus bisporus gpd promoter were constructed in an A. tumefaciens vector. ATMT was used to transform S. bovinus with the plasmids carrying the wild-type and mutated Sbcdc42 alleles. The isolation of Sbcdc42 and Sbrac1 genes and some other functionally related genes from ectomycorrhizal fungus, S. bovinus will form the basis of future work to resolve the signalling pathway leading to ectomycorrhizal symbiosis. The development of ATMT system will be a valuable tool in analysing the exact function of signalling pathway components in ectomycorrhizal symbiosis or in plant pathogenic interactions. The transformation frequency and broad applicability along with the simplicity of T-DNA integration make Agrobacterium a valuable, new and a powerfull tool for targeted and insertional mutagenesis in these plant associated fungi. The developed ATMT systems should therefore make it possible to generate large number of transformants with tagged genes which could then be screened for their specific roles in symbiosis and pathogenecity, respectively.

The Church and Its Boundaries : A Study of the Special Commission on Orthodox Participation in the WCC

The relationship between the Orthodox Churches and the World Council of Churches (WCC) became a crisis just before the 8th Assembly of the WCC in Harare, Zimbabwe in 1998. The Special Commission on Orthodox Participation in the WCC (SC), inaugurated in Harare, worked during the period 1999 2002 to solve the crisis and to secure the Orthodox participation in the WCC. The purpose of this study is: 1) to clarify the theological motives for the inauguration of the SC and the theological argumentation of the Orthodox criticism; 2) to write a reliable history and analysis of the SC; 3) to outline the theological argumentation, which structures the debate, and 4) to investigate the ecclesiological questions that arise from the SC material. The study spans the years 1998 to 2006, from the WCC Harare Assembly to the Porto Alegre Assembly. Hence, the initiation and immediate reception of the Special Commission are included in the study. The sources of this study are all the material produced by and for the SC. The method employed is systematic analysis. The focus of the study is on theological argumentation; the historical context and political motives that played a part in the Orthodox-WCC relations are not discussed in detail. The study shows how the initial, specific and individual Orthodox concerns developed into a profound ecclesiological discussion and also led to concrete changes in WCC practices, the best known of which is the change to decision-making by consensus. The Final Report of the SC contains five main themes, namely, ecclesiology, decision-making, worship/common prayer, membership and representation, and social and ethical issues. The main achievement of the SC was that it secured the Orthodox membership in the WCC. The ecclesiological conclusions made in the Final Report are twofold. On the one hand, it confirms that the very act of belonging to the WCC means the commitment to discuss the relationship between a church and churches. The SC recommended that baptism should be added as a criterion for membership in the WCC, and the member churches should continue to work towards the mutual recognition of each other s baptism. These elements strengthen the ecclesiological character of the WCC. On the other hand, when the Final Report discusses common prayer, the ecclesiological conclusions are much more cautious, and the ecclesiological neutrality of the WCC is emphasized several times. The SC repeatedly emphasized that the WCC is a fellowship of churches. The concept of koinonia, which has otherwise been important in recent ecclesiological questions, was not much applied by the SC. The comparison of the results of the SC to parallel ecclesiological documents of the WCC (Nature and Mission of the Church, Called to Be the One Church) shows that they all acknowledge the different ecclesiological starting points of the member churches, and, following that, a variety of legitimate views on the relation of the Church to the churches. Despite the change from preserving the koinonia to promises of eschatological koinonia, all the documents affirm that the goal of the ecumenical movement is still full, visible unity.

Transformation of 16-dehydroprogesterone and 17?-hydroxyprogesterone by Mucor piriformis

Mucor piriformis was used to study the mode of transformation of 16-dehydroprogesterone (I, pregna-4, 16-diene-3, 20-dione) and 17 alpha-hydroxyprogesterone (II, 17 alpha-hydroxypregn-4-ene-3, 20-dione). Biotransformation products formed from I were 14 alpha-hydroxypregna-4, 16-diene-3, 20-dione (Ia), 7 alpha, 14 alpha-dihydroxypregna-4 16-diene-3, 20-dione (Ib), 3 beta, 7 alpha, 14 alpha-trihydroxy-5 alpha-pregn-16-en-20-one (Ic), and 3 alpha, 7 alpha, 14 alpha-trihydroxy-5 alpha-pregn-16-en-20-one (Id). Metabolites Ic and Id appear to be hitherto unknown. Timecourse studies suggested that the transformation is initiated by hydroxylation at the 14 alpha-position (Ia) followed by hydroxylation at the 7 alpha-position (Ib). Microsomes (105,000 g sediment) prepared from 16-dehydroprogesterone-induced cells hydroxylate I to its 14 alpha-hydroxy derivative (Ia) in the presence of NADPH. Incubation of Ia with the organism resulted in the formation of Ib, Ic and Id. Biotransformation products formed from compound II were 17 alpha, 20 alpha-dihydroxypregn-4-en-3-one (IIa), 7 alpha, 17 alpha-dihydroxypregn-4-ene-3, 20-dione (IIb), 6 beta, 17 alpha, 20 alpha-trihydroxypregn-4-en-3-one (IIc) and 11 alpha, 17 alpha, 20 alpha-trihydroxypregn-4-en-3-one (IId). Time-course studies indicated that IIa is the initial product formed, which is further hydroxylated either at the 6 beta or 11 alpha position. Incubation of IIa with the organism resulted in the formation of IIc and IId. Reduction of the 4-en-3-one system and 20-keto group has not been observed before in organisms of the order Mucorales. In addition, M. piriformis has been shown to carry out hydroxylation at the C-6, C-7, C-11 and C-14 positions in the steroid molecules tested.

Transformation of dehydroepiandrosterone and pregnenolone by Mucor piriformis

The mode of transformation of dehydroepiandrosterone (I, 3 beta-hydroxyandrost-5-en-17-one) and pregnenolone (II, 3 beta-hydroxypregn-5-en-20-one) was studied using Mucor piriformis. Biotransformation products formed from I were 3 beta,17 beta-dihydroxyandrost-5-ene (Ia), 3 beta-hydroxyandrost-5-ene-7,17-dione (Ib), 3 beta,17 beta-dihydroxyandrost-5-en-7-one (Ic), 3 beta,7 alpha-dihydroxyandrost-5-en-17-one (Id) and 3 beta,7 alpha,17 beta-trihydroxyandrost-5-ene (Ie). Biotransformation products formed from compound II were 3 beta,7 alpha-dihydroxypregn-5-en-20-one (IIa) and 3 beta,7 alpha,11 alpha-trihydroxypregn-5-en-20-one (IIb). The organism did not carry out isomerization of the 5-en-3 beta-ol to a 4-en-3-one system in the steroid molecules tested. In addition, it failed to carry out 14 alpha-hydroxylation possibly because of the lack of a 4-en-3-one system in I and II, and stereospecific hydroxylation at the C-7 position in I and II.

Asymptotic analysis of plane-strain mode I steady-state crack growth in transformation toughening ceramics (II)

Based on a constitutive law which includes the shear components of transformation plasticity, the asymptotic solutions to near-tip fields of plane-strain mode I steadity propagating cracks in transformed ceramics are obtained for the case of linear isotropic hardening. The stress singularity, the distributions of stresses and velocities at the crack tip are determined for various material parameters. The factors influencing the near-tip fields are discussed in detail.

Interplay of martensitic phase transformation and plastic slip in polycrystals

<p>Inspired by key experimental and analytical results regarding Shape Memory Alloys (SMAs), we propose a modelling framework to explore the interplay between martensitic phase transformations and plastic slip in polycrystalline materials, with an eye towards computational efficiency. The resulting framework uses a convexified potential for the internal energy density to capture the stored energy associated with transformation at the meso-scale, and introduces kinetic potentials to govern the evolution of transformation and plastic slip. The framework is novel in the way it treats plasticity on par with transformation.</p> <p>We implement the framework in the setting of anti-plane shear, using a staggered implicit/explict update: we first use a Fast-Fourier Transform (FFT) solver based on an Augmented Lagrangian formulation to implicitly solve for the full-field displacements of a simulated polycrystal, then explicitly update the volume fraction of martensite and plastic slip using their respective stick-slip type kinetic laws. We observe that, even in this simple setting with an idealized material comprising four martensitic variants and four slip systems, the model recovers a rich variety of SMA type behaviors. We use this model to gain insight into the isothermal behavior of stress-stabilized martensite, looking at the effects of the relative plastic yield strength, the memory of deformation history under non-proportional loading, and several others.</p> <p>We extend the framework to the generalized 3-D setting, for which the convexified potential is a lower bound on the actual internal energy, and show that the fully implicit discrete time formulation of the framework is governed by a variational principle for mechanical equilibrium. We further propose an extension of the method to finite deformations via an exponential mapping. We implement the generalized framework using an existing Optimal Transport Mesh-free (OTM) solver. We then model the $\alpha$--$\gamma$ and $\alpha$--$\varepsilon$ transformations in pure iron, with an initial attempt in the latter to account for twinning in the parent phase. We demonstrate the scalability of the framework to large scale computing by simulating Taylor impact experiments, observing nearly linear (ideal) speed-up through 256 MPI tasks. Finally, we present preliminary results of a simulated Split-Hopkinson Pressure Bar (SHPB) experiment using the $\alpha$--$\varepsilon$ model.</p>

Intercultural Management and Leadership in the Context of Language Academies

Throughout this undergraduate thesis, a study of intercultural management and leadership will be carried out with a special focus on language academies. We begin by analyzing the importance of cultural values and their effects on the perception of a leader. We then study the role of Strategic Human Resources Management in an intercultural environment. Finally, as an original contribution to this thesis, an investigation is performed that examines three local language academies and their management practices. After reviewing the findings, we hope to propose a sort of ���best practices��� for language academies that could lead to a more harmonious relationship between teachers and their managers.

As pr��ticas de participa����o institucionalizadas e sua interface com a cultura pol��tica: um olhar sobre o cotidiano de um conselho municipal de sa��de no nordeste brasileiro

A Constitui����o federal e a Lei 8.142/90 definem a participa����o da comunidade como condi����o necess��ria para o funcionamento do Sistema ��nico de Sa��de (SUS). Tal defini����o constitucional surge no processo de l uta pela democratiza����o do pa��s e pela universaliza����o dos direitos sociais, entre eles, o direito �� sa��de. Todavia, esse processo de democratiza����o tem significado mais a ado����o de procedimentos democr��ticos para organiza����o do sistema pol��tico do que uma efetiva democratiza����o das rela����es sociais pautadas pelos valores democr��ticos de igualdade e justi��a social. No Brasil, a rela����o entre Estado e sociedade tem sido mediada por uma cultura pol��tica marcada pelo autoritarismo, patrimonialismo, clientelismo e o favor. Com o processo de democratiza����o, na d��cada de 1980, emergem elementos de uma nova cultura pol��tica adjetivada como democr��tica orientada pelos valores da autonomia, igualdade, solidariedade e justi��a que passa a coexistir com a velha cultura. O objetivo geral deste estudo �� analisar as pr��ticas de participa����o presentes no Conselho Municipal de Sa��de (CMS) de Fortaleza, no per��odo de 1997-2005, e sua rela����o com a cultura pol��tica local. Para tanto partiu-se do principal pressuposto te��rico: as pr��ticas de participa����o exercidas nos conselhos de sa��de inauguram uma nova institucionalidade que inclui novos sujeitos sociais os usu��rios na esfera p��blica, com as quais o processo de democratiza����o amplia essa esfera, criando visibilidade para identificar o confronto entre a cultura pol��tica tradicional e a cultura pol��tica democr��tica. As t��cnicas de pesquisa utilizadas foram: a an��lise documental, a observa����o participante e a entrevista semiestruturada. A partir das diferentes evid��ncias observadas no material emp��rico, identificou -se na an��lise dos dados a predomin��ncia da cultura pol��tica tradicional do autoritarismo e coopta����o nas rela����es entre o poder p��blico municipal e os representantes da sociedade civil ; e entre os conselheiros a tens��o se manifestava na n��o-observ��ncia dos procedimentos democr��ticos, como elei����es peri��dicas, respeito �� lei e ao regimento que regula o funcionamento do CMS e no encaminhamento dos conflitos e disputas pol��ticas. Quanto ��s pr��ticas de participa����o, manifestaram-se de forma contradit��ria e dial��tica em a����es caracterizadas pela cr��tica, den��ncia, reivindica����o, com poucas a����es propositivas e na maioria das vezes tendo seu poder deliberativo desconsiderado pelo gestor. A condu����o pol��tica do conselho muitas vezes foi questionada, ocasionando crises de hegemonia e gerando conflitos e disputas pelo poder. A partir da an��lise desses conflitos e disputas pol��ticas entre os grupos no interior do Conselho, tornou-se poss��vel realizar uma leitura met��dica acerca do confronto entre a cultura pol��tica tradicional e a democr��tica no CMS, constatando-se a predomin��ncia da primeira sobre a segunda. Por fim verificou-se o protagonismo do Minist��rio P��blico na resolu����o dos conflitos, em detrimento da for��a do melhor argumento. Em que pese a recorrente tutela do Minist��rio P��blico, foi pavimentado um caminho de resist��ncias, ainda que minorit��rias , contra a cultura pol��tica tradicional , cujas pr��ticas de participa����o apresentam elementos constituintes para a sua transforma����o.

Three-stage transformation of chlorophyll transient fluorescence pattern under sustained dehydration and the discovery of critical water content in seaweeds

The chlorophyll fluorescence kinetics of marine red alga Grateloupia turutunt Yamada, green alga Ulva pertusa Kjellm and brown alga Laminaria japonica Aresch during natural sustained dehydration were monitored and investigated. The pulse amplified modulation (PAM) system was used to analyze the distinct fluorescence parameters during thallus dehydration. Results proved that the fluorescence kinetics of different seaweed all showed three patterns of transformation with sustained water loss. These were: 1) peak kinetic pattern (at the early stage of dehydration fluorescence enhanced and quenched subsequently, representing a normal physiological state). 2) plateau kinetic pattern (with sustained water loss fluorescence enhanced continuously but quenching became slower, finally reaching its maximum). 3) Platform kinetic pattern (fluorescence fell and the shape of kinetic curve was similar to plateau kinetic pattern). A critical water content (CWC) could be found and defined as the percentage of water content just prior to the fluorescence drop and to be a significant physiological index for evaluation of plant drought tolerance. Once thallus water content became lower than this value the normal peak pattern can not be recovered even through rehydration, indicating an irreversible damage to the thylakoid membrane. The CWC value corresponding to different marine species were varied and negatively correlated with their desiccation tolerance, for example. Laminaria japonica had the highest CWC value (around 90%) and the lowest dehydration tolerance of the three. In addition, a fluorescence "burst" was found only in red algae during rehydration. The different fluorescence parameters F-o, F-v and F-v, F-m were measured and compared during water loss. Both F-o and F-v increased in the first stage of dehydration but F-v/F-m. kept almost constant. So the immediate response of in vivo chlorophyll fluorescence to dehydration was an enhancement. Later with sustained dehydration F-o increased continuously while F-v decreased and tended to become smaller and smaller. The major changes in fluorescence (including fluorescence drop during dehydration and the burst during rehydration) were all attributed to the change in F-o instead of F-v This significance of F-o indicates that it is necessary to do more research on F-o as well as on its relationship with the state of thylakoid membrane.

Transformation field method for calculating the effective properties of isotropic graded composites having arbitrary shapes

A method of transformation field is developed to estimate the effective properties of graded composites whose inclusions have arbitrary shapes and gradient profiles by means of a periodic cell model. The boundary-value problem of graded composites having arbitrary inclusion shapes is solved by introducing the transformation field into the inclusion region. As an example, the effective dielectric response of isotropic graded composites having arbitrary shapes and gradient profiles is handled by the transformation field method (TFM). Moreover, TFM results are validated by the exact solutions of isotropic graded spherical inclusions having a power-law profile and good agreement is obtained in the dilute limit. Furthermore, it is found that the inclusion shapes and the parameters of the gradient profiles can have profound effect on the effective properties of composite systems at high concentration of inclusions.

Through the Wire: Relations of Power and Relations of Violence

Edkins, J. and Pin-Fat, V. (2005). Through the Wire: Relations of Power and Relations of Violence. Millennium - Journal of International Studies. 34(1), pp.1-24 RAE2008

Form-focused instruction in Irish-medium immersion education: a critical examination of teachers' perspectives and practices. A small-scale qualitative case study

It has been suggested that the less than optimal levels of students��� immersion language ���persist in part because immersion teachers lack systematic approaches for integrating language into their content instruction��� (Tedick, Christian and Fortune, 2011, p.7). I argue that our current lack of knowledge regarding what immersion teachers think, know and believe and what immersion teachers��� actual ���lived��� experiences are in relation to form-focused instruction (FFI) prevents us from fully understanding the key issues at the core of experiential immersion pedagogy and form-focused integration. FFI refers to ���any planned or incidental instructional activity that is intended to induce language learners to pay attention to linguistic form��� (Ellis, 2001b, p.1). The central aim of this research study is to critically examine the perspectives and practices of Irish-medium immersion (IMI) teachers in relation to FFI. The study ���taps��� into the lived experiences of three IMI teachers in three different IMI school contexts and explores FFI from a classroom-based, teacher-informed perspective. Philosophical underpinnings of the interpretive paradigm and critical hermeneutical principles inform and guide the study. A multi-case study approach was adopted and data was gathered through classroom observation, video-stimulated recall and semistructured interviews. Findings revealed that the journey of ���becoming��� an IMI teacher is shaped by a vast array of intricate variables. IMI teacher identity, implicit theories, stated beliefs, educational biographies and experiences, IMI school cultures and contexts as well as teacher knowledge and competence impacted on IMI teachers��� FFI perspectives and practices. An IMI content teacher identity reflected the teachers��� priorities as shaped by pedagogical challenges and their educational backgrounds. While research participants had clearly defined instructional beliefs and goals, their roadmap of how to actually accomplish these goals was far from clear. IMI teachers described the multitude of choices and pedagogical dilemmas they faced in integrating FFI into experiential pedagogy. Significant gaps in IMI teachers��� declarative knowledge about and competence in the immersion language were also reported. This research study increases our understanding of the complexity of the processes underlying and shaping FFI pedagogy in IMI education. Innovative FFI opportunities for professional development across the continuum of teacher education are outlined, a comprehensive evaluation of IMI is called for and areas for further research are delineated.

Communication practices in physician decision-making for an unstable critically ill patient with end-stage cancer.

BACKGROUND: Shared decision-making has become the standard of care for most medical treatments. However, little is known about physician communication practices in the decision making for unstable critically ill patients with known end-stage disease. OBJECTIVE: To describe communication practices of physicians making treatment decisions for unstable critically ill patients with end-stage cancer, using the framework of shared decision-making. DESIGN: Analysis of audiotaped encounters between physicians and a standardized patient, in a high-fidelity simulation scenario, to identify best practice communication behaviors. The simulation depicted a 78-year-old man with metastatic gastric cancer, life-threatening hypoxia, and stable preferences to avoid intensive care unit (ICU) admission and intubation. Blinded coders assessed the encounters for verbal communication behaviors associated with handling emotions and discussion of end-of-life goals. We calculated a score for skill at handling emotions (0-6) and at discussing end of life goals (0-16). SUBJECTS: Twenty-seven hospital-based physicians. RESULTS: Independent variables included physician demographics and communication behaviors. We used treatment decisions (ICU admission and initiation of palliation) as a proxy for accurate identification of patient preferences. Eight physicians admitted the patient to the ICU, and 16 initiated palliation. Physicians varied, but on average demonstrated low skill at handling emotions (mean, 0.7) and moderate skill at discussing end-of-life goals (mean, 7.4). We found that skill at discussing end-of-life goals was associated with initiation of palliation (p = 0.04). CONCLUSIONS: It is possible to analyze the decision making of physicians managing unstable critically ill patients with end-stage cancer using the framework of shared decision-making.