Alternatives to Guardianship and Conservatorship for Adults in Iowa, Revised 2007

Independence, respect, and equality are values important to all people. These values help define the concepts of autonomy (independence and freedom) and self-determination (the right to make decisions for one’s self). Because these rights are so valued in our society and are something that most of us would value for ourselves, the “least restrictive alternative” should always be considered before taking away a person’s civil and legal rights to make decisions for him or herself. The least restrictive alternative is an option, which allows a person to keep as much autonomy, and self-determination as possible while providing only the level of protection and supervision that is necessary. Some examples may include: representative payee for certain government benefit checks, joint bank accounts or advance directives for health care.

Gift of Peace of Mind-The For yourself For your Family, May 2001

The purpose of this booklet is to educate the public about advance directives. By doing so, we hope to increase the use of advance directives, as well as the quality and accuracy of the documents themselves. The reader is led through a series of steps that ultimately lead to filling out the advance directive documents in an informed manner.

Ympäristövaikutusten velvoitetarkkailun tulosten epävarmuuden arviointi

Tämä diplomityö tehtiin Neste Oil Oyj:n Kehittäminen ja Laboratoriot yksikön HSE-palveluille. Työn tavoitteena oli arvioida Neste Oilin ympäristövaikutusten velvoitetarkkailujen mittaustulosten epävarmuutta. Tarkastelu koski ilmanlaadun SO2-, NO2-, TRS- sekä O3-mittauksia, ympäristömelumittauksia sekä pohjavesinäytteenottoa. Ympäristönsuojelulaki (86/2000) velvoittaa tuotantolaitoksia selvittämään toimintansa ympäristövaikutukset. Myös esimerkiksi akkreditoitaessa menetelmiä mittausepävarmuus on tunnettava. On arvioitu, että tulevaisuudessa direktiivit tulevat tiukentamaan päästöraja-arvoja ja mittausepävarmuuden käsite tulee käyttöön kaikilla ympäristösektoreilla.Tässä työssä ilmanlaadun mittausepävarmuus arvioitiin vertaamalla Neste Oilin mittaustuloksia Ilmatieteenlaitoksen vertailumittausten ja kalibrointien tuloksiin. Ympäristömelun mittausepävarmuus arvioitiin Ympäristöministeriön ympäristömelunmittausohjeen (1/1995)mukai-sesti. Pohjavesinäytteenoton mittausepävarmuus arvioitiin laskemalla haitta-aineiden ajallisen vaihtelun, näytteenottomenetelmien, näytteiden kuljetuksenja säilytyksen aiheuttaman kontaminaation sekä analyysivaiheen epävarmuustekijöiden yhdistetty mittausepävarmuus. Tarkastelussa todettiin, että ilmanlaadunmittaustulokset eivät poikenneet merkittävästi vertai-lumittausten ja kalibrointien tuloksista. Menetelmien laajennetuksi mittausepävarmuudeksi saatiin 6-8 %. Ympäristömelun mittausepävarmuus vastasi ympäristömelunmittausohjeessa esitettyjä arvoja ja vaihtelivat 2-10 dB:n välillä, riippuen mittausetäisyydestä ja mittauskertojen lukumäärästä. Pohjavesinäytteenoton mittausepävarmuudelle ei ole asetettu laatutavoitteita. Tässä tarkastelussa pohjavesinäytteenoton mittausepävarmuudeksi saatiin 33 %.

Kaasutuskaasun puhdistus

Tässä diplomityössä on selvitetty hiilestä, jätteestä tai biopolttoaineesta kaasutetun kaasun märkä- ja kuivapuhdistusta. Kaasutuskaasun puhdistuksella voidaan likainen ja jopa ongelmallinen aines muuttaa tai puhdistaa sellaiseksi ympäristökelpoiseksi polttoaineeksi, että sitä voidaan käyttää nykyisissä kulutuskohteissa ongelmitta. Lisäkannustusta kaasutuskaasun puhdistus saa uusista EU-direktiiveistä, jotka tulevat rajoittamaan jätteiden läjittämistä kaatopaikoille. Loppusijoitukseen meneviä jätevirtoja voidaan energiakäytöllä pienentää huomattavasti.Työ on tehty PVO-Engineering Oy:n voimalaitostekniikan osastolle kevään 2001 aikana. Työn tavoitteena oli kasvattaa yrityksen tietomäärää kaasutuskaasun puhdistuksen osalta. Lisäksi pyrittiin selvittämään uuden keraamisen pussisuodatinmateriaalin käyttöä kaasutuskaasun kuumakuivasuodatuksessa. Työn ensimmäisessä osassa esitetään kaasutuskaasun koostumuksen ja syntymisen lisäksi tämän työn lähtökohdat ja tavoitteet. Toisessa osassa selvitetään kaasulle asetettavia vaatimuksia eri käyttötapojen mukaan. Kolmannessa ja neljännessä osassa selvitetään puhdistettavien komponenttien käyttäytymistä ja sopivia puhdistusmenetelmiä.Kaasutuskaasun puhdistustekniikka vaihtelee paljonkin riippuen kaasun käyttökohteesta. Eroja syntyy käyttökohteen asetettamista vaatimuksista polttoaineelle, kaasutettavan polttoaineen koostumuksesta ja laadun vaihtelusta. Puhdistuksessa keskitytään kloori -, rikki -, typpi - ja metalliyhdisteiden poistamiseen kaasuvirrasta. Erotuskyvyllä arvioituna eri puhdistusmenetelmistä tehokkaimpia ovat pesurisähkösuodatinyhdistelmät. Niiden suuret jätemäärät ovat kuitenkin iso ongelma. Kuumakuivapuhdistuksessa pyritään kehittämään menetelmä, jossa syntyvät jätemäärät ovat pieniä ja puhdistustulos on riittävä. Puhdistuksen apukeinona käytetään usein erilaisia katalyyttejä. Tunnetuimpia ovat erilaiset kalsiumpohjaiset materiaalit ja mineraalit. Katalyyteillä voidaan tehostaa tarpeellisia kemiallisia reaktioita puhdistusprosessissa. Kaikki puhdistukseen liittyvät ongelmat ovat kooltaan niin suuria, että niiden ratkaisemiseksi on tulevaisuudessa tehtävä lujasti töitä. Markkinanäkymät toimivalle puhdistustekniikalle ovat nykymaailmassa hyvät. Niinpä tuotekehitykseen laitetut panokset voivat tulevaisuudessa olla yritykselle kullan arvoisia.

Erforschung und Antworten auf den vorzeitigen Todeswunsch eines Patienten mit einer schweren fortgeschrittenen Krankheit [Exploring and Responding to a Wish to Hasten Death of a patient with Advanced Illness].

It is not uncommon for patients with an advanced disease to express a desire to their physician to hasten their death. Recent studies show that the motivation of such a desire is multifactorial and multidimensional, including depression, physical, psycho-social and spiritual suffering, fears about the process of dying and/or misunderstandings about the options for end-of-life care. The objective of this paper is to propose to the physician how to explore the dimensions of this request and some elements to answer it.

Soins palliatifs en établissements médico-sociaux: Caractéristiques et spécificités [Palliative Care in Nursing Homes: Characteristics and Specificities].

Elderly patients in palliative situations residing in a nursing home present characteristics and specificities that clearly distinguish them from patients with advanced cancer. Besides the difficulty to define a precise prognosis, their many comorbidities, their communication difficulties because of cognitive disorders, their high sensitivity to primary and secondary effects of drugs render their management a real challenge for physician and caregivers. Accompanying these patients at the end of their life also raises many ethical problems, especially when they are no longer able to express their wishes and have not previously expressed advance directives.

Separation and Execution of graphical engine on a cross platform IDE to enhance performance

“Biosim” is a simulation software which works to simulate the harvesting system.This system is able to design a model for any logistic problem with the combination of several objects so that the artificial system can show the performance of an individual model. The system will also describe the efficiency, possibility to be chosen for real life application of that particular model. So, when any one wish to setup a logistic model like- harvesting system, in real life he/she may be noticed about the suitable prostitution for his plants and factories as well as he/she may get information about the least number of objects, total time to complete the task, total investment required for his model, total amount of noise produced for his establishment in advance. It will produce an advance over view for his model. But “Biosim” is quite slow .As it is an object based system, it takes long time to make its decision. Here the main task is to modify the system so that it can work faster than the previous. So, the main objective of this thesis is to reduce the load of “Biosim” by making some modification of the original system as well as to increase its efficiency. So that the whole system will be faster than the previous one and performs more efficiently when it will be applied in real life. Theconcept is to separate the execution part of ”Biosim” form its graphical engine and run this separated portion in a third generation language platform. C++ is chosenhere as this external platform. After completing the proposed system, results with different models have been observed. The results show that, for any type of plants of fields, for any number of trucks, the proposed system is faster than the original system. The proposed system takes at least 15% less time “Biosim”. The efficiency increase with the complexity of than the original the model. More complex the model, more efficient the proposed system is than original “Biosim”.Depending on the complexity of a model, the proposed system can be 56.53 % faster than the original “Biosim”.

Da acusação às professoras pelo aprisionamento do sujeito em um diagnóstico a uma interrogação acerca da posição do analista

This study arises with two questionings: what is the usefulness of a diagnosis in school? And what moves that demand for diagnosis? Such questions were drawn up in answer to a diagnostic demand produced in the context of our internship in Scholar/Educational Psychology. On the perspective of working these issues, we conducted a literature research on diagnosis, with regard to its history, as a review of the psychoanalytic literature about the subject. This venture led us to a new interrogation: what are the elaborations that teachers produce from the child diagnosis, which place her as having special educational needs? The need of deciding the method that would lead us to answer such question, taking as reference the psychoanalytic theory, led us to an incursion to the subject research in psychoanalysis. This tracking points us that, according to Freud, on what comes to psychoanalysis, theory and research go together and that psychoanalysis is not a totalitarian world vision. On Lacan, the research is from the analysand, research that always implies the analyst and its praxis. Such path forced us to position a change to question the positions we occupy, in this experience, guided by an analytical listening. To discuss our position, we started from two cases and submitted them to construction and analysis. As a result, we found out that there is no way to know in advance what will be done from a diagnosis, which will be its uses. Point we used to considerate devastating to a child. So, to us, all children that received a diagnosis would be destined to a tragedy and what the research has shown us is that not always, not all of them. Thus, more than knowing what moves the demand, the important is the subject uses and our position towards it so they can generate a work

Association between education in EOL care and variability in EOL practice: a survey of ICU physicians

This study investigated the association between physician education in EOL and variability in EOL practice, as well as the differences between beliefs and practices regarding EOL in the ICU. Physicians from 11 ICUs at a university hospital completed a survey presenting a patient in a vegetative state with no family or advance directives. Questions addressed approaches to EOL care, as well physicians' personal, professional and EOL educational characteristics. The response rate was 89%, with 105 questionnaires analyzed. Mean age was 38 +/- A 8 years, with a mean of 14 +/- A 7 years since graduation. Physicians who did not apply do-not-resuscitate (DNR) orders were less likely to have attended EOL classes than those who applied written DNR orders [0/7 vs. 31/47, OR = 0.549 (0.356-0.848), P = 0.001]. Physicians who involved nurses in the decision-making process were more likely to be ICU specialists [17/22 vs. 46/83, OR = 4.1959 (1.271-13.845), P = 0.013] than physicians who made such decisions among themselves or referred to ethical or judicial committees. Physicians who would apply "full code" had less often read about EOL [3/22 vs. 11/20, OR = 0.0939 (0.012-0.710), P = 0.012] and had less interest in discussing EOL [17/22 vs. 20/20, OR = 0.210 (0.122-0.361), P < 0.001], than physicians who would withdraw life-sustaining therapies. Forty-four percent of respondents would not do what they believed was best for their patient, with 98% of them believing a less aggressive attitude preferable. Legal concerns were the leading cause for this dichotomy. Physician education about EOL is associated with variability in EOL decisions in the ICU. Moreover, actual practice may differ from what physicians believe is best for the patient.

Attitudes toward end-of-life decision making in South Texas

Advance care planning has the potential to create positive outcomes in the realm of end-of-life health care. The completion of advance directives and living wills are vital in equipping patients with autonomy and ensuring that their end-of-life wishes are respected. However, there remains a lack of knowledge and low completion rates of advance directives despite their possible improvements and ramifications on health care at the end of life. This study seeks to determine the knowledge of and attitudes towards end-of-life decision-making in South Texas. The study is designed as a cross-sectional, exploratory survey using a descriptive survey instrument to query 71 subjects in South Texas. The setting for the study includes three distinct groups, two in San Antonio, Texas and one in Brownsville, Texas. Unique differences in demographics between the three groups, such as variability in age, ethnicity, language and religious affiliation allowed for preliminary associations to be concluded in describing the results of the survey instrument. Ultimately, this study describes the attitudes and perceptions of advance care planning in South Texas and reveals the need for further education and awareness of the topic, perhaps indicating the need for a public health initiative in this regard.^

Strange bedfellows: The ethics and politics of medical futility in Texas

Background: Futile medical treatments are interventions that are not associated with a benefit to the patient. The definition and concept of medical futility are controversial. The Texas Advance Directives Act (TADA) was passed in 1999 to address medically inappropriate interventions by allowing providers to withdraw inappropriate interventions against a surrogate decision maker's wishes following a review, attempt to transfer the patient, and 10-day waiting period. The original legislation was a negotiated compromise by players across the political spectrum. However, in recent years there has been increasing controversy regarding TADA and attempts to alter its applicability in Texas. ^ Purpose: The purpose of this project was to apply Paul Sabatier's advocacy coalition framework (ACF) to gain understanding into the historical, ethical, and political basis of the initial compromise, and determine the sources of conflict that have led to increased opposition to TADA. ^ Methods: Using the ACF model, key actors within the medical futility policy debate in Texas were aggregated into coalitions based on shared beliefs. A narrative summary based analysis identified the core elements of the policy subsystem, as well as the constraints and resources of the subsystem actors. Externalities that promoted adjustments to coalition beliefs and tactics used by coalition participants were analyzed. Data sources included review of the published literature regarding medical futility, as well as analysis of published newspaper accounts and editorials regarding the medical futility issue in Texas, legislative testimony, and review of weblogs and online commentaries dealing with the issue. ^ Results: Primary coalition participants in developing compromise legislation in 1999 were the Providers and Vitalists, with Autonomists gaining a prominent role starting in 2006. Internal factors associated with the breakdown of consensus included changes to the makeup of the governing coalition and changes in individual case information available to the Vitalist coalition. Externalities related to the intertwining of the Sun Hudson case and the Terri Schiavo case generated negative publicity for the TADA from progressive and conservative viewpoints. Dissemination of information in various venues regarding contentious cases was associated with more polarization of viewpoints, and realignment of coalition alliances. ^ Conclusions: The ACF provided an outline for the initial compromise over the creation of the Texas Advance Directives Act as well as the eventual loss of consensus. The debate between the Provider, Vitalist, and Autonomist coalitions has been affected by internal policy evolution, changes in the governing coalition, and important externalities. The debate over medical futility in Texas has had much broader implications in the dispute over Health Care Reform.^

Intensive care unit utilization among patients with cancer at the end of life

Over the last 2 decades, survival rates in critically ill cancer patients have improved. Despite the increase in survival, the intensive care unit (ICU) continues to be a location where end-of-life care takes place. More than 20% of deaths in the United States occur after admission to an ICU, and as baby boomers reach the seventh and eighth decades of their lives, the volume of patients in the ICU is predicted to rise. The aim of this study was to evaluate intensive care unit utilization among patients with cancer who were at the end of life. End of life was defined using decedent and high-risk cohort study designs. The decedent study evaluated characteristics and ICU utilization during the terminal hospital stay among patients who died at The University of Texas MD Anderson Cancer Center during 2003-2007. The high-risk cohort study evaluated characteristics and ICU utilization during the index hospital stay among patients admitted to MD Anderson during 2003-2007 with a high risk of in-hospital mortality. Factors associated with higher ICU utilization in the decedent study included non-local residence, hematologic and non-metastatic solid tumor malignancies, malignancy diagnosed within 2 months, and elective admission to surgical or pediatric services. Having a palliative care consultation on admission was associated with dying in the hospital without ICU services. In the cohort of patients with high risk of in-hospital mortality, patients who went to the ICU were more likely to be younger, male, with newly diagnosed non-metastatic solid tumor or hematologic malignancy, and admitted from the emergency center to one of the surgical services. A palliative care consultation on admission was associated with a decreased likelihood of having an ICU stay. There were no differences in ethnicity, marital status, comorbidities, or insurance status between patients who did and did not utilize ICU services. Inpatient mortality probability models developed for the general population are inadequate in predicting in-hospital mortality for patients with cancer. The following characteristics that differed between the decedent study and high-risk cohort study can be considered in future research to predict risk of in-hospital mortality for patients with cancer: ethnicity, type and stage of malignancy, time since diagnosis, and having advance directives. Identifying those at risk can precipitate discussions in advance to ensure care remains appropriate and in accordance with the wishes of the patient and family.^

End-of-life decision making in Europe and Australia - A physician survey

Background: The frequencies with which physicians make different medical end-of-life decisions (ELDs) may differ between countries, but comparison between countries has been difficult owing to the use of dissimilar research methods. Methods: A written questionnaire was sent to a random sample of physicians from 9 specialties in 6 European countries and Australia to investigate possible differences in the frequencies of physicians' willingness to perform ELDs and to identify predicting factors. Response rates ranged from 39% to 68% (N= 10 139). Using hypothetical cases, physicians were asked whether they would ( probably) make each of 4 ELDs. Results: In all the countries, 75% to 99% of physicians would withhold chemotherapy or intensify symptom treatment at the request of a patient with terminal cancer. In most cases, more than half of all physicians would also be willing to deeply sedate such a patient until death. However, there was generally less willingness to administer drugs with the explicit intention of hastening death at the request of the patient. The most important predictor of ELDs was a request from a patient with decisional capacity (odds ratio, 2.1-140.0). Shorter patient life expectancy and uncontrollable pain were weaker predictors but were more stable across countries and across the various ELDs (odds ratios, 1.1-2.4 and 0.9-2.4, respectively). Conclusion: Cultural and legal factors seem to influence the frequencies of different ELDs and the strength of their determinants across countries, but they do not change the essence of decision making.

LATERAL FLOW ASSAY FOR CRYPTOCOCCAL ANTIGEN: AN IMPORTANT ADVANCE TO IMPROVE THE CONTINUUM OF HIV CARE AND REDUCE CRYPTOCOCCAL MENINGITIS-RELATED MORTALITY

SUMMARYAIDS-related cryptococcal meningitis continues to cause a substantial burden of death in low and middle income countries. The diagnostic use for detection of cryptococcal capsular polysaccharide antigen (CrAg) in serum and cerebrospinal fluid by latex agglutination test (CrAg-latex) or enzyme-linked immunoassay (EIA) has been available for over decades. Better diagnostics in asymptomatic and symptomatic phases of cryptococcosis are key components to reduce mortality. Recently, the cryptococcal antigen lateral flow assay (CrAg LFA) was included in the armamentarium for diagnosis. Unlike the other tests, the CrAg LFA is a dipstick immunochromatographic assay, in a format similar to the home pregnancy test, and requires little or no lab infrastructure. This test meets all of the World Health Organization ASSURED criteria (Affordable, Sensitive, Specific, User friendly, Rapid/robust, Equipment-free, and Delivered). CrAg LFA in serum, plasma, whole blood, or cerebrospinal fluid is useful for the diagnosis of disease caused by Cryptococcusspecies. The CrAg LFA has better analytical sensitivity for C. gattii than CrAg-latex or EIA. Prevention of cryptococcal disease is new application of CrAg LFA via screening of blood for subclinical infection in asymptomatic HIV-infected persons with CD4 counts < 100 cells/mL who are not receiving effective antiretroviral therapy. CrAg screening of leftover plasma specimens after CD4 testing can identify persons with asymptomatic infection who urgently require pre-emptive fluconazole, who will otherwise progress to symptomatic infection and/or die.

Photographic art and dealing with death

Recently, we were faced with a request from a student photographer who wanted to take pictures of bodies donated to our institute and used for dissection courses for medical students or for scientific purposes. Students are expressly forbidden to take pictures in the dissection hall; however, we allowed this student photographer to do her diploma work in our institute. The reason why she was proposing such a topic was that her brother died young and her parents donated his body to science. To overcome this loss of a loved one, she wanted to know what happens to the donated bodies. She followed the procedure of embalming and different dissections that took place during the summer semester and she took pictures throughout. The outcome of this work was a very nice photographic document, called 'dissection', a book with many pictures but no figure legends. The image document shows the different steps in the preparation and preservation of bodies and the work of an anatomist in the dissection hall. As we impose rules on our students, we had also to give directives in the use of the photographs taken, especially for a photographer who will use the most prominent pictures for exhibitions, i.e. that the pictures do not show names or are used for publication on the internet, or show identification numbers of cadavers, or give indication ofn the institution and are relatively anonymous. This story tells how one can deal with death and at the same time advance one's personal career. The author represents the Swiss Anatomical Society SGAHE and is supported by the Swiss Academy of Science, ScNat.