Factors affecting the successful implementation and sustainability of the Liverpool Care Pathway for dying patients – a realist evaluation

Objectives: The Liverpool Care Pathway for the dying patient (LCP) was designed to improve end-of-life care in generalist health care settings. Controversy has led to its withdrawal in some jurisdictions. The main objective of this research was to identify the influences that facilitated or hindered successful LCP implementation.

Method: An organisational case study using realist evaluation in one health and social care trust in Northern Ireland. Two rounds of semi-structured interviews were conducted with two policy makers and twenty two participants with experience and/or involvement in management of the LCP during 2011 and 2012.

Results: Key resource inputs included facilitation with a view to maintaining LCP ‘visibility’, reducing anxiety among nurses and increasing their confidence regarding the delivery of end-of-life care; and nurse and medical education designed to increase professional self-efficacy and reduce misuse and misunderstanding of the LCP. Key enabling contexts were consistent senior management support; ongoing education and training tailored to the needs of each professional group; and an organisational cultural change in the hospital setting that encompassed end-of-life care.

Conclusion: There is a need to appreciate the organizationally complex nature of intervening to improve end-of-life care. Successful implementation of evidence-based interventions for end-of-life care requires commitment to planning, training and ongoing review that takes account of different perspectives, institutional hierarchies and relationships and the educational needs of professional disciplines. There is a need also to recognise that medical consultants require particular support in their role as gatekeepers and as a lead communication channel with patients and their relatives.

An Appraisal of End-of-Life Care in Persons with Chronic Kidney Disease Dying in Hospital Wards

AIM: To review end-of-life care provided by renal healthcare professionals to hospital in-patients with chronic kidney disease, and their carers, over a 12-month period in Northern Ireland.

METHODS: Retrospective review of 100 patients.

RESULTS: Mean age at death was 72 years (19-95) and 56% were male. Eighty three percent of patients had a 'Not For Attempted Resuscitation' order during their last admission and this was implemented in 42%. Less than 20% of all patients died in a hospital ward. No patients had an advanced care plan, although 42% had commenced the Liverpool Care Pathway for the Dying Patient. Patients suffered excessive end-of-life symptoms. In addition, there was limited documentation of carer involvement and carer needs were not formally assessed.

CONCLUSION: End-of-life care for patients with advanced chronic renal disease can be enhanced. There is significant variation in the recording of discussions regarding impending death and little preparation. There is poor recording of the patients' wishes regarding death. Those with declining functional status, including those frequently admitted to hospital require holistic assessment regarding end-of-life needs. More effective communication between the patient, family and multi-professional team is required for patients who are dying and those caring for them.

The Art of Dying

Invited annual international lecture

Palliative Care: culture, caring and dying

Invited presentation

St. Catharines documents including mortgages, wills and declarations, 1871-1914 (not inclusive)

Most of these documents refer to a tract of land located on the intersection of King and Court Streets (part of the Lawrie plan) and Carter properties in St. Catharines Ontario. The Security Loan and Savings Company of St. Catharines existed between 1870 and 1906. Thomas Rodman Merritt was the president.

Dying for the vote : how ordinary people won the right to vote.

Estudia los movimientos sociales para conquistar y extender el derecho al voto entre todos los hombres y mujeres, denominados cartismo y sufragistas. Cumple con los requisitos del currículo nacional inglés para la etapa de 3 de secundaria (key stage 3). Este texto esta preparado para el Schools History Project creado en 1972 para mejorar el estudio de la historia entre estudiantes de trece a dieciséis años. Reconsidera las formas en que la historia contribuye a las necesidades educativas de los jóvenes, y por ello idea nuevos objetivos, nuevos criterios para la planificación y desarrollo del curso, así como de nuevos materiales de apoyo. Requiere nuevos criterios de evaluación y, por tanto nuevos exámenes y, adquirió mayor expansión con la introducción del General Certificate of Secondary Education (GCSE) en 1987.

Can we predict when “dying” will be difficult?: Progressive achievements in L2 English

A large body of research has focused on the observation that second language (L2) learners are limited in their production of temporal and aspectual forms. For example, in L2 English, it has been shown learners use progressive marking with activity verbs and only rarely extend the form to telic verb phrases such as accomplishments or achievements (Bardovi-Harlig and Reynolds, 1995; Bardovi-Harlig, 2000; Robison, 1995). Shirai and Andersen (1995) proposed that activities represent the prototype for the category of progressive aspect and learners generally acquire the prototype first. However, very little research has focused explicitly on advanced learners to see if they eventually extend beyond the prototype. In addition, properties of the native language have not systematically been taken into account. Achievements such as "die" are especially interesting in that they interact differently with markers of progressive aspect across languages. The present study investigated the acquisition of progressive achievements in English by native speakers of Chinese and Korean in order to examine whether there is evidence of universal difficulty, as would be predicted by the prototype account, or whether similarity between the L1 and L2 (as in the case of English and Korean) can facilitate acquisition, as would be predicted by transfer. Our results suggest that the properties of the native language play an important role, supporting the transfer account. However, neither L1 group performs at the level of native speakers. We argue that the acquisition of aspect is influenced by both the properties of the native language and the semantic and pragmatic complexity of the target computation.

The absent body: representations of dying early modern women in a selection of seventeenth-century diaries

This article seeks to explore the absence of the body in the depiction of dying women in a selection of seventeenth-century diaries. It considers the cultural forces that made this absence inevitable, and the means by which the physical body was replaced in death by a spiritual presence. The elevation of a dying woman from physical carer to spiritual nurturer in the days before death ensured that gender codes were not broken. The centrality of the body of the dying woman, within a female circle of care and support, was paradoxically juxtaposed with an effacement of the body in descriptions of a good death. In death, a woman might achieve the stillness, silence and compliance so essential to perfect early modern womanhood, and retrospective diary entries can achieve this ideal by replacing the body with images that deflect from the essential physicality of the woman.

Punk, Politics and British (fan)zines, 1974-84:'While the world was dying, did you wonder why?

This article recovers and contextualizes the politics of British punk fanzines produced in the late 1970s and early 1980s. It argues that fanzines – and youth cultures more generally – provide a contested cultural space for young people to express their ideas, opinions and anxieties. Simultaneously, it maintains that punk fanzines offer the historian a portal into a period of significant socio-economic, political and cultural change. As well as presenting alternative cultural narratives to the formulaic accounts of punk and popular music now common in the mainstream media, fanzines allow us a glimpse of the often radical ideas held by a youthful milieu rarely given expression in the political arena.

Living to die and dying to live: the survival strategy behind leaf senescence

Senescence represents the final developmental act of the leaf, during which the leaf cell is dismantled in a coordinated manner to remobilize nutrients and to secure reproductive success. The process of senescence provides the plant with phenotypic plasticity to help it adapt to adverse environmental conditions. Here, we provide a comprehensive overview of the factors and mechanisms that control the onset of senescence. We explain how the competence to senesce is established during leaf development, as depicted by the senescence window model. We also discuss the mechanisms by which phytohormones and environmental stresses control senescence, as well as the impact of source-sink relationships on plant yield and stress tolerance. In addition, we discuss the role of senescence as a strategy for stress adaptation and how crop production and food quality could benefit from engineering or breeding crops with altered onset of senescence.

Dying young: a palaeopathological analysis of child health in Roman Britain

Children represent the most vulnerable members of society, and as such provide valuable insight into past lifeways. Adverse environmental conditions translate more readily into the osteological record of children, making them primary evidence for the investigation of ill-health in the past. To date, most information on growing up in Roman Britain has been based on the Classical literature, or discussed in palaeopathological studies with a regional focus, e.g. Dorset or Durnovaria. Thus, the lifestyles and everyday realities of children throughout Britannia remained largely unknown. This study sets out to fill this gap by providing the first large scale analysis of Romano-British children from town and country. The palaeopathological analysis of 1643 non-adult (0-17 years) skeletons, compiled from the literature (N=690) and primary osteological analysis (N=953), from 27 urban and rural settlements has highlighted diverse patterns in non-adult mortality and morbidity. The distribution of ages-at-death suggest that older children and adolescents migrated from country to town, possibly for commencing their working lives. True prevalence rates suggest that caries (1.8%) and enamel hypoplasia (11.4%) were more common in children from major urban towns, whereas children in the countryside displayed higher frequencies of scurvy (6.9%), cribra orbitalia (27.7%), porotic hyperostosis (6.2%) and endocranial lesions (10.9%). Social inequality in late Roman Britain may have been the driving force behind these urban-rural dichotomies. The results may point to exploitation of the peasantry on the one hand, and higher status of the urban population as a more ‘Romanised’ group on the other. Comparison with Iron Age and post-medieval non-adults also demonstrated a decline in health in the Roman period, with some levels of ill-health, particularly in the rural children, similar to those from post-medieval London. This research provides the most comprehensive study of non-adult morbidity and mortality in Roman Britain to date. It has provided new insights into Romano-British lifeways and presents suggestions for further work.

The dying child in seventeenth-century England

This article offers a historical perspective on an important and controversial issue within the emerging field of paediatric palliative care: the question of whether to talk to terminally ill children about their prognosis.