End-of-life care pathways for improving outcomes in caring for the dying

This is an updated version of a Cochrane review published in Issue 11, 2013 in the Cochrane Library. In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans that detail essential steps in caring for patients with specific clinical problems. In particular, care pathways for the dying have been developed as a model to improve care of patients who are in the last days of life. The care pathways were designed with an aim of ensuring that the most appropriate management occurs at the most appropriate time, and that it is provided by the most appropriate health professional. Since the last update, there have been sustained concerns about the safety of implementing end-of-life care pathways, particularly in the United Kingdom (UK). Therefore, there is a significant need for clinicians and policy makers to be informed about the effects of end-of-life care pathways via a systematic review.

An Investigation of Environmental Conditions Experienced During the Life of High Value Wood Components and Products

Australian forest industries have a long history of export trade of a wide range of products from woodchips(for paper manufacturing), sandalwood (essential oils, carving and incense) to high value musical instruments, flooring and outdoor furniture. For the high value group, fluctuating environmental conditions brought on by changes in mperature and relative humidity, can lead to performance problems due to consequential swelling, shrinkage and/or distortion of the wood elements. A survey determined the types of value-added products exported, including species and dimensions packaging used and export markets. Data loggers were installed with shipments to monitor temperature and relative humidity conditions. These data were converted to timber equilibrium moisture content values to provide an indication of the environment that the wood elements would be acclimatising to. The results of the initial survey indicated that primary high value wood export products included guitars, flooring, decking and outdoor furniture. The destination markets were mainly located in the northern hemisphere, particularly the United States of America, China, Hong Kong, Europe including the United Kingdom), Japan, Korea and the Middle East. Other regions importing Australian-made wooden articles were south-east Asia, New Zealand and South Africa. Different timber species have differing rates of swelling and shrinkage, so the types of timber were also recorded during the survey. Results from this work determined that the major species were ash-type eucalypts from south-eastern Australia (commonly referred to in the market as Tasmanian oak), jarrah from Western Australia, spotted gum, hoop pine, white cypress, black butt, brush box and Sydney blue gum from Queensland and New South Wales. The environmental conditions data indicated that microclimates in shipping containers can fluctuate extensively during shipping. Conditions at the time of manufacturing were usually between 10 and 12% equilibrium moisture content, however conditions during shipping could range from 5 (very dry) to 20% (very humid). The packaging systems incorporated were reported to be efficient at protecting the wooden articles from damage during transit. The research highlighted the potential risk for wood components to ‘move’ in response to periods of drier or more humid conditions than those at the time of manufacturing, and the importance of engineering a packaging system that can account for the environmental conditions experienced in shipping containers. Examples of potential dimensional changes in wooden components were calculated based on published unit shrinkage data for key species and the climatic data returned from the logging equipment. The information highlighted the importance of good design to account for possible timber movement during shipping. A timber movement calculator was developed to allow designers to input component species, dimensions, site of manufacture and destination, to see validate their product design. This calculator forms part of the free interactive website www.timbers.com.au.

Transitioning from university to the workplace: Stakeholder perceptions of academic and professional writing demands

This study provides a detailed insight into the changing writing demands from the last year of university study to the first year in the workforce of engineering and accounting professionals. The study relates these to the demands of the writing component of IELTS, which is increasingly used for exit testing. The number of international and local students whose first language is not English and who are studying in English-medium universities has increased significantly in the past decade. Many of these students aim to start working in the country they studied in; however, some employers have suggested that graduates seeking employment have insufficient language skills. This study provides a detailed insight into the changing writing demands from the last year of university study to the first year in the workforce of engineering and accounting professionals (our two case study professions). It relates these to the demands of the writing component of IELTS, which is increasingly used for exit or professional entry testing, although not expressly designed for this purpose. Data include interviews with final year students, lecturers, employers and new graduates in their first few years in the workforce, as well as professional board members. Employers also reviewed both final year assignments, as well as IELTS writing samples at different levels. Most stakeholders agreed that graduates entering the workforce are underprepared for the writing demands in their professions. When compared with the university writing tasks, the workplace writing expected of new graduates was perceived as different in terms of genre, the tailoring of a text for a specific audience, and processes of review and editing involved. Stakeholders expressed a range of views on the suitability of the use of academic proficiency tests (such as IELTS) as university exit tests and for entry into the professions. With regard to IELTS, while some saw the relevance of the two writing tasks, particularly in relation to academic writing, others questioned the extent to which two timed tasks representing limited genres could elicit a representative sample of the professional writing required, particularly in the context of engineering. The findings are discussed in relation to different test purposes, the intersection between academic and specific purpose testing and the role of domain experts in test validation.

Doctors’ perspectives on law and life-sustaining treatment: Survey design and recruitment strategies for a challenging cohort

- Background Palliative medicine and other specialists play significant legal roles in decisions to withhold and withdraw life-sustaining treatment at the end of life. Yet little is known about their knowledge of or attitudes to the law, and the role they think it should play in medical practice. Consideration of doctors’ views is critical to optimizing patient outcomes at the end of life. However, doctors are difficult to engage as participants in empirical research, presenting challenges for researchers seeking to understand doctors’ experiences and perspectives. - Aims To determine how to engage doctors involved in end-of-life care in empirical research about knowledge of the law and the role it plays in medical practice at the end of life. - Methods Postal survey of all specialists in palliative medicine, emergency medicine, geriatric medicine, intensive care, medical oncology, renal medicine, and respiratory medicine in three Australian states: New South Wales, Victoria, and Queensland. The survey was sent in hard copy with two reminders and a follow up reminder letter was also sent to the directors of hospital emergency departments. Awareness was further promoted through engagement with the relevant medical colleges and publications in professional journals; various incentives to respond were also used. The key measure is the response rate of doctors to the survey. - Results Thirty-two percent of doctors in the main study completed their survey with response rate by specialty ranging from 52% (palliative care) to 24% (medical oncology). This overall response rate was twice that of the reweighted pilot study (16%). - Conclusions Doctors remain a difficult cohort to engage in survey research but strategic recruitment efforts can be effective in increasing response rate. Collaboration with doctors and their professional bodies in both the development of the survey instrument and recruitment of participants is essential.

Ystävä sä lapsien : Lasten virret ja hengelliset laulut suomenkielisissä kokoelmissa 1824-1938 ja niiden vaikutus vuoden 1938 virsikirjaan

Ystävä sä lapsien. Collections of Finnish language children s hymns and spiritual songs from 1824─1938 and their influence on the Hymnal 1938. The Hymnal has been the common song book of Lutheran parishes since the 1500s. In the beginning, the congregations sang the hymns from memory led by the choir or the church musician. The fundamentals of Christian faith are taught through the hymns, both in church and in family devotions. The Hymnal was the only song book of the church in Finland until the end of the 1800s. This study attempts to clarify when and by who were spiritual songs and hymns for children written in Finland. Research materials used were all the books I could find (approximately 200), whose headings were for pupils and young children in the home and school circles. The method of study is historical and analytical. In the first chapter, it is explained that children s literature in Finland differentiated from other literature at the end of the 1700s. Eric Juvelius published a small prayer book in 1781 with the prayer Gud, som hafver barnen kär / Jumala joka Lapsia rakasta. From that, after many Finnish translations, the first verse of the hymn Ystävä sä lapsien took shape. The second chapter considers singing instruction in the folk school from the beginning of the 1860s. Textbooks, including songbooks, were produced for the pupils. Some of the first pioneers in producing these materials were the teachers P.J. Hannikainen, Sofie Lithenius, Mikael Nyberg, Anton Rikström and Aksel Törnudd, as well as Hilja Haahti, Immi Hellén and Alli Nissinen, who were all teachers gifted in writing poetry. Several new spiritual songs appeared in the folk school songbooks. Hymns were sung often, especially in connection with church year celebrations. Children s songs in Christian education are discussed in the third chapter. The Lutheran Evangelical Association of Finland recognized children already in its early song collections. The illustrative teaching methods in the folk school influenced the Sunday school activities and especially the Sunday school hymns. Hymns introduced as exclusively for children and pupils which appear in the Hymnal from 1886 and the supplement to the 1923 Hymnal are explored in the fourth and fifth chapters. The study shows that the renewal of church life at the beginning of the 1900s also resulted in an increase of the number of spiritual songs for children. This is also seen in the diverse choice of songs in the supplementary materials from 1923. The final chapter deals with the School and Childhood section of the 1938 Hymnal. The Hymnal committee did not think that the already well known folk school and Sunday school songs received enough attention in the Hymnal. Those songs were, among others, Kautta tyynen, vienon yön, Oi, katsopa lintua oksalla puun, Olen Luojani pikku varpunen, Rakas Isä taivahan ja Tuolla keinuu pieni pursi. Heikki Klemetti, Ilmari Krohn, Armas Maasalo and Aarni Voipio influenced the opinion that the spiritual songs still were not suitable to be sung in church. Hymns for children and pupils were brought into the same line as the entire Hymnal. The same hymn tunes, which were mainly old ones, were used as common settings for numerous hymn texts. No special type of melody emerged for the children s hymns. It was still notable that hymns for children and pupils were collected at all. In addition, the Hymnal committee marked those verses suggested for singing in both the folk school and Sunday school with an asterisk (*) throughout the entire Hymnal.

Pyhä Teresa ja keskiajan mystiikan teoriat

In my dissertation I have studied St Teresa (1515-1582) in the light of medieval mystical theories. I have two main levels in my research: historical and theological. On the historical level I study St Teresa s personal history in the context of her family and the Spanish society. On the theological level I study both St Teresa s mysticism and her religious experience in the light of medieval mysticism. St Teresa wrote a book called Life , which is her narrative autobiography and story about her mystical spiritual formation. She reflected herself through biblical texts interpreting them in the course of the biblical hermeneutics like allegory, typology, tropology and anagogy. In addition to that she read others life stories from her period of time, but reflected herself only slightly through the sociological point of view. She used irony as a means to gain acceptance to her authority and motive to write. Her position has been described as a double bind because of writing at the request of educated men and to the non-educated women as she herself was uneducated. She used irony as a means to achieve valuation to women, to gain negative attributes connected to them and to gain authority to teach them mystical spirituality, the Bible and prayer. In this ironic tendency she was a feminist writer. In order to understand medieval mysticism I have written in the first chapter a review of the main trends in medieval mysticism in connection with the classical emotional theories. Two medieval mystical theories show an important role in St Teresa s mysticism. One is love mysticism and the other is the three partite way of mysticism (purification, illumination and union). The classic-philosophical emotional theories play a role in both patterns. The theory of love mysticism St Teresa interpreted in the traditional way stressing the spiritual meaning of love in connexion with God and neighbors. Love is an emotion, which is bound with other emotions, but all objects of love don t strengthen spiritual love. In the three partite way of mysticism purification means to find biblical values in life and to practice meditative self-knowledge theologically interpreted. In illumination human understanding has to be illuminated by God and united to mystical knowledge from God. St Teresa considered illumination a way to learn things. Illumination has also psychological aspects like recognition of many trials and pains, which come from life on earth. Theologically interpreted in illumination one should die to oneself, let oneself be transformed and renewed by God. I have also written a review of the modern philosophical discussion on personal identity where memory and mental experiences are important creators of personal identity. St Teresa bound medieval mystical teaching together with her personal religious experience. Her personal identity is by its character based on her narrative life story where mental experiences play important role. Previous researchers have labelled St Teresa as an ecstatic person whose experiences produced ecstatic phenomena to the mysticism. These phenomena combined with visions have in one respect made of her a person who has brought physical and visionary tendencies to theology. In spite of that she also represents a modern tendency trying to give words to experiences, which at first seem to be exceptional and extreme and which are easily interpreted as one-sided either physical or sexual or unsaid. In other respect I have stressed the personality of St Teresa that was represented as both strong and weak. The strong personality for her is demonstrated by religious faith and in its practice. The weak personality was for her a natural personal identity. St Teresa saw a unifying aspect in almost all. Firstly, her mysticism was aimed towards union with God and secondly, the unifying aspects and common rules in human relations in community life were central. Union with God is based on the fact that in a soul God is living in its centre, where God is present in the Trinitarian way. The picture of God in ourselves is a mirror but to get to know God better is to recognize his/her presence in us. When the soul recognizes itself as a dwelling place of God, it knows itself as God knows him/herself. There is equality between God and the soul. To be a Christian means to participate in God in his Trinitarian being. The participation to God is a process of divinization that puts a person into transformation, change and renewal. The unitive aspect concludes also knowledge of opposites between experience of community and solitude as well as community and separateness. As a founder of monasteries St Teresa practiced theology of poverty. She renewed the monastic life founding a rule called discalced that stressed ascetic tendencies. Supporters of her work were after the difficulties in the beginning both society and churchly leaders. She wrote about the monasteries including in her description at times seriousness at times humor and irony. Her stories are said to be picaresque histories that contain stories of ordinary laymen and many unexpected occasions. She exercised a kind of Bakhtinian dialogue in her letters. St Teresa stressed the virtues like sacrifice, determination and courage in the monastic life. Most of what she taught of virtues is based on biblical spirituality but there are also psychological tendencies in her writings. The theological pedagogical advice is mixed with psychology, but she herself made no distinction between different aspects in her teaching. To understand St Teresa and her mysticism is to recognize that she mixes her personal religious experience and mysticism, which widens mysticism to religious experience in a new way, although this corresponds also the very definition of mysticism. St Teresa concentrated on mental-spiritual experiences and the aim of her mystical teaching was to produce a human mind well cured like a garden that has God as its gardener.

Elämää syövän kanssa : Narratiivinen tutkimus henkisen ja hengellisen tuen merkityksestä syöpää sairastavalle

Cancer diseases are considered to be relatively common among the Finnish population, every fourth Finn has been affected by cancer in their lifetime. Around 24,000 new cases of cancer are diagnosed each year in Finland. According to the estimations, about half of all diseased will recover. This research examines cancer patients experiences and needs for mental and spiritual support. This paper answers questions what kind of support cancer patients were given after the diagnosis and how did they felt about it. My research was conducted by thematic interviews (N=7) with cancer patients and letters (N=13). To analyze I used narrative holistic-content analysis and holistic analysis of form. Narrative holistic-content analysis consists of reading the material and writing down common points, themes and deflections. By using holistic analysis of form, I observed changes and turning points in one s story of life. Then I could graphically show the emotional changes in the cancer patients life. By rereading the material, examining and comparing it, I was able to build different categories. After defining these categories (Longing, Supported, Individualists, Believers) I reread the interviews in terms of which category it belonged to. I chose one story from each category to represent the whole group. This so-called central story was complemented by other stories from the same group. Analysis enables to define a type story from each group, they were examples of the various ways of reacting about support that they were giving or not having the support that were needed. The stories reflect the participants feelings about support they were given but some cases feeling rejected.

Stalinismin lyhyt kurssi : Suomalaiset Moskovan Lenin-koulussa 1926-1938

This study of the Finns at the International Lenin School (ILS) reflects history of the Soviet Union during Stalin's era, history of the Communist International (Comintern) as well as history of Finnish communism. The life span of the ILS (1926-1938) matches up with creating and establishing the power structures of Stalinism. Both the ILS and Finnish Communism in the USSR became casualties of the Great Terror (1937-1938). After the WW2, however, the Soviet education was appreciated inside the Communist Party of Finland (CPF). If Finland would have become People's Democracy, the former ILS students would have composed the inner circle of the new "democratic" government. The Finnish teachers of the ILS were leaders of the CPF that was headquartered in Moscow. At the ILS studied in total 141 Finnish communists. The purpose of the ILS was to educate the communist parties' leading stratum of functionaries. They were supposed to internalize current values, methods and discipline of the Bolsheviks. This study evaluates the effects of the total school experience on the Finns that often ended in another total institution in Finland: prison. The curricula of the ILS consisted of theory of Marxism-Leninism, party history, political economics and themes of campaigns of Stalinism. The ILS year included participation in Bolshevik party life and practical work. During summer excursions (praktikas) the students could acquaint themselves with building of socialism in the Soviet Republics. At the ILS, intention to ideological moulding was not hidden. The students were supposed to adopt the Stalinist identity of the professional revolutionaries of the era. The ILS was saturated with ideology and propaganda. This study analyzes especially uses of history as vehicle of ideological standardisation and as instrument of power. Stalin contributed personally to shortcomings of history writing of the communist party. Later he supervised writing of the inclusive handbook of communism, "History of the All-Union Communist Party. Short Course". Special attention will be paid to the effects of Stalin's intervention at the ILS and inside the CPF. The life of the Finns at the ILS and outside the school is described at grass roots. The dividing line between personal and political is analyzed by charting emotional, intimate and bodily experiences of the Finns of the ILS. The fates of the ILS Finns after the studying or teaching period in Moscow are explored in detail. The protagonist among the teachers is Yrjö Sirola that was called "father of the CPF cadres". The Finnish ILS teachers and the formed students that had remained in the USSR were most severely hit by the Great Terror. The Soviet education had most importance in Finland of post WW2 period. The training at the ILS, however, did not contribute to revolution in Finland. The main heading of the study, "A Short Course of Stalinism", crystallises interpretation of the ILS as seat of learning of ideological unity of Stalinism. On the other hand, the title includes a statement of incompleteness of the Stalinist education if the schooling at the ILS had remained in one year.

Measuring the impact of burn scarring on health-related quality of life: Development and preliminary content validation of the Brisbane Burn Scar Impact Profile (BBSIP) for children and adults

INTRODUCTION No burn-scar specific, health-related quality of life (HRQOL) measure exists. This study aimed to develop a patient-reported, evaluative HRQOL measure to assess the impact of burn scarring in children and adults. METHOD Semi-structured interviews, content validation surveys, and cognitive interviews were used to develop and test content validity of a new measure - the Brisbane Burn Scar Impact Profile (BBSIP). RESULTS Participants comprised Australian adults (n=23) and children (n=19) with burn scarring; caregivers of children with burn scarring (n=28); and international scar management experts (n=14). Items distinct from other burn scar measures emerged. Four versions of the BBSIP were developed; one for children aged 8-18 years, one for adults, one for caregivers (as proxies for children aged less than 8-years), and one for caregivers of children aged 8-18 years. Preliminary content validity of the BBSIP was supported. Final items covered physical and sensory symptoms; emotional reactions; impact on social functioning and daily activities; impact of treatment; and environmental factors. CONCLUSION The BBSIP was developed to assess burn-scar specific HRQOL and will be available at http://www.coolburns.com.au under a creative commons license. Further testing is underway.

Climate forcing on avian life history

In the 21st century, human-induced global climate change has been highlighted as one of the most serious threats to ecosystems worldwide. According to global climate scenarios, the mean temperature in Finland is expected to increase by 1.8 4.0°C by the end of the century. The regional and seasonal change in temperature has predicted to be spatially and temporally asymmetric, where the High-Arctic and Antarctic areas and winter and spring seasons have been projected to face the highest temperature increase. To understand how species respond to the ongoing climate change, we need to study how climate affects species in different phases of their life cycle. The impact of climate on breeding and migration of eight large-sized bird species was studied in this thesis, taking food availability into account. The findings show that climatic variables have considerable impact on the life-history traits of large-sized birds in northern Europe. The magnitude of climatic effects on migration and breeding was comparable with that of food supply, conventionally regarded as the main factor affecting these life-history traits. Based on the results of this thesis and the current climate scenarios, the following not mutually exclusive responses are possible in the near future. Firstly, asymmetric climate change may result in a mistiming of breeding because mild winters and early spring may lead to earlier breeding, whereas offspring are hatching into colder conditions which elevate mortality. Secondly, climate induced responses can differ between species with different breeding tactics (income vs. capital breeding), so that especially capital breeders can gain advantage on global warming as they can sustain higher energy resources. Thirdly, increasing precipitation has the potential to reduce the breeding success of many species by exposing nestlings to more severe post-hatching conditions and hampering the hunting conditions of parents. Fourthly, decreasing ice cover and earlier ice-break in the Baltic Sea will allow earlier spring migration in waterfowl. In eiders, this can potentially lead to more productive breeding. Fifthly, warming temperatures can favour parents preparing for breeding and increase nestling survival. Lastly, the climate-induced phenological changes in life history events will likely continue. Furthermore, interactions between climate and food resources can be complex and interact with each other. Eiders provide an illustrative example of this complexity, being caught in the crossfire between more benign ice conditions and lower salinity negatively affecting their prime food resource. The general conclusion is that climate is controlling not only the phenology of the species but also their reproductive output, thus affecting the entire population dynamics.

Driving whole-of-life efficiencies through BIM and procurement

Building Information Modelling (BIM) is a digital process that encompasses all aspects, disciplines and systems of built assets within a single virtual model. This allows stakeholders to collaborate more accurately and efficiently than with traditional processes. Case study 1 Design: New Generation Rollingstock Maintenance Centre, Queensland. Case Study 2 Construction: Perth Children's Hospital, Western Australia. Case Study 3 Asset Management: Sydney Opera House, New South Wales. This project sought to provide the built environment industry with a framework to measure and maximize benefits from implementing BIM across the life-cycle phases of a built asset.

Living on voles - plastic life of the Ural owl

Individuals face variable environmental conditions during their life. This may be due to migration, dispersion, environmental changes or, for example, annual variation in weather conditions. Genetic adaptation to a novel environment happens through natural selection. Phenotypic plasticity allows, however, a quick individual response to a new environment. Phenotypic plasticity may also be beneficial for individual if the environment is highly variable. For example, eggs are costly to produce. If the food conditions vary significantly between breeding seasons it is useful to be able to adjust the clutch and egg size according to the food abundance. In this thesis I use Ural owl vole system to study phenotypic plasticity and natural selection using a number of reproduction related traits. The Ural owl (Strix uralensis) is a long-lived and sedentary species. The reproduction and survival of the Ural owl, in fact their whole life, is tied to the dramatically fluctuating vole densities. Ural owls do not cause vole cycles but they have to adjust their behaviour to the rather predictable population fluctuations of these small mammals. Earlier work with this system has shown that Ural owl laying date and clutch size are plastic in relation to vole abundance. Further, individual laying date clutch size reaction norms have been shown to vary in the amount of plasticity. My work extends the knowledge of natural selection and phenotypic plasticity in traits related to reproduction. I show that egg size, timing of the onset of incubation and nest defense aggressiveness are plastic traits with fitness consequences for the Ural owl. Although egg size is in general thought to be a fixed characteristic of an individual, this highly heritable trait in the Ural owl is also remarkably plastic in relation to the changes in vole numbers, Ural owls are laying the largest eggs when their prey is most abundant. Timing of the onset of incubation is an individual-specific property and plastic in relation to clutch size. Timing of incubation is an important underlying cause for asynchronous hatching in birds. Asynchronous hatching is beneficial to offspring survival in Ural owl. Hence, timing of the onset of incubation may also be under natural selection. Ural owl females also adjust their nest defense aggressiveness according to the vole dynamics, being most aggressive in years when they produce the largest broods. Individual females show different levels of nest defense aggressiveness. Aggressiveness is positively correlated with the phenotypic plasticity of aggressiveness. As elevated nest defense aggressiveness is selected for, it may promote the plasticity of aggressive nest defense behaviour. All the studied traits are repeatable or heritable on individual level, and their expression is either directly or indirectly sensitive to changes in vole numbers. My work considers a number of important fitness-related traits showing phenotypic plasticity in all of them. Further, in two chapters I show that there is individual variation in the amount of plasticity exhibited. These findings on plasticity in reproduction related traits suggest that variable environments indeed promote plasticity.