The challenge to health professionals when carers resist truth telling at the end of life: a qualitative secondary analysis

Aims and objectives: To draw out the similar complexities faced by staff around
truth-telling in a children’s and adult population and to interrogate the dilemmas faced by staff when informal carers act to block truth-telling.

Background: Policy encourages normalisation of death, but carers may act to protect or prevent the patient from being told the truth. Little is known about the impact on staff.

Design: Secondary analysis of data using a supra-analysis design to identify commonality of experiences.

Methods: Secondary ‘supra-analysis’ was used to transcend the focus of two primary studies in the UK, which examined staff perspectives in a palliative children’s and a palliative adult setting, respectively. The analysis examined new theoretical questions relating to the commonality of issues independently derived in each primary study. Both primary studies used focus groups. Existing empirical data were analysed thematically and compared across the studies.

Results: Staff reported a hiding of the truth by carers and sustained use of activities aimed at prolonging life. Carers frequently ignored the advance of end of life, and divergence between staff and carer approaches to truth-telling challenged professionals. Not being truthful with patients had a deleterious effect on staff, causing anger and feelings of incompetence.

Conclusions: Both children’s and adult specialist palliative care staff found themselves caught in a dilemma, subject to policies that promoted openness in planning for death and informal carers who often prevented them from being truthful with patients about terminal prognosis. This dilemma had adverse psychological effects upon many staff.

Relevance to clinical practice: There remains a powerful death-denying culture in
many societies, and carers of dying patients may prevent staff from being truthful with their patients. The current situation is not ideal, and open discussion of this problem is the essential first step in finding a solution.

The rise of the digital citizen-stakeholder: rebalancing multistakeholder governance

The principle feature in the evolution of the internet has been its ever growing reach to include old and young, rich and poor. The internet’s ever encroaching presence has transported it from our desktop to our pocket and into our glasses. This is illustrated in the Internet Society Questionnaire on Multistakeholder Governance, which found the main factors affecting change in the Internet governance landscape were more users online from more countries and the influence of the internet over daily life. The omnipresence of the internet is self- perpetuating; its usefulness grows with every new user and every new piece of data uploaded. The advent of social media and the creation of a virtual presence for each of us, even when we are not physically present or ‘logged on’, means we are fast approaching the point where we are all connected, to everyone else, all the time. We have moved far beyond the point where governments can claim to represent our views which evolve constantly rather than being measured in electoral cycles.
The shift, which has seen citizens as creators of content rather than consumers of it, has undermined the centralist view of democracy and created an environment of wiki democracy or crowd sourced democracy. This is at the heart of what is generally known as Web 2.0, and widely considered to be a positive, democratising force. However, we argue, there are worrying elements here too. Government does not always deliver on the promise of the networked society as it involves citizens and others in the process of government. Also a number of key internet companies have emerged as powerful intermediaries harnessing the efforts of the many, and re- using and re-selling the products and data of content providers in the Web 2.0 environment. A discourse about openness and transparency has been offered as a democratising rationale but much of this masks an uneven relationship where the value of online activity flows not to the creators of content but to those who own the channels of communication and the metadata that they produce.
In this context the state is just one stakeholder in the mix of influencers and opinion formers impacting on our behaviours, and indeed our ideas of what is public. The question of what it means to create or own something, and how all these new relationships to be ordered and governed are subject to fundamental change. While government can often appear slow, unwieldy and even irrelevant in much of this context, there remains a need for some sort of political control to deal with the challenges that technology creates but cannot by itself control. In order for the internet to continue to evolve successfully both technically and socially it is critical that the multistakeholder nature of internet governance be understood and acknowledged, and perhaps to an extent, re- balanced. Stakeholders can no longer be classified in the broad headings of government, private sector and civil society, and their roles seen as some sort of benign and open co-production. Each user of the internet has a stake in its efficacy and each by their presence and participation is contributing to the experience, positive or negative of other users as well as to the commercial success or otherwise of various online service providers. However stakeholders have neither an equal role nor an equal share. The unequal relationship between the providers of content and those who simple package up and transmit that content - while harvesting the valuable data thus produced - needs to be addressed. Arguably this suggests a role for government that involves it moving beyond simply celebrating and facilitating the on- going technological revolution. This paper reviews the shifting landscape of stakeholders and their contribution to the efficacy of the internet. It will look to critically evaluate the primacy of the individual as the key stakeholder and their supposed developing empowerment within the ever growing sea of data. It also looks at the role of individuals in wider governance roles. Governments in a number of jurisdictions have sought to engage, consult or empower citizens through technology but in general these attempts have had little appeal. Citizens have been too busy engaging, consulting and empowering each other to pay much attention to what their governments are up to. George Orwell’s view of the future has not come to pass; in fact the internet has insured the opposite scenario has come to pass. There is no big brother but we are all looking over each other’s shoulder all the time, while at the same time a number of big corporations are capturing and selling all this collective endeavour back to us.

Pre-operative fasting for intravenous conscious sedation used in dental treatment: are conclusions based on relative risk management or evidence?

Intravenous sedation is a widely used pharmacological method of patient management commonly used in dental surgery for the treatment of anxious patients. Variety exists in fasting regimes between different centres offering dental sedation, with some advocating starvation in line with general anaesthesia protocols and others not enforcing starvation at all. The currently available guidelines on fasting protocols are ambiguous and open to interpretation partly because they are based on expert opinion rather than evidence-based research. This article reviews the available evidence on the subject of pre-operative fasting and discusses current guidelines.

Deglacial mesophotic reef demise on the Great Barrier Reef

Submerged reefs are important recorders of palaeo-environments and sea-level change, and provide a substrate for modern mesophotic (deep-water, light-dependent) coral communities. Mesophotic reefs are rarely, if ever, described from the fossil record and nothing is known of their long-term record on Great Barrier Reef (GBR). Sedimentological and palaeo-ecological analyses coupled with 67 14C AMS and U–Th radiometric dates from dredged coral, algae and bryozoan specimens, recovered from depths of 45 to 130 m, reveal two distinct generations of fossil mesophotic coral community development on the submerged shelf edge reefs of the GBR. They occurred from 13 to 10 ka and 8 ka to present. We identified eleven sedimentary facies representing both autochthonous (in situ) and allochthonous (detrital) genesis, and their palaeo-environmental settings have been interpreted based on their sedimentological characteristics, biological assemblages, and the distribution of similar modern biota within the dredges. Facies on the shelf edge represent deep sedimentary environments, primarily forereef slope and open platform settings in palaeo-water depths of 45–95 m. Two coral–algal assemblages and one non-coral encruster assemblage were identified: 1) Massive and tabular corals including Porites, Montipora and faviids associated with Lithophylloids and minor Mastophoroids, 2) platy and encrusting corals including Porites, Montipora and Pachyseris associated with melobesioids and Sporolithon, and 3) Melobesiods and Sporolithon with acervulinids (foraminifera) and bryozoans. Based on their modern occurrence on the GBR and Coral Sea and modern specimens collected in dredges, these are interpreted as representing palaeo-water depths of < 60 m, < 80–100 m and > 100 m respectively. The first mesophotic generation developed at modern depths of 85–130 m from 13 to 10.2 ka and exhibit a deepening succession of < 60 to > 100 m palaeo-water depth through time. The second generation developed at depths of 45–70 m on the shelf edge from 7.8 ka to present and exhibit stable environmental conditions through time. The apparent hiatus that interrupted the mesophotic coral communities coincided with the timing of modern reef initiation on the GBR as well as a wide-spread flux of siliciclastic sediments from the shelf to the basin. For the first time we have observed the response of mesophotic reef communities to millennial scale environmental perturbations, within the context of global sea-level rise and environmental changes.

Managing pain medications in long-term care: nurses' views

The purpose of this study was to explore nurses' perceptions of their current practices related to administering pain medications to long-term care (LTC) residents. A cross-sectional survey design was used, including both quantitative and open-ended questions. Data were collected from 165 nurses (59% response rate) at nine LTC homes in southern Ontario, Canada. The majority (85%) felt that the medication administration system was adequate to help them manage residents' pain and 98% felt comfortable administering narcotics. In deciding to administer a narcotic, nurses were influenced by pain assessments, physician orders, diagnosis, past history, effectiveness of non-narcotics and fear of making dosage miscalculations or developing addictions. Finally, most nurses stated that they trusted the physicians and pharmacists to ensure orders were safe. These findings highlight nurses' perceptions of managing pain medications in LTC and related areas where continuing education initiatives for nurses are needed.

John Thompson: Seeing through China

In 1848, Karl Marx predicted that a flow of cheap commodities would be the heavy artillery which would batter down all Chinese walls and open up the country to the west (Marx, 1978, p. 477). The Scottish photographer John Thomson (1837-1921) was both chronicler of and participant in the early moments of this process. Thomson was a commercial photographer who first arrived in the Far East in 1862. He earned the moniker of 'China' in a decade-long stay during which he photographed what he considered to be the key aspects of its culture and landscape. In this body of work, Illustrations of China and its People (first published in 1874) is perhaps the most comprehensive. It explores, through two hundred photographs and accompanying texts, a series of phenomena from the macro-scale of landscape, infrastructure and industry to the smaller scales of streetscapes, domestic spaces, individual portraits, and other details of everyday life. Despite his own description of the volumes as encyclopedic, Illustrations is geographically quite limited. Thomson's explorations into the hinterland proceed up the country’s principal rivers from those coastal ports which had already been wrested into western hands during the Opium Wars (of the 1840s) and subsequently opened up to trade. This is perhaps one of the reasons why Illustrations has been described as an explicitly colonial text, a guide-book for the prospective settler whose content offered the strategic knowledge of land, culture and natural resources necessary if the territorial advantages of the coastal periphery were to extended to the interior (Jeffrey, 1981, p. 64). It can also be argued, however, that Thomson’s volume offered justification for a potential colonial presence. Faced with a civilization whose history was as sophisticated as the west, it depicts a culture that is static and moribund, its addiction to traditional values an impediment to progress. While this is perhaps most explicit in the texts of Illustrations of China, it can also be seen in the images whose uniform chemical rendering also serves to make an essentially diverse culture seem homogenous. Yet it is these images that distinguish Illustrations from previous attempts to collate China’s culture and landscape. Here, the mechanical precision of his camera captures a reality that often subverts the colonial narrative, confounding stereotypes as Thomson’s mass-produced images allow another China to emerge.

City centre sidewalks: Improving pedestrian experience through design

Sidewalks are integral features of city centres. They provide the channels through which activities and interactions evolve and in turn these interactions cause the sidewalks to evolve. They help to articulate the builtform and open spaces in tying together. However, historically sidewalks have received less attention relative to urban squares and civic spaces. Owing to the concept of walkable cities, sidewalks are gaining importance. This paper provides a critical overview on the apparent ‘amnesia’ in urban design and planning theories and visits a popular sidewalk in Belfast city centre to examine the paradox and perspectives.

Wireless networks congestion control

Congestion control in wireless networks is an important and open issue. Previous research has proven the poor performance of the Transport Control Protocol (TCP) in such networks. The factors that contribute to the poor performance of TCP in wireless environments concern its unsuitability to identify/detect and react properly to network events, its TCP window based ow control algorithm that is not suitable for the wireless channel, and the congestion collapse due to mobility. New rate based mechanisms have been proposed to mitigate TCP performance in wired and wireless networks. However, these mechanisms also present poor performance, as they lack of suitable bandwidth estimation techniques for multi-hop wireless networks. It is thus important to improve congestion control performance in wireless networks, incorporating components that are suitable for wireless environments. A congestion control scheme which provides an e - cient and fair sharing of the underlying network capacity and available bandwidth among multiple competing applications is crucial to the definition of new e cient and fair congestion control schemes on wireless multi-hop networks. The Thesis is divided in three parts. First, we present a performance evaluation study of several congestion control protocols against TCP, in wireless mesh and ad-hoc networks. The obtained results show that rate based congestion control protocols need an eficient and accurate underlying available bandwidth estimation technique. The second part of the Thesis presents a new link capacity and available bandwidth estimation mechanism denoted as rt-Winf (real time wireless inference). The estimation is performed in real-time and without the need to intrusively inject packets in the network. Simulation results show that rt-Winf obtains the available bandwidth and capacity estimation with accuracy and without introducing overhead trafic in the network. The third part of the Thesis proposes the development of new congestion control mechanisms to address the congestion control problems of wireless networks. These congestion control mechanisms use cross layer information, obtained by rt-Winf, to accurately and eficiently estimate the available bandwidth and the path capacity over a wireless network path. Evaluation of these new proposed mechanisms, through ns-2 simulations, shows that the cooperation between rt-Winf and the congestion control algorithms is able to significantly increase congestion control eficiency and network performance.

Grounding human vocabulary in robot perception through interaction

This thesis addresses the problem of word learning in computational agents. The motivation behind this work lies in the need to support language-based communication between service robots and their human users, as well as grounded reasoning using symbols relevant for the assigned tasks. The research focuses on the problem of grounding human vocabulary in robotic agent’s sensori-motor perception. Words have to be grounded in bodily experiences, which emphasizes the role of appropriate embodiments. On the other hand, language is a cultural product created and acquired through social interactions. This emphasizes the role of society as a source of linguistic input. Taking these aspects into account, an experimental scenario is set up where a human instructor teaches a robotic agent the names of the objects present in a visually shared environment. The agent grounds the names of these objects in visual perception. Word learning is an open-ended problem. Therefore, the learning architecture of the agent will have to be able to acquire words and categories in an openended manner. In this work, four learning architectures were designed that can be used by robotic agents for long-term and open-ended word and category acquisition. The learning methods used in these architectures are designed for incrementally scaling-up to larger sets of words and categories. A novel experimental evaluation methodology, that takes into account the openended nature of word learning, is proposed and applied. This methodology is based on the realization that a robot’s vocabulary will be limited by its discriminatory capacity which, in turn, depends on its sensors and perceptual capabilities. An extensive set of systematic experiments, in multiple experimental settings, was carried out to thoroughly evaluate the described learning approaches. The results indicate that all approaches were able to incrementally acquire new words and categories. Although some of the approaches could not scale-up to larger vocabularies, one approach was shown to learn up to 293 categories, with potential for learning many more.

O interesse socioeducativo (e as dificuldades) de traduzir em português-espanhol

O Projeto que apresentamos insere-se nos estudos do Mestrado em Tradução Especializada dentro da vertente da Saúde e Ciências da Vida; é por isso que, partindo de um texto/suporte que visa promover uma alimentação saudável nas escolas (manual de referência difundido pelos Ministérios da Educação e Ciência e Ministério da Saúde de Portugal), procedemos à tradução (de português para espanhol) de um conteúdo que suscita, nos nossos dias, um grande interesse socioeducativo e cultural. É preciso destacar que o facto de ter nascido e vivido na Venezuela durante doze anos permitiu-me superar com êxito os meus estudos de espanhol na Licenciatura e no referido Mestrado; mas, ao mesmo tempo, tive que me adaptar, enquanto cidadã portuguesa, ao complexo e inacabado processo de ir interiorizando estas duas línguas – português/espanhol – tão próximas e no entanto com sistemas linguísticos bem distintos. Esta evidência encontra a sua maior justificação no grande capítulo dos erros (de forma e de significado) que consegui detetar e analisar graças à ajuda da minha professora orientadora, ao longo deste meu primeiro trabalho académico (texto traduzido para espanhol). Só agora, depois da minha primeira e “ingénua” tradução desse texto/manual, sou capaz de perceber com toda nitidez a dimensão do erro na atividade tradutora, assim como das suas consequências. Além desta importante reflexão, também o facto de elaborar este projeto permitiu-me abordar um aspeto linguístico da língua espanhola que me cativa pessoalmente (no que me diz respeito): o das variantes lexicais do castelhano nos países hispanofalantes. Não duvido em apontar um outro aspeto fundamental: o esforço de ter tido que corrigir minuciosamente e com rigor esta tarefa tradutora (com os seus respetivos comentários tradutológicos) converteu-se numa fonte de múltiplas satisfações pessoais; são aquelas que têm a ver com o cultivo de valores tais como o esforço, o espírito de superação, o exercício da responsabilidade e o (re)conhecimento da honestidade intelectual, entre outros.

A global assessment of the effectiveness of different protection levels in marine protected areas of tropical waters, following a new categorization

Dissertação de mestrado, Biologia Marinha, Faculdade de Ciências e Tecnologia, Universidade do Algarve, 2015

Representações dos pais primíparos e multíparos sobre creche

Dissertação apresentada na Escola Superior de Educação de Lisboa, para obtenção do grau de Mestre em Ciências da Educação - Especialidade Intervenção Precoce

Influencing factors on the buying behavior in the software market

The case of desktop Operating System and Office Suite choices considering Proprietary and Open Source Software alternatives.