Critical appraisal of advance directives given by patients with fatal acute stroke: an observational cohort study

Background: Advance directives (AD) imply the promise of determining future medical treatment in case of decisional incapacity. However, clinical practice increasingly indicates that standardized ADs often fail to support patients’ autonomy. To date, little data are available about the quality and impact of ADs on end-of-life decisions for incapacitated acute stroke patients. Methods: We analyzed the ADs of patients with fatal stroke, focusing on: (a) their availability and type, (b) stated circumstances to which the AD should apply, and (c) stated wishes regarding specific treatment options. Results: Between 2011 and 2014, 143 patients died during their hospitalization on our stroke unit. Forty-two of them (29.4%) had a completed and signed, written AD, as reported by their family, but only 35 ADs (24.5%) were available. The circumstances in which the AD should apply were stated by 21/35 (60%) as a “terminal condition that will cause death within a relatively short time” or an ongoing “dying process.” A retrospective review found only 16 of 35 ADs (45.7%) described circumstances that, according to the medical file, could have been considered applicable by the treating physicians. A majority of patients objected to cardiopulmonary resuscitation (22/35, 62.9%), mechanical ventilation (19/35, 54.3%), and artificial nutrition (26/35, 74.3%), while almost all (33/35, 94.3%) directed that treatment for alleviation of pain or discomfort should be provided at all times even if it could hasten death. Conclusions: The prevalence of ADs among patients who die from acute stroke is still low. A major flaw of the ADs in our cohort was their attempt to determine single medical procedures without focusing on a precise description of applicable scenarios. Therefore, less than half of the ADs were considered applicable for severe acute stroke. These findings stress the need to foster educational programs for the general public about advance care planning to facilitate the processing of timely, comprehensive, and individualized end-of-life decision-making

Robust design optimization: On methodology and short review

Integrated circuit (IC) packages can delaminate under thermal cyclic loading because of elastic properties mismatch between the components. On the other hand, delamination has no pattern which points out the effect of variations of the design parameters on the response. Hence, a robustness estimation should be done to have more stable IC packages which show no important variations in the response with respect to uncertainties in the design parameters. In this paper, the importance of the robustness estimation for IC package design will be explained and a methodology on robust design estimations will be introduced. After that a short literature review will be given about robust design optimization

Fatigue Crack Growth Analysis of Interface between Lead Frame and Molding Compound

Cyclic thermo-mechanical loading together with mismatch of elastic properties between the components can lead to fatigue crack growth at interfaces and finally to interfacial delamination, potentially resulting in malfunction of an integrated circuit (IC) at the end. This work aims for a methodology to characterize one of such interfaces. The overall intention is to integrate methods into virtually conducted DoEs (design-of-experiments) for the determination of most robust design of packages with respect to fatigue crack growth at lead frame molding compound interface. In this manner, a miniaturized sub-critical bending test (MSCB), first demonstrated by [1], was optimized and used to characterize the interface between lead frame (LF) and molding compound (MC). Interfacial fatigue crack growth was quantitatively determined on samples taken from production line. Experimental crack length is determined by compliance method and by help of finite element method. Finally, sub-critical strain energy release rate is determined by using numerical methods and then Paris-Erdogan curves at different temperatures are formed for the related interface. Later these sub-critical strain energy release rate values are used to forecast crack growth in IC Packages under temperature cycle tests in which initial crack is created by a separator