Do-Not-Attempt-Resuscitation orders for people with intellectual disabilities : dilemmas and uncertainties for ID physicians and trainees. The importance of the deliberation process

Item does not contain fulltextBACKGROUND: Not much is known about Do-Not-Attempt-Resuscitation (DNAR) decision-making for people with intellectual disabilities (IDs). The aim of this study was to clarify the problems and pitfalls of non-emergency DNAR decision-making for people with IDs, from the perspective of ID physicians. METHODS: This qualitative study was based on semi-structured individual interviews, focus group interviews and an expert meeting, all recorded digitally and transcribed verbatim. Forty ID physicians and trainees were interviewed about problems, pitfalls and dilemmas of DNAR decision-making for people with IDs in the Netherlands. Data were analysed using Grounded Theory procedures. RESULTS: The core category identified was 'Patient-related considerations when issuing DNAR orders'. Within this category, medical considerations were the main contributory factor for the ID physicians. Evaluation of quality of life was left to the relatives and was sometimes a cause of conflicts between physicians and relatives. The category of 'The decision-maker role' was as important as that of 'The decision procedure in an organisational context'. The procedure of issuing a non-emergency DNAR order and the embedding of this procedure in the health care organisation were important for the ID physicians. CONCLUSION: The theory we developed clarifies that DNAR decision-making for people with IDs is complex and causes uncertainties. This theory offers a sound basis for training courses for physicians to deal with uncertainties regarding DNAR decision-making, as well as a method for advance care planning. Health care organisations are strongly advised to implement a procedure regarding DNAR decision-making

Bespreken van het reanimatiebeleid op een afdeling geriatrie: de ervaring van patiënt en familie

Doel: Achterhalen van de ervaring van het gesprek over het reanimatiebeleid dat standaard bij iedere opname wordt gevoerd bij geriatrische patiënten of hun vertegenwoordigers. Opzet: Prospectief, observationeel, exploratief survey-onderzoek Methode: Gedurende 10 weken werd aan alle nieuw opgenomen patiënten of vertegenwoordigers van wilsonbekwame patiënten op een afdeling geriatrie van een algemeen ziekenhuis, met een semi-gestructureerd interview gevraagd naar hun ervaring van het gesprek over het reanimatiebeleid. Ook werd er gevraagd naar factoren die mogelijk invloed hebben op deze ervaring, en naar verbeterpunten van het gesprek. De primaire uitkomst was het cijfer op een schaal van 1 t/m 10 met betrekking tot de tevredenheid over het reanimatiegesprek. Resultaten: Er werden 76 deelnemers, waarvan 29 wilsbekwame patiënten en 47 vertegenwoordigers, geïncludeerd. Het reanimatiegesprek duurde gemiddeld 4,5 minuut (SD 3,2) en in 70% (n=53) werd een niet-reanimatiebesluit genomen. De beoordeling van het reanimatiegesprek op een schaal van 1 t/m 10 was gemiddeld 7,8 (SD 1,5). In totaal werden er 121 positieve opmerkingen gemaakt tegenover 70 negatieve. Als belangrijkste verbeterpunten worden genoemd: beter inleiden van het gesprek (17%), meer uitleg geven over reanimatie en de kans op succes (17%) en het geven van informatie voorafgaand aan de opname, zodat patiënt en vertegenwoordiger al op de hoogte zijn dat er gesproken gaat worden over het reanimatiebeleid (12%). Conclusie: Patiënten en vertegenwoordigers van wilsonbekwame patiënten staan positief tegenover het standaard bespreken van het reanimatiebeleid met de arts tijdens het opnamegesprek op een afdeling geriatrie, en beoordelen dit gesprek met een 7,8/10. Ter verbetering wordt voorbereiding van de patiënt en vertegenwoordiger voor het reanimatiegesprek en uitgebreidere communicatie tijdens het gesprek aanbevolen

Community Capacity for Implementing Clean Development Mechanism Projects Within Community Forests in Cameroon

There is a growing assumption that payments for environmental services including carbon sequestration and greenhouse gas emission reduction provide an opportunity for poverty reduction and the enhancement of sustainable development within integrated natural resource management approaches. Yet in experiential terms, community-based natural resource management implementation falls short of expectations in many cases. In this paper, we investigate the asymmetry between community capacity and the Land Use Land Use Change Forestry (LULUCF) provisions of the Clean Development Mechanism within community forests in Cameroon. We use relevant aspects of the Clean Development Mechanism criteria and notions of “community capacity” to elucidate determinants of community capacity needed for CDM implementation within community forests. The main requirements are for community capacity to handle issues of additionality, acceptability, externalities, certification, and community organisation. These community capacity requirements are further used to interpret empirically derived insights on two community forestry cases in Cameroon. While local variations were observed for capacity requirements in each case, community capacity was generally found to be insufficient for meaningful uptake and implementation of Clean Development Mechanism projects. Implications for understanding factors that could inhibit or enhance community capacity for project development are discussed. We also include recommendations for the wider Clean Development Mechanism/Kyoto capacity building framework

R&D policy instruments – a critical review of what we do and don’t know

In recent years, the term ‘policy instrument’ has been used more frequently with regard to R&D policy and innovation policy. What does this term mean? Where did it come from? What do we know about it, both with regard to the general field of policy studies but also in the specific context of R&D policy? This article examines the development of the notion of policy instruments as part of a body of research known as ‘policy design’. Over the last 50 years, there has been substantial progress in setting policy design on a more systematic basis, with the development of established concepts and analytical frameworks, including various taxonomies of policy instruments. However, with just a few exceptions, this body of research seems to have had little impact in the world of R&D policy. The paper reviews the literature on R&D policy instruments. It identifies a number of challenges for R&D policy instruments in the light of four transitions – the shift from linear to systemic thinking about R&D and innovation, the shift from national governments to multi-level governance, the shift from individual actors to collaborations and networks, and the shift from individual policies to policy mixes. It sets out a research agenda for the study of R&D policy instruments, before ending with a number of conclusions

Neo-Atlantis: The Netherlands under a 5-m sea level rise

What could happen to the Netherlands if, in 2030, the sea level starts to rise and eventually, after 100 years, a sea level of 5 m above current level would be reached? This question is addressed by studying literature, by interviewing experts in widely differing fields, and by holding an expert workshop on this question. Although most experts believe that geomorphology and current engineering skills would enable the country to largely maintain its territorial integrity, there are reasons to assume that this is not likely to happen. Social processes that precede important political decisions - such as the growth of the belief in the reality of sea level rise and the framing of such decisions in a proper political context (policy window) - evolve slowly. A flood disaster would speed up the decision-making process. The shared opinion of the experts surveyed is that eventually part of the Netherlands would be abandoned. © 2008 The Author(s)

Low-Cycle Fatigue of Ultra-Fine-Grained Cryomilled 5083 Aluminum Alloy

The cyclic deformation behavior of cryomilled (CM) AA5083 alloys was compared to that of conventional AA5083-H131. The materials studied were a 100 pct CM alloy with a Gaussian grain size average of 315 nm and an alloy created by mixing 85 pct CM powder with 15 pct unmilled powder before consolidation to fabricate a plate with a bimodal grain size distribution with peak averages at 240 nm and 1.8 μm. Although the ultra-fine-grain (UFG) alloys exhibited considerably higher tensile strengths than those of the conventional material, the results from plastic-strain-controlled low-cycle fatigue tests demonstrate that all three materials exhibit identical fatigue lives across a range of plastic strain amplitudes. The CM materials exhibited softening during the first cycle, similar to other alloys produced by conventional powder metallurgy, followed by continual hardening to saturation before failure. The results reported in this study show that fatigue deformation in the CM material is accompanied by slight grain growth, pinning of dislocations at the grain boundaries, and grain rotation to produce macroscopic slip bands that localize strain, creating a single dominant fatigue crack. In contrast, the conventional alloy exhibits a cell structure and more diffuse fatigue damage accumulation