Ethical decisions in endof- life care

No Abstract

Evaluating palliative care training in the oncology registrar programme in South Africa

Background. Following a World Health Assembly call in 2014 to strengthen palliative care, the South African (SA) Department of Health approved this strategy as part of the SA National Policy Framework and Strategy on Palliative Care. In 2016, the University of Cape Town, together with the College of Radiation Oncology of SA, identified the need to integrate palliative care (PC) into the oncology curriculum. In collaboration with the Cancer Association of SA, a research project was developed to introduce a 12-module curriculum at five teaching hospitals. The aim of this research was to evaluate the impact of a 1-year PC course within the training programme for specialist oncologists in SA. Objective. To determine the reaction of oncology registrars and their supervisors to the course to determine changes in knowledge and skills, and to determine the application in oncology practice. Methods. This study was a mixed-method prospective evaluation of an educational intervention. The educational programme used a blended learning method to train and support registrars (n=32) and facilitators (n=5) across five universities from August 2017 to September 2018. Evaluation feedback was electronically collected to determine the registrars’ reactions to the course materials. Pre and post multiple-choice questions (MCQs) were used to review their knowledge. Focus group discussions (FGDs) were used to explore reactions, change in knowledge and skills and how registrars integrated PC into their daily work. Results. There was an overwhelmingly positive reaction to the PC course by the oncology registrars and their supervisors. The training was found to be feasible, and the topics addressed appropriate. Concerns previously raised by the College of Radiation Oncology of SA regarding the feasibility and appropriateness of the course and material were found to be unsubstantiated. The poor MCQ results can be ascribed to poor sequencing of the execution of the question. However, the MCQs in modules 7 and 8 (symptom management) demonstrated the most significant change in knowledge and skills (symptom management). The FGDs demonstrated a perceived change in knowledge and skills, especially for communication skills and pain and symptom management. The FGDs also indicated that the registrars’ approach to PC changed in that they were able to integrate the principles of PC into practice, and now saw PC as an essential component of oncology. Lastly, registrars and their supervisors felt that the course addressed topics that formed part of their daily clinical work. Conclusion. This research supports the view that PC training is an essential component of oncology training in the SA setting. PC forms part of the daily practice of oncologists, and a structured curriculum prepares clinicians to be able to integrate evidence-based PC into the practice of oncology if they receive appropriate training. Supervisors of the oncology training programme and registrars are confident that the training of 12 modules across 1 year is feasible and appropriate

Postgraduate Palliative care education: Evaluation of a South African Programme

AIM: We aimed to assess the postgraduate palliative care distance education programme of the University of Cape Town (UCT) in terms of its perceived ability to influence palliative care delivery. METHODS: A mixed-methods approach, consisting of two surveys using open-ended and multiple-choice options, was conducted from January to December 2007 at the UCT School of Public Health and Family Medicine. All students registered in the programme from 2000 - 2007 were invited to participate; 83 (66.4% of all eligible participants) completed the general survey, and 41 (65.7%) of the programme's graduates completed the graduate survey. The survey scores and open-ended data were triangulated to evaluate UCT's palliative care postgraduate programme. RESULTS: General survey scores of graduates were significantly higher in 5 of the 6 categories in comparison with current students. The graduate survey indicated that curriculum and teaching strengths were in communication and dealing with challenging encounters. Graduates also stressed the need to develop a curriculum that incorporated a practical component. CONCLUSIONS: In addition to current postgraduate training, palliative care education in South Africa should be extended to undergraduate medical students, as the benefits of UCT's programme were limited to a small cohort of practitioners

Comparison of 4-dimensional variational and ensemble optimal interpolation data assimilation systems using a Regional Ocean Modeling System (v3.4) configuration of the eddy-dominated East Australian Current system

Ocean models must be regularly updated through the assimilation of observations (data assimilation) in order to correctly represent the timing and locations of eddies. Since initial conditions play an important role in the quality of short-term ocean forecasts, an effective data assimilation scheme to produce accurate state estimates is key to improving prediction. Western boundary current regions, such as the East Australia Current system, are highly variable regions, making them particularly challenging to model and predict. This study assesses the performance of two ocean data assimilation systems in the East Australian Current system over a 2-year period. We compare the time-dependent 4-dimensional variational (4D-Var) data assimilation system with the more computationally efficient, time-independent ensemble optimal interpolation (EnOI) system, across a common modelling and observational framework. Both systems assimilate the same observations: satellite-derived sea surface height, sea surface temperature, vertical profiles of temperature and salinity (from Argo floats), and temperature profiles from expendable bathythermographs. We analyse both systems' performance against independent data that are withheld, allowing a thorough analysis of system performance. The 4D-Var system is 25 times more expensive but outperforms the EnOI system against both assimilated and independent observations at the surface and subsurface. For forecast horizons of 5 d, root-mean-squared forecast errors are 20 %–60 % higher for the EnOI system compared to the 4D-Var system. The 4D-Var system, which assimilates observations over 5 d windows, provides a smoother transition from the end of the forecast to the subsequent analysis field. The EnOI system displays elevated low-frequency (&gt;1 d) surface-intensified variability in temperature and elevated kinetic energy at length scales less than 100 km at the beginning of the forecast windows. The 4D-Var system displays elevated energy in the near-inertial range throughout the water column, with the wavenumber kinetic energy spectra remaining unchanged upon assimilation. Overall, this comparison shows quantitatively that the 4D-Var system results in improved predictability as the analysis provides a smoother and more dynamically balanced fit between the observations and the model's time-evolving flow. This advocates the use of advanced, time-dependent data assimilation methods, particularly for highly variable oceanic regions, and motivates future work into further improving data assimilation schemes.</p

Postgraduate palliative care education: Evaluation of a South African programme

Aim. We aimed to assess the postgraduate palliative care distance education programme of the University of Cape Town (UCT) in terms of its perceived ability to influence palliative care delivery. Methods. A mixed-methods approach, consisting of two surveys using open-ended and multiple-choice options, was conducted from January - December 2007 at the UCT School of Public Health and Family Medicine. All students registered in the programme from 2000 - 2007 were invited to participate; 83 (66.4% of all eligible participants) completed the general survey, and 41 (65.7%) of the programme's graduates completed the graduate survey. The survey scores and open-ended data were triangulated to evaluate UCT’s palliative care postgraduate programme. Results. General survey scores of graduates were significantly higher in 5 of the 6 categories in comparison with current students. The graduate survey indicated that curriculum and teaching strengths were in communication and dealing with challenging encounters. Graduates also stressed the need to develop a curriculum that incorporated a practical component. Conclusions. In addition to current postgraduate training, palliative care education in South Africa should be extended to undergraduate medical students, as the benefits of UCT’s programme were limited to a small cohort of practitioners

Impact of ocean forcing on the Aurora Basin in the 21st and 22nd centuries

The grounded ice in the Totten and Dalton glaciers is an essential component of the buttressing for the marine-based Aurora basin, and hence their stability is important to the future rate of mass loss from East Antarctica. Totten and Vanderford glaciers are joined by a deep east-west running subglacial trench between the continental ice sheet and Law Dome, while a shallower trench links the Totten and Dalton glaciers. All three glaciers flow into the ocean close to the Antarctic circle and experience ocean-driven ice shelf melt rates comparable with the Amundsen Sea Embayment. We investigate this combination of trenches and ice shelves with the BISICLES adaptive mesh ice-sheet model and ocean-forcing melt rates derived from two global climate models. We find that ice shelf ablation at a rate comparable with the present day is sufficient to cause widespread grounding line retreat in an east-west direction across Totten and Dalton glaciers, with projected future warming causing faster retreat. Meanwhile, southward retreat is limited by the shallower ocean facing slopes between the coast and the bulk of the Aurora sub-glacial trench. However the two climate models produce completely different future ice shelf basal melt rates in this region: HadCM3 drives increasing sub-ice shelf melting to ~2150, while ECHAM5 shows little or no increase in sub-ice shelf melting under the two greenhouse gas forcing scenarios

Seasonal dynamics of Totten Ice Shelf controlled by sea ice buttressing

Previous studies of Totten Ice Shelf have employed surface velocity measurements to estimate its mass balance and understand its sensitivities to interannual changes in climate forcing. However, displacement measurements acquired over timescales of days to weeks may not accurately characterize long-term flow rates wherein ice velocity fluctuates with the seasons. Quantifying annual mass budgets or analyzing interannual changes in ice velocity requires knowing when and where observations of glacier velocity could be aliased by subannual variability. Here, we analyze 16 years of velocity data for Totten Ice Shelf, which we generate at subannual resolution by applying feature-tracking algorithms to several hundred satellite image pairs. We identify a seasonal cycle characterized by a spring to autumn speedup of more than 100&thinsp;m&thinsp;yr−1 close to the ice front. The amplitude of the seasonal cycle diminishes with distance from the open ocean, suggesting the presence of a resistive back stress at the ice front that is strongest in winter. Springtime acceleration precedes summer surface melt and is not attributable to thinning from basal melt. We attribute the onset of ice shelf acceleration each spring to the loss of buttressing from the breakup of seasonal landfast sea ice.</p