Does national policy in England help deliver better and more consistent care for those at the end of life?

Objectives: To explore the extent to which national policy in end of life care in England influences and guides local practice, to ensure that care for patients over the age 75 years is of a consistently good quality. Method: This paper reports on phase one of a larger study and focuses its discussion on the high level (macro) determinants emerging from the analysis. Fifteen in-depth interviews were conducted with professionals involved in the development of English policy in end of life care. Results: Factors influencing the quality of end of life care were stratified into three system levels: meso, macro and micro. English national policy was reported to be an important macro-level determinant of effective outcomes and examples were provided to demonstrate how policy was influencing practice. Yet the complexity of the area and the range of interacting contributory factors mean the value of policy alone is hard to assess. At the macro-level concern was voiced around: whether policy was effective in tackling rising inequity; lack of mandatory leverage to exert change relating to end of life outcomes; the impact of ongoing infrastructural change on statutory services; workforce pressures; over-reliance on acute services; and continued abdication of responsibility for end of life care to medical professionals supported by the continued dominance of the medical model of care. Conclusions: The links between the existence of policy at the macro-level of the system, and the effective enactment of good practice remain unclear although strategies are suggested to help achieve greater national consistency in end of life care outcomes. Policymakers must pay attention to the following: controlling the rise in localism and its contribution to regional inequalities; the impact of continuous infrastructural change together with increasing workforce pressures; encouraging broader professional and public responsibility for recognition; and care of those at the end of life

The rhetoric and reality of choice and autonomy when older people are discharged from community hospital at the end-of-Life in England: A constructivist grounded theory study

There has been an increasing acknowledgement in the UK of the importance of recognising frailty as a condition that leaves older people vulnerable to dramatic, sudden changes in health triggered by seemingly small events. In policy, the approach to managing frailty is often an emphasis on staying well with limited consideration to frailty as an end-of-life phase. Meanwhile, discharge from hospital continues to be complex. Overstretched acute hospitals are juxtaposed with community and social services that struggle to keep up with the demand of those being discharged and the labelling of older people as “bed blockers” at the centre of delayed discharges. This paper reports a study underpinned by constructivist grounded theory methodology, with the aim of exploring the experiences and perceptions of stakeholders. Semistructured interviews were conducted with 57 participants including patients, their informal carer(s), community hospital staff, community health professionals, and care home managers. The core category of “the drive to discharge conveyor belt” was derived from data analysis. A significant finding of this study was that of the carer, their burden, and their intrinsic role in facilitating discharge, filling in gaps in services, coordinating services, and enabling the patient to stay at home, with little consideration of their choices or autonomy. The “drive to discharge” impacts older people, their informal carers, and health professional. This study suggests how they may be supported, through an ethical lens

Adaptation strategies and approaches for forested watersheds

Intentional climate adaptation planning for ecosystems has become a necessary part of the job for natural resource managers and natural resource professionals in this era of non-stationarity. One of the major challenges in adapting ecosystems to climate change is in the translation of broad adaptation concepts to specific, tangible actions. Addressing management goals and values while considering the long-term risks associated with local climate change can make forested watershed management plans more robust to uncertainty and changing conditions. We provide a menu of tiered adaptation strategies, which we developed with a focus on forests of the Midwest and Northeastern U.S., as part of a flexible framework to support the integration of climate change considerations into forested watershed management and conservation activities. This menu encapsulates ideas from the literature into statements that signify climate adaptation intention and provide examples of associated tactics to help ground the concepts in specific actions. Finally, we describe two demonstration projects, shared through the Northern Institute of Applied Climate Science’s Climate Change Response Framework, that have used this Forested Watershed Adaptation Menu and Adaptation Workbook in project-level planning

Understanding what works, why and in what circumstances in Hospice at Home Services for End of Life Care: applying a realist logic of analysis to a systematically searched literature review

Background: We have undertaken a systematically searched literature review using a realist logic of analysis to help synthesise the diverse range of literature available on hospice at home services. Aim: To find out in the existing literature what features of hospice at home models work best, for whom and under what circumstances. Design: A realist logic of analysis was applied to synthesise the evidence focusing on mechanisms by which an intervention worked (or did not work). An initial programme theory was developed using the National Association for Hospice at Home standards, Normalisation Process Theory and through refinement using stakeholder engagement. Data sources: PubMed, Science Direct, AMED, BNI, CINAHL, EMBASE, Health Business Elite, HMIC, Medline, PsychINFO, SCOPUS, Web of Science, DARE, Google Scholar, NHS Evidence, NIHR CRN portfolio database, NIHR journal library of funded studies, including searches on websites of relevant professional bodies [August 2014, June 2017, June 2019]. Results: Forty-nine papers were reviewed, of which 34 wereincluded contributing evidence to at least one of eight theory areas: marketing and referral, sustainable funding model, service responsiveness and availability, criteria for service admission, knowledge and skills of care providers, integration and co-ordination, anticipatory care, support directed at carers. Conclusions: Our literature review showed how it was possible to develop a coherent framework and test it against 34 published papers and abstracts. Central to this review was theory building, and as further evidence emerges, our programme theories can be refined and tested against any new empirical evidence

Guidelines for Facilitating a Patient Empowerment Program

The traditional medical treatment model often ignores the emotional, spiritual, social, and cognitive aspects of living with a chronic disease such as diabetes. Empowerment programs address these psychosocial areas by helping individuals develop skills and self-awareness in goal setting, problem solving, stress management, coping, social support, and motivation. Although many diabetes educators have been taught to use an empowerment curriculum to facilitate self-management, there is minimal research concerning the actual process of providing such programs to patients. We evaluated an empowerment curriculum (Empowerment: A Personal Path to Self-Care) with a diverse group of individuals with diabetes to determine the key elements of planning and implementing a successful diabetes patient empowerment program.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/68728/2/10.1177_014572179502100408.pd

Swift J2058.4+0516: Discovery of a Possible Second Relativistic Tidal Disruption Flare?

We report the discovery by the Swift hard X-ray monitor of the transient source Swift J2058.4+0516 (Sw J2058+05). Our multi-wavelength follow-up campaign uncovered a long-lived (duration >~ months), luminous X-ray (L_X,iso ~ 3 x 10^47 erg s^-1) and radio (nu L_nu,iso ~ 10^42 erg s^-1) counterpart. The associated optical emission, however, from which we measure a redshift of 1.1853, is relatively faint, and this is not due to a large amount of dust extinction in the host galaxy. Based on numerous similarities with the recently discovered GRB 110328A / Swift J164449.3+573451 (Sw J1644+57), we suggest that Sw J2058+05 may be the second member of a new class of relativistic outbursts resulting from the tidal disruption of a star by a supermassive black hole. If so, the relative rarity of these sources (compared with the expected rate of tidal disruptions) implies that either these outflows are extremely narrowly collimated (theta < 1 degree), or only a small fraction of tidal disruptions generate relativistic ejecta. Analogous to the case of long-duration gamma-ray bursts and core-collapse supernovae, we speculate that rapid spin of the black hole may be a necessary condition to generate the relativistic component. Alternatively, if powered by gas accretion (i.e., an active galactic nucleus [AGN]), Sw J2058+05 would seem to represent a new mode of variability in these sources, as the observed properties appear largely inconsistent with known classes of AGNs capable of generating relativistic jets (blazars, narrow-line Seyfert 1 galaxies).Comment: Minor typos correcte

Beyond planning tools: Experiential learning in climate adaptation planning and practices

In the past decade, several dedicated tools have been developed to help natural resources professionals integrate climate science into their planning and implementation; however, it is unclear how often these tools lead to on-the-ground climate adaptation. Here, we describe a training approach that we developed to help managers effectively plan to execute intentional, climate-informed actions. This training approach was developed through the Climate Change Response Framework (CCRF) and uses active and focused work time and peer-to-peer interaction to overcome observed barriers to using adaptation planning tools. We evaluate the effectiveness of this approach by examining participant evaluations and outlining the progress of natural resources projects that have participated in our trainings. We outline a case study that describes how this training approach can lead to place and context-based climate-informed action. Finally, we describe best practices based on our experience for engaging natural resources professionals and helping them increase their comfort with climate-informed planning