At the end: a vignette-based investigation of strategies for managing end-of-life decisions in the intensive care unit

Background: Decision-making on end-of-life is an inevitable, yet highly complex, aspect of intensive care decision-making. End-of-life decisions can be challenging both in terms of clinical judgement and social interaction with families, and these two processes often become intertwined. This is especially apparent at times when clinicians are required to seek the views of surrogate decision makers (i.e., family members) when considering palliative care.  Methods: Using a vignette-based interview methodology, we explored how interactions with family members influence end-of-life decisions by intensive care unit clinicians (n = 24), and identified strategies for reaching consensus with families during this highly emotional phase of care.  Results: We found that the enactment of end-of-life decisions were reported as being affected by a form of loss aversion, whereby concerns over the consequences of not reaching a consensus with families weighed heavily in the minds of clinicians. Fear of conflict with families tended to arise from anticipated unrealistic family expectations of care, family normalization of patient incapacity, and belief systems that prohibit end-of-life decision-making.  Conclusions: To support decision makers in reaching consensus, various strategies for effective, coherent, and targeted communication (e.g., on patient deterioration and limits of clinical treatment) were suggested as ways to effectively consult with families on end-of-life decision-making

Safety culture and power: interactions between perceptions of safety culture, organisational hierarchy, and national culture

Practices that involve power dynamics are integral to maintaining organisational safety (e.g. speaking-up, challenging poor behaviour, admitting error, communicating on safety), and staff engagement in these is assumed to be shaped by perceptions of safety culture. These perceptions, in-turn, are associated with (1) positions within an organisational hierarchy (which makes power-related acts more or less threatening), and (2) societal values for power distance (e.g. challenging authority). With a sample of 13,573 of air traffic control staff (controllers, engineers, administrative, and management) from 21 national air traffic providers, we reconfirm the observation that managers perceive safety culture more positively than frontline staff (hypothesis 1), and that workers in countries with established values for hierarchy and power report safety culture as less positive than those from countries with low power distance (hypothesis 2). We then, for the first time, examine the interaction between these two factors, and establish that differences in safety culture perceptions between those higher in the hierarchy (management) and those lower in the hierarchy (air traffic controllers and administrative staff) are exacerbated by national contexts for large power distance (hypothesis 3). The study contributes to the literature by theorising the role of power in safety culture theory, and its influence upon safety culture perceptions. Moving forward, safety culture research and interventions may benefit from considering how power exists and manifests at the level of superior-subordinate dynamics

Review of SERT 2 power conditioning

SERT 2 spacecraft power conditioner performanc

Burnout in the ICU : potential consequences for staff and patient well-being

Peer reviewedAuthor versio

EUV spectra of highly-charged ions W54+^{54+}-W63+^{63+} relevant to ITER diagnostics

We report the first measurements and detailed analysis of extreme ultraviolet (EUV) spectra (4 nm to 20 nm) of highly-charged tungsten ions W$^{54+}$ to W$^{63+}$ obtained with an electron beam ion trap (EBIT). Collisional-radiative modelling is used to identify strong electric-dipole and magnetic-dipole transitions in all ionization stages. These lines can be used for impurity transport studies and temperature diagnostics in fusion reactors, such as ITER. Identifications of prominent lines from several W ions were confirmed by measurement of isoelectronic EUV spectra of Hf, Ta, and Au. We also discuss the importance of charge exchange recombination for correct description of ionization balance in the EBIT plasma.Comment: 11 pages, 4 figure

Do national policies for complaint handling in English hospitals support quality improvement? Lessons from a case study

Background. A range of public inquiries in the English National Health Service have indicated repeating failings in complaint handling, and patients are often left dissatisfied. The complex, bureaucratic nature of complaints systems is often cited as an obstacle to meaningful investigation and learning, but a detailed examination of how such bureaucratic rules, regulations, and infrastructure shape complaint handling, and where change is most needed, remains relatively unexplored. Methods. Through staff interviews and documentary analysis, we examined how complaints are handled, investigated, and monitored within an acute NHS trust rated as well-performing in complaint handling. We sought to examine how national policies structure local practices of complaint handling, how are they understood by those responsible for enacting them within local practice, and if there are any discrepancies between policies-as-intended and their reality in local practice. Results. Findings illustrate four areas of practice where national policies and regulations result in adverse consequences in local practices, and partly function to undermine an improvement-focused approach to complaints. These include muddled routes for raising formal complaints, investigative procedures structured to scrutinize the ‘validity’ of complaints, irreliable data collection systems, and adverse incentives and workarounds resulting from bureaucratic performance targets. Conclusion. This study demonstrates how national policies and regulations for complaint handling can impede, rather than promote, quality improvement in local settings. Accordingly, we propose a number of necessary reforms, including patient involvement in complaints investigations, the establishment of independent investigation bodies, and more meaningful data analysis strategies to uncover and address systemic causes behind recurring complaints

Production of Sodium Bose--Einstein condensates in an optical dimple trap

We report on the realization of a sodium Bose--Einstein condensate (BEC) in a combined red-detuned optical dipole trap, formed by two beams crossing in a horizontal plane and a third, tightly focused dimple trap propagating vertically. We produce a BEC in three main steps: loading of the crossed dipole trap from laser-cooled atoms, an intermediate evaporative cooling stage which results in efficient loading of the auxiliary dimple trap, and a final evaporative cooling stage in the dimple trap. Our protocol is implemented in a compact setup and allows us to reach quantum degeneracy even with relatively modest initial atom numbers and available laser power

Discrete or indiscrete? Redefining the colour polymorphism of the land snail Cepaea nemoralis

Biologists have long tried to describe and name the different phenotypes that make up the shell polymorphism of the land snail Cepaea nemoralis. Traditionally, the view is that the ground colour of the shell is one of a few major colour classes, either yellow, pink or brown, but in practise it is frequently difficult to distinguish the colours, and define different shades of the same colour. To understand whether colour variation is in reality continuous, and to investigate how the variation may be perceived by an avian predator, we applied psychophysical models of colour vision to shell reflectance measures. We found that both achromatic and chromatic variation are indiscrete in Cepaea nemoralis, being continuously distributed over many perceptual units. Nonetheless, clustering analysis based on the density of the distribution did reveal three groups, roughly corresponding to human-perceived yellow, pink and brown shells. We also found large-scale geographic variation in the frequency of these groups across Europe, and some covariance between shell colour and banding patterns. Although further studies are necessary, the observation of continuous variation in colour is intriguing because the traditional theory is that the underlying supergene that determines colour has evolved to prevent phenotypes from “dissolving” into continuous trait distributions. The findings thus have significance for understanding the Cepaea polymorphism, and the nature of the selection that acts upon it, as well as more generally highlighting the need to measure colour objectively in other systems

Effects of Land Crabs on Leaf Litter Distributions and Accumulations in a Mainland Tropical Rain Forest 1

The effect of the fossorial land crab Gecarcinus quadratus (Gecarcinidae) on patterns of accumulation and distribution of leaf litter was studied for two years in the coastal primary forests of Costa Rica's Corcovado National Park. Within this mainland forest, G, quadratus achieve densities up to 6 crabs/m 2 in populations extending along the Park's Pacific coastline and inland for ca 600 m. Crabs selectively forage for fallen leaf litter and relocate what they collect to burrow chambers that extend from 15 to 150 cm deep ( N = 44), averaging (±SE) 48.9 ± 3.0 cm. Preference trials suggested that leaf choice by crabs may be species-specific. Excavated crab burrows revealed maximum leaf collections of 11.75 g dry mass– 2.5 times more leaf litter than collected by square-meter leaf fall traps over several seven-day sampling periods. Additionally, experimental crab exclosures (25 m 2 ) were established using a repeated measures randomized block design to test for changes in leaf litter as a function of reduced crab density. Exclosures accumulated significantly more (5.6 ± 3.9 times) leaf litter than did control treatments during the wet, but not the dry, seasons over this two-year study. Such extensive litter relocation by land crabs may affect profiles of soil organic carbon, rooting, and seedling distributions.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/73250/1/j.1744-7429.2003.tb00590.x.pd