End-of-life Treatment Research Articles

Feasibility and Acceptability of a Palliative Care Intervention Among Older or Adults with Advanced CKD and their Caregivers.

In non-nephrology settings, specialty Palliative Care (PC) improves decision-making, patient's quality of life (QoL), advance care planning (ACP), and certain indicators of the quality of end-of-life (EoL) care. This pilot RCT explored the feasibility and acceptability of a PC intervention, CKD-EDU, for older adults ≥75 years with eGFR ≤25 ml/min and their caregivers. Participants randomized to the control group received standard nephrology care and routine kidney therapy (KT) education, while those randomized to CKD-EDU received a decision aid and met with a PC clinician up to three times to discuss KT decisions and EoL planning. Patients were assessed at baseline, 4-6, 12-14, and 24-26 weeks. Main outcomes included intervention feasibility and acceptability, decision-conflict, and patient QoL. The mediating effects of reduced decision conflict on improved QOL were explored, as were the effects of CKD-EDU on ACP, EoL treatment intensity and 6-month-hospitalization. Statistical analyses encompassed descriptive analyses, adjusted repeated-measure-models, mediation analyses and logistic-regression models. Among the 127 eligible patients screened, 58 (44%) consented: 30 were randomized to CKD-EUD and 28 to the control arm. All patients completed baseline assessments, and 89% completed at least one intervention session (n=26/29), underscoring intervention adherence and feasibility. Similarly, assessments completion rates at 4 (83%, n=45/54) ), 12 (93%, n=42/45), and 24 (95%, n=40/42) weeks were high. The intervention received over 85% acceptability ratings for all questions. Patients exposed to CKD-EDU exhibited significant improvement in decisional conflict scale scores (P = 0.003) at 4-6 weeks and improvements in QoL at 24-26 weeks (P=0.02). Exploratory analyses were not statistically significant in this pilot, but all effect sizes were in the predicted direction. This study demonstrates the feasibility and acceptability of CKD-EDU. A larger scale trial is warranted to assess its effectiveness in improving key outcomes important to patients and families.

A Scoping Review of the Barriers and Facilitators to Clinician Engagement in Hospital-Based Palliative Care in Australian Hospitals.

Background: Current research has shown that inpatient palliative care (PC) services are under-utilized, poorly integrated, and frequently introduced too late during inpatient hospital stays. The aim of this study was to identify a comprehensive list of multi-disciplinary facilitators and barriers to inpatient PC in Australian hospitals through a scoping literature review. Methods: This review identified articles published since 2000 from 3 electronic databases (CINAHL Plus, MEDLINE and Embase), which included discussion of collaboration among non-palliative care clinicians and palliative care professionals in Australian hospitals. We used an inductive approach to identifying key domains of barriers and facilitators. Results: Thirty-four articles met inclusion criteria following full text review. Barriers and facilitators were categorized in 7 domains: (1) Patient concerns, (2) Family concerns, (3) Clinician knowledge, education, and experience in palliative care, (4) Recognition and acceptance of prognosis when a patient was dying or needing end of life treatment, (5) Reconciliation of individual and professional values around PC, (6) Clinician access to resources for PC in the hospital, and (7) Communication between the PC team and ward clinicians. Each domain included potentially substantial barriers to PC delivery and practice. However, given the small sample sizes and specialized settings of many included studies, it was difficult to draw conclusions on the relative significance of different barriers across hospitals. Conclusion: This review identified a number of barriers and facilitators across studies. Subsequent research needs to more comprehensively compare factors impacting PC use in order to improve implementation of PC across hospital settings.

Prognostic Value of Performance Status, Albumin, and CRP in Last-Line Chemotherapy for Pancreatic vs. Other Gastrointestinal Cancers-Simple Tools Matter.

Patients with advanced gastrointestinal cancers often receive chemotherapy near the end of life (EoL), raising concerns about overtreatment. The PALLiON trial, a cluster-randomized trial, assessed the impact of a complex intervention on frequency of EoL treatment; the intervention involved palliative care referrals and the use of PROMs. The present secondary analysis evaluated the prognostic value of baseline performance status (PS), albumin (alb), C-reactive protein (CRP), and body mass index (BMI) for overall survival, comparing pancreatic (PAN, n = 189) vs. other gastrointestinal cancer patients (GI, n = 286). Baseline PS, alb, CRP, mGPS (modified Glasgow prognostic score), and BMI were analyzed using Cox regression. Adjusted for age, sex, and hospital size, PS ≥ 2 and alb < 35 g/L predicted shorter survival in both PAN and GI cancers, while CRP > 10 predicted shorter survival only in GI cancers. In PAN, PS ≥ 2 predicted a 78.4% higher probability of shorter survival, and mGPS 2 predicted a 68.7% higher probability. In GI, mGPS 2 predicted a 70.8% higher probability, whereas PS was not significant. BMI did not improve predictive models. PS ≥ 2 and low albumin are strong predictors of short survival in PAN, whereas increased CRP and low albumin (mGPS 2) are predictors in GI.

End of life treatment in gynecological cancers in an integrated care model: A single institution experience from Oman.

e24036 Background: The use of chemotherapy closer to the end of life (EOL) and the optimal time of initiating palliative care interventions are subjects of ongoing debate. In a traditional care model (TCM), the institution of EOL care is a complex decision-making process, that involves patient, family members, and the oncologist, and involves transfer of patients from one to the other service. Integrated care model (ICM) is a newer concept, is designed around the needs of the patients, and may have the potential to improve quality of life and reduce the cost of healthcare towards EOL. At our center, we work in ICM in organ-based clinical programs and report the use of systemic treatment in patients with gynecological cancers (GC) nearing EOL. Methods: We analyzed retrospectively the use of chemotherapy and other systemic cancer-directed therapies in patients with GC, who died between Sept 2021 and December 2023 at a single institution. Information on the cancer-type, intention of treatment, and the time between last treatment and death was obtained from electronic patient records (EPR). Results: Over the study period, a total of 22 patients passed away. All patients received palliative care as part of the integrated care. All patients had been declared ‘not for resuscitation’ before death. Twelve patients had ovarian cancer, 5 had endometrial cancer, 4 had cancer of cervix, and one had vulvar cancer. The median age at diagnosis was 53 years (29-80). The systemic treatment was 1st line in 5 patients (23%), 2nd line in 8 patients (36%), and 3rd or more line in 6 patients (27%) respectively. Three patients (14%) did not receive any cancer-directed treatment (aged 80, 71 and 61). The ultimate line of treatment was cytotoxic chemotherapy for all patients, except for one who received Olaparib, and one who received trastuzumab with chemotherapy. There was no treatment-related mortality. The median time from last treatment to death was 55 days. Of the 19 patients who received treatment, 6 patients (32%) received treatment in the last 30 days, 5 between 30 and 60 days (26%), 5 between 60 and 90 days (26%), and 3 more than 90 days before death. Four patients died at home. Age at diagnosis (51 vs 55 years), age at death (51.5 vs 57.5 years), or time from diagnosis to death (11.5 vs 22 months), did not predict whether patients received treatment within the 30 days of death or earlier. Conclusions: All patients received palliative care as part of integrated cancer care. The ICM may have led to lower use of cancer treatment near EOL. The data may provide a benchmark for the region.

Analysis of the Carbon Footprint of Academic Gowns: A Case Study of Thai University

The apparel industry has a significant impact on climate change due to the substantial amount of greenhouse gas (GHG) emissions. Academic gowns commonly used in Thailand may be a significant contributor to high GHG levels due to apparel consumption. The objective of this study was to quantify the carbon footprint (CF) of an academic gown for bachelor degree students worn during the commencement ceremony at a private Thai university. The evaluation complies with the national guidelines on Carbon Footprint of Product (CFP) established by the Thailand Greenhouse Gas Management Organization (TGO) in line with ISO 14067:2018 Greenhouse gases - Carbon footprint of products - Requirements and guidelines for quantification. Considering only a single impact category: climate change, GHG emissions were calculated for the entire product life cycle, including raw material acquisition, production process, distribution, use, and the end-of-life (EoL) treatment, and relevant transportation/delivery. Data in this study were collected from the entrepreneur producing academic gowns for rental purposes. The numerical results revealed that CFP of an academic gown with a length of 40 inches, weighing 1,284.30 g, is 42.7 kgCO2-eq over its entire life cycle with 39.71% contributing from use phase and EoL treatment. The stages of raw material acquisition, use phase and production process caused most of the emissions at 41.08%, 33.69% and 18.49%, respectively. The carbon footprint of this gown serves as an important baseline data to enhance design development and the production process for emission reductions.

Direct Recycling Technology for Spent Lithium-Ion Batteries: Limitations of Current Implementation

The significant deployment of lithium-ion batteries (LIBs) within a wide application field covering small consumer electronics, light and heavy means of transport, such as e-bikes, e-scooters, and electric vehicles (EVs), or energy storage stationary systems will inevitably lead to generating notable amounts of spent batteries in the coming years. Considering the environmental perspective, material resource sustainability, and terms of the circular economy, recycling represents a highly prospective strategy for LIB end-of-life (EOL) management. In contrast with traditional, large-scale, implemented recycling methods, such as pyrometallurgy or hydrometallurgy, direct recycling technology constitutes a promising solution for LIB EOL treatment with outstanding environmental benefits, including reduction of energy consumption and emission footprint, and weighty economic viability. This work comprehensively assesses the limitations and challenges of state-of-the-art, implemented direct recycling methods for spent LIB cathode and anode material treatment. The introduced approaches include solid-state sintering, electrochemical relithiation in organic and aqueous electrolytes, and ionothermal, solution, and eutectic relithiation methods. Since most direct recycling techniques are still being developed and implemented primarily on a laboratory scale, this review identifies and discusses potential areas for optimization to facilitate forthcoming large-scale industrial implementation.

Reverse-engineering for improved end-of-life and circularity of PLA beverage cups

Over two-thirds of the life-cycle greenhouse gas emissions of a disposable PLA beverage cup are attributed to the production of the granules. Hence, an effective material recycling in the end-of-life (EoL) phase is vital to preserve the embodied energy and emissions from PLA production. According to the current state of technology, this poses a process engineering challenge, as direct shredding leads to elongated, not particularly free-flowing flakes, making further processing significantly more difficult. To address this, a tempering step can be introduced, which loosens the molecular structure and induces an isotropic behavior in the PLA, resulting in free-flowing granules after shredding (Ginter, 2019). These granules can be efficiently processed into re-compounds, similar to new PLA material.Based on these findings, this paper presents a methodological reverse engineering approach to examine the manufacturing phase, in order to identify changes and characteristics and hence potentials for further improvement within EoL treatment. From these findings, approaches are derived which can be integrated into the process chain to improve circularity and reduce life-cycle gaps. The applicability of the methodological approach and its contribution to greater sustainability will be demonstrated using the example of PLA beverage cups, including the application of the life-cycle gap analysis (Dieterle & Ginter 2022).

Life-Sustaining Treatments Among Medicare Beneficiaries with and without Dementia at the End of Life.

Older adults with dementia including Alzheimer's disease may have difficulty communicating their treatment preferences and thus may receive intensive end-of-life (EOL) care that confers limited benefits. This study compared the use of life-sustaining interventions during the last 90 days of life among Medicare beneficiaries with and without dementia. This cohort study utilized population-based national survey data from the 2000-2016 Health and Retirement Study linked with Medicare and Medicaid claims. Our sample included Medicare fee-for-service beneficiaries aged 65 years or older deceased between 2000 and 2016. The main outcome was receipt of any life-sustaining interventions during the last 90 days of life, including mechanical ventilation, tracheostomy, tube feeding, and cardiopulmonary resuscitation. We used logistic regression, stratified by nursing home use, to examine dementia status (no dementia, non-advanced dementia, advanced dementia) and patient characteristics associated with receiving those interventions. Community dwellers with dementia were more likely than those without dementia to receive life-sustaining treatments in their last 90 days of life (advanced dementia: OR = 1.83 [1.42-2.35]; non-advanced dementia: OR = 1.16 [1.01-1.32]). Advance care planning was associated with lower odds of receiving life-sustaining treatments in the community (OR = 0.84 [0.74-0.96]) and in nursing homes (OR = 0.68 [0.53-0.86]). More beneficiaries with advanced dementia received interventions discordant with their EOL treatment preferences. Community dwellers with advanced dementia were more likely to receive life-sustaining treatments at the end of life and such treatments may be discordant with their EOL wishes. Enhancing advance care planning and patient-physician communication may improve EOL care quality for persons with dementia.

"Gives peace of mind" - Relatives' perspectives of end-of-life conversations.

Planning for end-of-life (EOL) and future treatment and care through advance care planning (ACP) is being increasingly implemented in different healthcare settings, and interest in ACP is growing. Several studies have emphasized the importance of relatives participating in conversations about wishes for EOL and being included in the process. Likewise, research has highlighted how relatives can be a valuable resource in an emergency setting. Although relatives have a significant role, few studies have investigated their perspectives of ACP and EOL conversations. This study explores relatives' experiences of the benefits and disadvantages of having conversations about wishes for EOL treatment. Semi-structured telephone interviews were held with 29 relatives who had participated in a conversation about EOL wishes with a patient and physician 2 years prior in a variety of Danish healthcare settings. The relatives were interviewed between September 2020 and June 2022. Content analysis was performed on the qualitative data. The interviews revealed two themes: "gives peace of mind" and "enables more openness and common understanding of EOL." Relatives found that conversations about EOL could help assure that patients were heard and enhance their autonomy. These conversations relieved the relatives of responsibility by clarifying or confirming the patients' wishes, and they also made the relatives reflect on their own wishes for EOL. Moreover, they helped patients and relatives address other issues regarding EOL and made wishes more visible across settings. The results indicate that conducting conversations about wishes for EOL treatment and having relatives participate in those conversations were perceived as beneficial for both relatives and patients. Involving relatives in ACP should be prioritized by physicians and healthcare personnel when holding conversations about EOL.

The Effect of Simulation on Nursing Student Perceptions of Readiness to Provide End-of-Life Care.

Evidence suggests that nursing students in a prelicensure nursing program lack the required preparation to care for patients at the end of life (EOL), causing feelings of inadequacy and stress. New graduate nurses (years 0-5) struggle to address the needs of this patient population, leading to considering career changes. Nursing simulation has been shown to enhance competency and is gaining increasing favor in prelicensure nursing education. Little research has been conducted on the application of simulation using standardized patients in EOL patient scenarios. This study used live standardized patients who simulated a home health patient encounter with the nursing student acting as a home health hospice nurse. Watson's theory of caring and interpretive phenomenological analysis guided the qualitative research method and analysis. Five students chose to participate in this simulation and completed 6 reflective questions. After simulation, they felt more comfortable having difficult discussions about EOL care, treatment options, and patient fears. Participants noted the importance of communication in a team setting, which included the caregiver as an integral member. The use of standardized patient-simulated experiences increases realism and provides students the opportunity to bridge the gap between didactic education and clinical practice. This will enhance their readiness and confidence in providing EOL care.

End-of-Life Systemic Oncologic Treatment in the Immunotherapy Era: The Role of Race, Insurance, and Practice Setting.

Receipt of antineoplastic systemic treatment near end of life (EOL) has been shown to harm patient and caregiver experience, increase hospitalizations, intensive care unit and emergency department use, and drive-up costs; yet, these rates have not declined. To understand factors contributing to use of antineoplastic EOL systemic treatment, we explored its association with practice- and patient-level factors. We included patients from a real-world electronic health record-derived deidentified database who received systemic therapy for advanced or metastatic cancer diagnosed starting in 2011 and died within 4 years between 2015 and 2019. We assessed use of EOL systemic treatment at 30 and 14 days before death. We divided treatments into three subcategories: chemotherapy alone, chemotherapy and immunotherapy in combination, and immunotherapy (with/without targeted therapy), and estimated conditional odds ratios (ORs) and 95% CIs for patient and practice factors using multivariable mixed-level logistic regression. Among 57,791 patients from 150 practices, 19,837 received systemic treatment within 30 days of death. We observed 36.6% of White patients, 32.7% of Black patients, 43.3% of commercially insured patients, and 37.0% of Medicaid patients received EOL systemic treatment. White patients and those with commercial insurance were more likely to receive EOL systemic treatment than Black patients or those with Medicaid. Treatment at community practices was associated with higher odds of receiving 30-day systemic EOL treatment than treatment at academic centers (adjusted OR, 1.51). We observed large variations in EOL systemic treatment rates across practices. In a large real-world population, EOL systemic treatment rates were related to patient race, insurance type, and practice setting. Future work should examine factors that contribute to this usage pattern and its impact on downstream care.

Sustainability Assessment of the End-of-Life Technologies for Biocomposite Waste in the Aviation Industry.

Biocomposites have emerged as promising alternative materials for the aviation industry. However, there is a limited body of scientific literature addressing the end-of-life management of biocomposites. This article evaluated different end-of-life technologies for biocomposite recycling in a structured, five-step approach applying the innovation funnel principle. First, ten end-of-life (EoL) technologies were compared in terms of their circularity potential and technology readiness levels (TRL). Second, a multi-criteria decision analysis (MCDA) was carried out to find out the top four most promising technologies. Afterwards, experimental tests were conducted at a laboratory scale to evaluate the top three technologies for recycling biocomposites by analysing (1) three types of fibres (basalt, flax, carbon) and (2) two types of resins (bioepoxy and Polyfurfuryl Alcohol (PFA) resins). Subsequently, further experimental tests were performed to identify the top two recycling technologies for the EoL treatment of biocomposite waste from the aviation industry. Finally, the sustainability and economic performance of the top two identified EoL recycling technologies were evaluated through life cycle assessment (LCA) and techno-economic analysis (TEA). The experimental results, performed via the LCA and TEA assessments, demonstrated that both solvolysis and pyrolysis are technically, economically, and environmentally viable options for the EoL treatment of biocomposite waste from the aviation industry.

Environmental performance of plastic food packaging: Life cycle assessment extended with costs on marine ecosystem services

Packaging can play a substantial role in moving towards more sustainable food systems by affecting the amount of food loss and waste. However, the use of plastic packaging gives rise to environmental concerns, such as high energy and fossil resource use, and waste management issues such as marine litter. Alternative biobased biodegradable materials, such as poly(3-hydroxybutyrate-co-3-hydroxyvalerate) (PHBV) could address some of these issues. For a careful comparison in terms of environmental sustainability between fossil-based, non-biodegradable and alternative plastic food packaging, not only production but also food preservation and end-of-life (EoL) fate must be considered. Life cycle assessment (LCA) can be used to evaluate the environmental performance, but the environmental burden of plastics released into the natural environment is not yet embedded in classical LCA. Therefore, a new indicator is being developed that accounts for the effect of plastic litter on marine ecosystems, one of the main burdens of plastic's EoL fate: lifetime costs on marine ecosystem services. This indicator enables a quantitative assessment and thus addresses a major criticism of plastic packaging LCA. The comprehensive analysis is performed on the case of falafel packaged in PHBV and conventional polypropylene (PP) packaging. Considering the impact per kilogram of packaged falafel consumed, food ingredients make the largest contribution. The LCA results indicate a clear preference for the use of PP trays, both in terms of (1) impact of packaging production and dedicated EoL treatment and (2) packaging-related impacts. This is mainly due to the higher mass and volume of the alternative tray. Nevertheless, since PHBV has limited persistence in the environment compared to PP packaging, the lifetime costs for marine ES are about seven times lower, and this despite its higher mass. Although further refinements are needed, the additional indicator allows for a more balanced evaluation of plastic packaging.

GCIG SB-001/NSGO-CTU-PEACE/ANZGOG 1923/2020: Palliation in gynae-oncology—Patients' expectations and assessment of care.

TPS5635 Background: Patients with advanced gynaecological cancers who are approaching end of life (EOL) have a high symptom burden and following several prior lines of therapy, a low likelihood of response to further anti-cancer treatment. Despite this, 20-30% of women with gynecological cancer received chemotherapy in the last 30 days of life, with potentially detrimental effects on health and quality of life. Little is known about patients' and carers' perceptions and preferences in this phase of illness. Eliciting patient’s values and preferences for EOL care and shared decision-making are central elements of GCIG SB-001/NSGO-CTU-PEACE with the aim of improving patient-centered EOL care. The primary aim of PEACE is to assess the feasibility of collecting data on patient satisfaction towards EOL. Secondary aims include collecting data on patient and carer satisfaction with care, as well as prospective collection of details of their care. Methods: PEACE will prospectively enroll patients in Norway and Australia. Key eligibility criteria include: Patients with gynaecological cancer at an advanced stage with a predicted life expectancy of approximately 4 months. Patients may be on anti-cancer treatment or may be under observation/palliative care. In addition, the patient must be able (both physically and cognitively) to complete patient-reported outcome measures independently. The study will also include an appointed carer (not mandatory). Patient and carer satisfaction with care and the importance of domains of care will be assessed with the CANHELP-Lite individualized (Canadian Health Care Evaluation Project) instrument and FACIT (Functional Assessment of Chronic Illness Therapy). Carer’s perception of the bereavement period and the quality of the patient’s death will be assessed with the CANHELP lite bereavement and the Quality of Death and Dying questionnaire. The study will prospectively collect data on EOL treatment. Patient and carer satisfaction with care and quality of the dying process will be summarized by standard descriptive statistical measures. A sample size of 65 patients would have at least 80% power with 95% confidence to rule out a 60% completion rate in favour of the more interesting 75% rate. Assuming a 10% drop-out rate, PEACE will enrol 73 patients. Enrolment commenced in December 2022. ClinicalTrials.gov Identifier: NCT05142150 Clinical trial information: NCT05142150 .

Italian pediatric intensive care units admitting critically ill cancer children: results from a national survey.

Pediatric patients affected by oncologic disease have a significant risk of clinical deterioration that requires admission to the intensive care unit. This study reported the results of a national survey describing the characteristics of Italian onco-hematological units (OHUs) and pediatric intensive care units (PICUs) that admit pediatric patients, focusing on the high-complexity treatments available before PICU admission, and evaluating the approach to the end-of-life (EOL) when cared in a PICU setting. A web-based electronic survey has been performed in April 2021, involving all Italian PICUs admitting pediatric patients with cancer participating in the study. Eighteen PICUs participated, with a median number of admissions per year of 350 (IQR 248-495). Availability of Extracorporeal Membrane Oxygenation therapy and the presence of intermediate care unit are the only statistically different characteristics between large or small PICUs. Different high-level treatments and protocols are performed in OHUs, non depending on the volume of PICU. Palliative sedation is mainly performed in the OHUs (78%), however, in 72% it is also performed in the PICU. In most centers protocols that address EOL comfort care and treatment algorithms are missing, non depending on PICU or OHU volume. A non-homogeneous availability of high-level treatments and in OHUs is described. Moreover, protocols addressing EOL comfort care and treatment algorithms in palliative care are lacking in many centers.

California's harvested wood products: A time-dependent assessment of life cycle greenhouse gas emissions

Following life-cycle assessment (LCA) methodology, this study presents a state-level estimation of embodied carbon of wood products harvested in 2019 from California and subsequently processed, manufactured, transported, used, and disposed at the end-of-life (EoL). In a conventional static approach to LCA, all GHG emissions were aggregated and considered to occur at year 0 of the given time horizon (500 years in this study) and used a static characterization factor (CF). In dynamic LCA, GHG emissions occurring in different years were considered, and their global warming impact (GWI) was determined using a time-dependent CF over the selected time horizon of 500 years. Four scenarios were developed to examine the impact of EoL choices on GWI. It was found that dynamic GWI for all scenarios ranged from 0.27 to 0.93 million tonne CO₂e, which were 45–73 % lower than those estimated with static LCA approach, indicating that the static LCA approach could lead to an underestimation of the benefits of substituting wood for non-wood products, compared to those based on dynamic LCA approach. This analysis also demonstrated that the choice of EoL treatment option is a key factor affecting the estimated GWI as it directly determines the annual emission of GHGs released into atmosphere and subsequently their warming effect depending on the time harvested wood products (HWPs) spend in the horizon of assessment. Overall, the dynamic LCA performed in this study enabled more robust interpretations of embodied carbon by including temporal boundaries associated with the HWPs life cycle.

Product Lifecycle Information Flow in E-waste Handling: a Means to Increase Circularity?

Electronic waste (e-waste) is a growing waste stream. In Europe, e-waste is regulated by the Waste Electrical and Electronic Equipment (WEEE) Directive. Each manufacturer or importer is responsible for the end-of-life (EoL) treatment of the equipment it handles, although this task is usually outsourced to producer responsibility organizations (PROs) that collect and treat the e-waste. The WEEE regime has been criticized for focusing on waste handling according to the traditional linear economy, while, in a circular economy, the goal is to eliminate waste. Information sharing helps improve circularity, and digital technology is seen as enabling information transparency and visibility in the supply chain. However, there is need for empirical studies demonstrating the use of information in supply chains to improve circularity. We conducted a case study of a manufacturer, including its subsidiaries and PROs in eight European countries, in which we investigated the product lifecycle information flow related to e-waste. Our findings indicate that product lifecycle information is available, but that it is provided for purposes other than e-waste handling. Actors are willing to share this information, but it is not regarded as useful for EoL treatment since the actors involved in EoL handling believe that using this information could lead to delays and poorer performance in e-waste handling. Our findings contradict the optimistic view of digital technology as improving circularity in circular supply chain management. The findings further give reason to question the implementation of digital technology to improve the product lifecycle information flow as long as the involved actors do not request this information.

Community workshops increase advance care planning knowledge, appointment of legal proxies and completion of end-of life written plans

Advance Care Planning involves having conversations, completing documents detailing individuals’ end-of life treatment and care preferences, and appointing legal proxies who make health, lifestyle, or financial decisions. Although beneficial outcomes have been demonstrated, community rates of Advance Care Planning remain low. We developed a theoretically based workshop to increase knowledge and change behaviors in relation to Advance Care Planning; 347 participants completed the workshop. Advance Care Planning knowledge and action significantly improved three months post workshop. The intervention increased Advance Care Planning knowledge and changed behaviors.

INDIVIDUALS' KNOWLEDGE ABOUT A LOVED ONE’S END-OF-LIFE CARE WISHES IS ASSOCIATED WITH THEIR OWN ADVANCE CARE PLANNING

Abstract Despite evidence that ACP can improve quality of life for both patient and family, it remains underutilized. Only 37% US adults have a complete advance directive (Kuldeep et al., 2017). Existing studies primarily examined factors associated with patients’ ACP engagement but very few explored ACP among patients’ family. The goal of this study is to examine whether individuals’ knowledge about a loved one’s end-of-life (EOL) care preferences is associated with their ACP engagement. Data are from the US arm of the 2015 Four-Country Survey on Aging and End-of-Life Medical Care. The sample included N=609 adults who experienced the death of a family or close friend in the past 5 years.Three binary dependent variables were measured by different facets of ACP: having a serious conversation about EOL medical care wishes (1) with loved ones, (2) with doctors and (3) documenting those wishes. The primary independent variable was participants’ knowledge about their deceased family’s EOL treatment wishes.Three separate logistic regression models were used. Individuals who had a greater knowledge about their loved one’s EOL treatment wishes were twice as likely to have a conversation with family about their own EOL wishes (OR=2.32, P&amp;lt; 0.001) and documented wishes than those who didn’t(OR=2.03, P&amp;lt; 0.05). Results have direct implications for clinicians who work with families in EOL care settings. They may have opportunities to engage individuals – other than patients – in ACP. Focusing the experience of involvement in a loved one’s EOL care may be an effective strategy to enhance ACP engagement.

End-of-life discussions reduce the utilization of life-sustaining treatments during the last three months of life in cancer patients.

Studies to examine the impact of end-of-life (EOL) discussions on the utilization of life-sustaining treatments near death are limited and have inconsistent findings. This nationwide population-based cohort study determined the impact of EOL discussions on the utilization of life-sustaining treatments in the last three months of life in Taiwanese cancer patients. From 2012 to 2018, this cohort study included adult cancer patients, which were confirmed by pathohistological reports. Life-sustaining treatments during the last three months of life included cardiopulmonary resuscitation, intubation, and defibrillation. EOL discussions in cancer patients were confirmed by their medical records. Association of EOL discussions with utilization of life-sustaining treatments were assessed using multiple logistic regression. Of 381,207 patients, the mean age was 70.5 years and 19.4% of the subjects received life-sustaining treatments during the last three months of life. After adjusting for other covariates, those who underwent EOL discussions were less likely to receive life-sustaining treatments during the last three months of life compared to those who did not (Adjusted odds ratio [AOR] 0.87; 95% confidence interval [CI] 0.85–0.89). Considering the type of treatments, EOL discussions correlated with a lower likelihood of receiving cardiopulmonary resuscitation (AOR = 0.45, 95% CI 0.43–0.47), endotracheal intubation (AOR = 0.92, 95%CI 0.90–0.95), and defibrillation (AOR = 0.54, 95%CI 0.49–0.59). Since EOL discussions are associated with less aggressive care, our study supports the importance of providing these discussions to cancer patients during the EOL treatment.