End Of Life Research Articles

Forecasting wind turbine blade waste with material composition and geographical distribution: Methodology and application to Germany

Wind energy has become a key player in global electricity generation. The management of end-of-life (EoL) wind turbine blade (WTB) material streams is a challenge that requires urgent attention. The aim of this study was to forecast the future EoL WTB material, composition and geographical distribution of decommissioned on- and offshore wind turbines in Germany. Based on the German core energy market data register and a review of forecasting methods, a hybrid approach was developed that combines a statistical, deterministic and stochastic model with three scenarios to assume the service life of wind turbines in operation. This method was applied to Germany to estimate the mass of WTBs until 2050. The results show that a total EoL WTB material mass of 698 kt is expected, consisting of 492 kt of glass fibre reinforced polymer WTBs and 206 kt of hybrid WTB material with a carbon fibre reinforced polymer mass share of approximately 12.4 kt. From 2024 onwards, a displacement of 64.4 km in the centre of gravity of the expected EoL WTB material stream towards the north-west coast of Germany could be observed. The authors demonstrate the novelty of the method and findings in relation to circular economy paths of EoL WTB material.

Associations between palliative-care consultations and end-of-life quality in cancer patients' last 6months.

Improving end-of-life (EOL) quality for terminally ill cancer patients is crucial. However, associations between hospice/palliative care and EOL quality, as perceived by patients, are underreported. We aimed to examine the impact of palliative care consultative services on the EOL quality during cancer patients' last six months. In this prospective, longitudinal study, 174 cancer patients were divided into a palliative care consultative services group (n = 65) or a non palliative care consultative services group (n = 109). The impact of palliative care consultative services on EOL quality, assessed using the Quality of Dying and Death (QODD) scale at the first and last assessments within the patients' last six months, was analyzed by linear regression with generalized estimating equations, adjusting for covariates. Cancer patients received palliative care consultative services a median of 34.0days before death. There were significant main effects of groups, indicating that patients receiving palliative care consultative services had better QODD total scores (β [95% confidence interval] = 2.12 [0.32,3.93], p = .021), death preparation (3.80 [1.71,5.89], p < .001), and treatment preferences than the reference group (3.27 [0.90,5.64], p = .007). No group differences were found in other dimensions, including symptom and personal care, whole person concern, and time with family. Palliative care consultative services significantly improved cancer patients' perceptions of death preparation, treatment preferences, and the QODD total score. Therefore, healthcare professionals should offer palliative care consultative services to cancer patients, initiate early referrals for such care, and implement effective and individualized interventions to enhance EOL quality.

Perspectives on advance care planning and related end-of-life care in people with heart failure: A Q methodology study.

Negative perspectives around advance care planning (ACP) prevent people with heart failure (HF) from preparing their end-of-life (EOL) effectively. A Q methodology study was conducted to identify types of ACP perspectives in Koreans with HF. The Q sample (31 statements representing ACP perspectives) was constructed through an extensive literature review and in-depth qualitative interview. The P sample (individuals with HF) completed each grid with a statement on the Q sorting table. The data were analyzed using the PQ program. Individuals with HF have both different and common perspectives on ACP. Three types of perspectives were identified: "positive acceptance," "contemplative support," and "hesitancy in acceptance." Common perspectives across types indicated that people with HF had positive attitudes toward ACP and emphasized their autonomy in EOL decisions. Clinicians need to consider these different and common perspectives on ACP to facilitate patients' engagement and provide relevant support.

Dyadic advance care planning: systematic review of patient–caregiver interventions and effects

IntroductionFamily caregiver’s involvement in advance care planning (ACP) is essential to provide high-quality end-of-life (EOL) care and to ease the surrogate decision-making burden. However, no systematic review has focused on...

Assessing the circularity and sustainability of circular carpets — a demonstration of circular life cycle sustainability assessment

Abstract Purpose Robust assessments are needed to identify the best circular economy (CE) approaches related to their contribution to achieving a CE by simultaneously considering the complexity of the three pillars of sustainability (environmental, economic, social). In this regard, the circular life cycle sustainability assessment (C-LCSA) framework was recently developed. This study aimed to demonstrate its applicability and capability of identifying trade-offs and interlinkages between the different dimensions using a case study of different CE approaches to carpet tiles. Methods C-LCSA integrates circularity and life cycle sustainability assessments (LCSA). Thus, this study applied the material circularity indicator (MCI) in parallel to life cycle assessment (LCA), life cycle costing (LCC), and social life cycle assessment (S-LCA). The last technique was applied as social hotspot assessment. Five CE approaches of carpet tiles produced in the US, including strategies like reducing the consumption of primary materials through recycled and bio-based feedstock or replacing carpet tiles for a longer overall service life, as well as recycling, were assessed and compared to their mainly linear counterpart. Results and discussion The study revealed that recycling carpet tiles containing recycled and bio-based materials at the end-of-life (EoL) resulted in the lowest global warming potential (8.47 kg CO2 eq.) and the highest circularity (MCI value of 0.76, with 1 indicating the maximum level of circularity) compared to the other scenarios. However, this scenario had a trade-off with a higher acidification potential (0.039 kg SO2 eq.) and higher costs (US$19.98) compared to the disposal scenario. On the other hand, the scenario using primary, non-bio-based materials in production and disposing of the carpet tiles at their EoL performed the worst in circularity (MCI value of 0.11) and implied high environmental impacts while being more cost-effective (US$10.27). Conclusions C-LCSA transparently revealed interlinkages in terms of circularity and the overall sustainability performance of different CE approaches. While no significant differences in terms of social hotspots were identified, approaches associated with a higher circularity and improved environmental performance in most impact categories tended to result in higher costs. This emphasized the need for individual and holistic assessments of the new CE approach to identify and address trade-offs. To enhance and foster C-LCSA in academia and industry, further studies applying the framework to different sectors are encouraged.

A study of the documentation of withholding and withdrawing life‐sustaining therapies in a tertiary intensive care unit in Hong Kong

AbstractBackgroundIn the Intensive Care Unit (ICU), recommended end‐of‐life (EOL) care practice encompasses do‐not‐attempt cardiopulmonary resuscitation (DNACPR), withholding (WH), and withdrawing (WD) life‐sustaining treatment (LST).ObjectivesOur study aims to evaluate the adequacy of physicians' documentation of EOL care practices.MethodsWe conducted a retrospective observational study, which evaluated the documentation of 18 pre‐identified critical components related to decision‐making, implementation, and communication of WD and WH of LST in a general medical‐surgical ICU of a tertiary hospital in the Hong Kong Special Administrative Region (HKSAR) of the People's Republic of China. One hundred twenty‐nine patients with EOL care before death were enrolled from 1 January 2013 to 31 March 2015. For documentation to be considered clear, the responsible ICU physician had to record notes in written form on the medical record.ResultsIn documenting the decision‐making process, the indication of patients' decision‐making capacity was present in 6.2% of the reviewed records. DNACPR orders were documented substantially poorer (51.6%) than WH/WD other LSTs (71.4%–96.9%) in documenting the implementation process. Reviewing the communication documentation showed that 15.5% detailed the process of determining the patient's previously expressed wishes, 16.3% included explanations of shared decisions and 5.4% covered substituted decisions. None of the patient records met the complete documentation criteria while 17% met the minimal compliance level, defined as records missing 30% or fewer items.ConclusionsDespite following international standards for EOL care, documentation by ICU physicians for key aspects of decision‐making, implementation, and communication for LST limitations was inadequate. Strategies to improve documentation should be encouraged.

Bereaved parent preferences on quality end-of-life care for children with cancer in the South.

The authors sought to understand bereaved family preferences for end-of-life (EOL) care, particularly among Black families and those in the South. Semi-structured interviews were conducted with parents of children who died of cancer ≥6 months before at Children's of Alabama. Themes were identified via content analysis. Quotes related to medical intensity, chemotherapy, and location of death (LOD) were scored on 5-point Likert scales, ranging from 1 (comfort care, chemotherapy, or home death) to 5 (medically intense care, avoidance of chemotherapy, or hospital death). Twenty-seven bereaved parents (12 Black) were interviewed. Children died at a mean of 13.1 years (SD=6.1 years) and a median of 3 years before the interview (range=1-12 years). Ten children (42%) had central nervous system tumors and the majority (63%) died in the hospital. Family decision-making involved maintaining hope, not causing harm, doing what was best for their child and themselves, and religious beliefs. There was no clear preference for home versus hospital death (3.0 [1.8-4.0]). Instead, parents considered their child's desires and/or medical needs, siblings, and prior experiences with death. To have a comfortable death, parents highlighted the need for comprehensive education about their child's EOL, a caring and comfortable environment, and 24/7 access to their care team. Families expressed a dual preference for comfort care (1.8 [1.3-2.8]) and chemotherapy (3.5 [2.7-4.1]) at EOL. Families did not see chemotherapy and comfort care as conflicting goals. They sought quality care emphasizing flexibility, quality time with their child, and open access to their care team, regardless of LOD.

Identifying and modelling the barriers to returns of end-of-life (EOL) heavy-duty machinery in Nigeria: A consumers’ perspective

EOL product returns has become more prevalently practiced in companies in developed nations as a response to government's strict regulations and customers' expectations. Correspondingly, there is a growing body of theoretical literature on the topic within this context as a crucial strategy to accelerate the development of the circular economy (CE). However, consumers' participation in EOL returns of heavy-duty machinery is immature in developing nations due to barriers, and studies are scarce on the analysis of the barriers. To fill this gap, this study aims to identify and analyze the barriers that hinder consumers' participation in EOL returns of heavy-duty machinery within a developing nation-Nigeria. Barriers were identified from published literature and experts' inputs and then, classified under technological, organizational, and environmental (supply chain) categories. Then, analysis was done via a methodology integrating interval-valued neutrosophic analytical hierarchy process (IVN-AHP) with multi-objective optimization on the basis of a ratio analysis plus the full multiplicative form (MULTIMOORA). Findings indicate that the environmental(supply chain) barriers rank the highest, followed by technological barriers. Specifically, consumers participation in EOL returns of heavy-duty machinery in Nigeria is mostly hindered by lack of regulations, lack of financial incentives, lack of skills, undeveloped reverse logistics system and poor access to facilities for recovery operations. Furthermore, we proposed some strategies to support stakeholders to mitigate the barriers. Thus, this study gives valuable guidelines to decision-makers to enable the transition to a CE paradigm in the heavy-duty sector within developing nations for utmost sustainability.

Organisational learning through a charitable trust-initiated project focusing on end-of-life care

PurposeWe identify lessons from a project sponsored by a large charitable trust, which sought to build capability for end-of-life (EOL) care in Hong Kong through interdisciplinary and multi-agency collaboration.Design/methodology/approachAn in-depth case study drawing on 21 in-depth interviews with diverse stakeholders was conducted. Lyman et al.’s (2018) model of organisational learning (OL) in healthcare settings was applied to analyse the relative emphasis on particular contextual factors and mechanisms, and to identify outcomes perceived to have been achieved.FindingsInfrastructure such as materials for assessment and education received the most emphasis among the contextual factors and deliberate learning such as training sessions received the greatest attention among the mechanisms. While perceptions indicated that desired outcomes were being achieved in terms of social impact, there were relatively few mentions of “soft” factors such as enhanced motivation, leadership or OL skills among staff.Originality/valueThis study extends the literature on how to create valuable social impact through OL. While prior studies have examined social impact in terms of solutions for social and environmental problems, ours is one of the few that examines how improvements are made to organisations’ capability to deliver such impacts in the context of healthcare.

Towards end-of-life of photovoltaic systems in Malaysia: An assessment of management strategies using a life cycle approach

This paper presents the development of photovoltaic (PV) end-of-life (EoL) policy options in Malaysia with consideration of the respective environmental impacts and economic implication. Five policy options were initially formulated based on different combinations of voluntary and regulatory approaches, PV module EoL pathways, i.e. recycling, landfill and incineration, and types of EoL PV modules. Then, the environmental impacts of each option were evaluated using life cycle assessment based on seven relevant impact categories. Later, the economic implication of each policy option was determined based on revenue gained from recovered materials and cost of recycling. Results showed that recycling yields net environmental benefits in all impact categories for crystalline silicon (c-Si) modules and almost all impact categories for cadmium telluride (CdTe) modules. While both regulatory and voluntary approaches offer reduced environmental impacts, the former is more beneficial than the latter as it provides higher quantity of recycled EoL PV modules, net environmental benefit, net primary energy avoidance and net economic benefit. Also, the inclusion of both c-Si and CdTe in recycling is preferred as it yields higher quantity of recycled PV modules as well as higher net environmental benefit and net primary energy avoidance gained in most impact categories. However, the net economic benefit is lower than recycling c-Si alone because the cost of recycling CdTe modules is higher than the revenue gained from recovered materials. These findings seek to assist in establishing sustainable EoL PV management.

Palliative Care Experiences Among Adults From Underrepresented Racial and Ethnic Groups in the United States: A Scoping Review.

Patients from underrepresented racial and ethnic groups (URGs) in the United States (US) experience disparities in accessing palliative care (PC) at the end of life (EOL). Additionally, little effort has been made to understand their experiences with PC. To identify and synthesize existing literature on PC experiences among adults from URGs in nursing homes, community settings, and hospitals in the US. Guided by the Joanna Briggs Institute methodological recommendation and Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews, we conducted a scoping review. We searched PubMed, EMBASE, CINAHL, Scopus, and ProQuest Dissertations & Theses Global from inception to January 2024. We included five studies representing Hispanic/Latino, American Indian, African/Black American, and Chinese individuals. Data were organized around two themes: navigating PC pathway and choices and practices during PC. Navigating PC pathway theme highlights that despite the several barriers URGs face when accessing PC, they seek PC services due to their limited formal family assistance in managing their chronic conditions and pain. The choices and practices during PC theme emphasize the roles URG family members play in EOL care, the patient's care preferences, and their spiritual practices and beliefs related to EOL care. This scoping review reveals limited literature about URG experiences with PC and highlights the need for more studies to focus on making PC services more accessible to URGs and providing culturally sensitive care to meet the needs of the diverse growing US population.

Aggregated planning to solve multi-product multi-period disassembly line balancing problem by considering multi-manned stations: A generic optimization model and solution algorithms

Disassembly lines are crucial in the recovery process of end-of-life (EOL) products, facilitating the systematic extraction of parts to meet predetermined objectives. While previous studies have made significant advancements, they have not addressed the disassembly line planning and balancing problem by focusing on the real-life significance of combining long-term decision-making and short-term operational missions. This study fills this gap by combining multi-product, multi-period, and multi-manned disassembly line concepts into a novel integrated approach. Initially, a generic optimization model is formulated, incorporating the concept of multi-manned stations. Subsequently, genetic algorithm (GA)-based solution approaches are developed to address the problem’s complexity. Three tactical-level policies, including economic disassembly quantity (EDQ), just-in-time (JIT), and random (R) based lot size policies, are explored within the algorithms. Additionally, simulated annealing-based local search algorithms and two crossover operators, CR1 and CR2, are incorporated to enhance solution quality. Through computational analysis, six algorithms are evaluated, with the GACR1-JIT algorithm demonstrating significant cost reductions compared to alternatives. The findings underscore the growing importance of JIT-based lot size policies, particularly with an increasing number of periods. This research bridges theoretical and practical considerations by highlighting the strategic importance of combining long-term disassembly line planning and short-term lot sizing decisions to improve system performance.

A Tale of 2 Experiences: Navigating End-of-Life Care With a History of Incarceration.

The adverse health effects of incarceration are well-documented, affecting individuals throughout their life course. However, the influence of a history of incarceration on end-of-life (EOL) experiences remains unexplored. This study aims to examine how prior incarceration affects individuals' experiences and care needs as they approach the EOL. Leveraging the Health and Retirement Study, we conducted secondary analyses on 1710 individuals who participated between 2012 and 2018. Through retrospective cohort analysis, we explored the association between incarceration history and EOL care, focusing on pain and symptom burden. Analyses showed that individuals with a history of incarceration experienced significantly higher levels of pain (65% reported "moderate" or "severe" pain) compared tononincarceratedindividuals (50%; adjusted odds ratio = 1.45, 95% confidence interval [CI]: 1.22-1.71, p < .001). Additionally, the symptom burden index revealed that formerly incarcerated individuals had a higher average symptom score (2.8 vs 2.1; β = 0.7, 95% CI: 0.5-0.9, p < .001), indicating a greater range of symptoms in their final year of life. These disparities persisted after adjusting for demographic, health, and socioeconomic variables. This study reveals that a history of incarceration significantly affects EOL experiences, with formerly incarcerated individuals facing higher levels of pain and a greater symptom burden compared tononincarceratedindividuals. This underscores the need for tailored palliative care to address the unique needs of this vulnerable population. This research highlights a critical area for intervention and calls for healthcare systems to adapt their practices to better serve those with incarceration histories.

Hybrid closed-loop supply chain with different collection competition in reverse channel

In the hybrid closed-loop supply chain (CLSC) with diverse collectors, customers increasingly prioritize the convenience in returning end-of-life (EOL) products. This trend necessitates supply chain entities to enhance their collection service to address the intensifying competition for EOL products collection. To devise appropriate convenience and pricing strategies, we construct a hybrid game-theoretic CLSC model encompassing a manufacturer, a retailer, and a third-party collector, and we propose new collection functions that cater to varying levels of collection competition, spanning monopoly, duopoly, and hybrid competitive scenarios. Furthermore, we delve into the influence of customers' preferences or distrust towards a specific collector on the collection competition, which is caused by factors such as more convenient offline stores or unqualified recycling process. Our study first reveals that collection competition is affected by all collectors' convenience strategies, while the total collection rate is dominated by the most preferred collectors' convenience strategy. Second, both customer's preference and distrust negatively affect pricing and convenience strategies, albeit with differing effects on collection rates across various competition levels. Notably, channel distrust exerts a more substantial influence on manufacturers' and third-party collectors' strategies. Third, we also examine how competitive collection and customer behavior shape the proportion of collected products destined for different recovery options, i.e., remanufacturing and recycling, as well as the overall efficiency of recovering collected products across the entire supply chain. And channel preference plays a more positive role in enhancing the overall collection rate for the supply chain.

Parent-Clinician Communication and Prolonged Grief in Parents Whose Child Died From Cancer

ContextParent-clinician communication is essential for high-quality end-of-life (EOL) care in children with cancer. However, it is unknown how parent-clinician communication affects parents’ experience in the first two years after their child's death. ObjectivesTo examine the association between communication and prolonged grief among parents whose child died from cancer and to explore the mediation effect of preparation for EOL care. MethodsWe analyzed data from a cross-sectional survey of parents of children who died from cancer in the prior 6-24 months. We used multiple linear regression to examine the association between communication variables and prolonged grief symptoms. We also examined how preparation for EOL mediates these associations. ResultsAcross N = 124 parents, the mean age was 46 years, 82% were White, and 64% were mothers. The average PG-13 sum score was 32.7 ± 10.6 (range 11-55, with higher scores indicating greater symptom severity). Most parents reported “very good/excellent” communication with clinicians (80%), adequate prognostic information (64%), and high levels of trust (90%). Nearly 39% of parents reported feeling “not at all prepared” for their child's EOL. Compared to parents who wanted more prognostic information, parents who perceived prognostic information to be adequate had significantly lower PG-13 sum scores (36.4 ± 10.8 vs. 30.5 ± 10.1, F = 9.26, P = 0.003). Preparation for EOL fully mediated this association. ConclusionEarly bereaved parents report severe prolonged grief symptoms. Interventions focused on providing adequate prognostic information and improving preparation for EOL may mitigate parental prolonged grief symptoms in the first two years of their bereavement.

Advance Directives Revisited (2002 vs. 2023): Are We Closer to Uniformity?

Advance directives (AD) are based on state-specific statutes that vary in structure, terminology, and options. This variability leads to inconsistent end-of-life (EOL) care for patients who have executed an AD in one state but fall ill in another state. This study revisits a 2002 article that identified considerable differences in ADs to determine whether ADs have become more uniform. ADs from all 50 states and the District of Columbia were examined to determine the frequency of document types and seven key issues. The results were = compared to the 2002 study using non-parametric approaches. Mean numbers of key issues were compared using t-tests and one-way ANOVA. Consistent with 2002, three states in 2023 provide statutes for Health Care Power of Attorney (HCPOA). However, states offering a combined HCPOA, and living will (LW), deemed an advance directive for health care (ADHC), increased from 13 to 30. Between both studies, Long Term Care increased significantly in LW and ADHC, while Artificial Sustenance significantly increased in LW. Despite the rising prevalence of Alzheimer's in the United States, only 10% of states included this issue in 2023. Despite evolving healthcare trends, minimal revisions have been made to ADs since 2002. This lack of uniformity can cause confusion regarding proper understanding of EOL wishes. The authors recommend that the Uniform Act for Advance Directives be revisited to promote greater uniformity in ADs and ensure that individuals' preferences are understood and respected across different states.

Understanding in-Plane Movement of Iridium in Proton Exchange Membrane Electrolyzer after Accelerated Stress Test

In the rapidly evolving field of clean energy, proton exchange membrane water electrolyzers (PEMWEs) stand at the forefront, heralding a new era of sustainable hydrogen fuel production. PEMWEs need to operate for at least 10 years and material degradation is a challenge that needs to be overcome. Here we use H2NEW accelerated stress (AST) protocol to degrade 5 cm2 PEMWE cell having low iridium loadings on the anode side. Using X-ray fluorescence (XRF) mapping, we first assessed the iridium distribution at the beginning of life (BOL) of the electrolyzer cell and then afterwards at the end of life (EOL). Regular electrical characterization with specific time intervals was conducted, such as collection of polarization curves, electrochemical impedance spectroscopy and cyclic voltammetry. Identical location was selected for iridium mapping. To complement XRF mapping, we also conducted X-ray diffraction (XRD) studies at the BOL and at the EOL. XRD reveals the crystalline structure and phase transitions of iridium, crucial for understanding how iridium’s atomic arrangement adapts to operational stresses. This comprehensive approach, combining XRF and XRD, aims to provide a multifaceted view of iridium’s behavior, distribution, and structural changes from the BOL to EOL. This research aims to unravel the behavior of iridium after AST, particularly whether it migrates into the ionomer, moves to the cathode, or undergoes other transformational shifts.Figure 1.micro-XRF map of iridium distribution on the anode of the PEMWE at the BOL. The map is 2 mm x 2 mm. Figure 1

Durability Investigation of Low Pt-Loaded PEM Fuel Cells with Different Catalyst Layer Morphologies

Low-temperature Polymer Electrolyte Membrane Fuel Cells (PEMFCs) emerge as the most promising fuel cell technology for transportation. Despite the growing interest in fuel cell electric vehicles (FCEVs) motivated by their rapid refueling, high power density, and long-range, their commercialization lags behind that of battery electric vehicles (BEVs) and internal combustion engine vehicles (ICVs). Apart from the lack of hydrogen infrastructure, other primary bottleneck lies in the cost-intensive production of essential components, particularly the dependence on noble metals such as platinum (Pt) to achieve high catalytic activity in the catalyst layer (CL). Simultaneously, meeting durability requirements for long-term performance and stability proposes another challenge. Therefore, enhancing the durability of PEM fuel cell systems without compromising performance and cost presents a significant challenge which stems from the trade-off relationships among these factors. The current target set by the U.S. Department of Energy (DOE) is achieving a durability of 8,000 hours of operation time, meaning 15,000 miles of driving, with less than 10% performance degradation using a 0.1 mg/cm2 Pt-loaded catalyst.The CL is a complex, heterogeneous structure composed of multiple components with different functionalities, and the electrochemical reaction takes place at the interfaces of the components. Several requirements are essential for the CL, including the presence of highly-dispersed Pt sites with high catalytic activity, a continuous path for efficient proton transport and electron conduction, and a through-connected pore network facilitating gas transport and water removal. Extensive research has been directed toward reducing Pt loading in the CL , motivated by the high cost and limited availability of Pt. At low Pt-loadings, researchers detailed the increased oxygen transport resistance within the CL, which is attributed to the reduction of active sites, as well as the heightened flux of reactants near each active site [1]. Therefore, optimizing the CL, both in terms of mass transport and reaction rate, as well as meeting economic and technical requirements, poses a significant challenge. While the impact of CL compositions on the cell performance is studied previously [2][3], systematic investigations are necessary to reveal the effect of CL characteristics on the electrode degradation. The understanding of performance losses during degradation processes is necessary for optimizing the CL for long-term operation and reducing Pt-loading in the cathode without compromising cell durability.This work aims on tailoring the impact of CL characteristics on electrode degradation for low Pt-loaded cells. To achieve this, five different samples with distinct CL features including Pt-loading, CL thickness, Pt/C ratio, and dilution ratio are fabricated. The samples are fabricated using the catalyst-coated membrane approach to suppress interfacial resistances between the membrane and the ionomer in the CL. In addition, a novel ultrasonic deposition method is employed to develop uniform and ultra-thin CLs enabling precise control of the CL thickness. With the use of an accelerated stress test (AST) ranging within 0.6-1 V in an air/H2 environment, the performance loss of the samples at the beginning-of-life (BOL), end-of-life (EOL) and at different stages during the applied AST is investigated. This experimental study serves as a foundational exploration into comprehending the individual impacts of CL compositions on electrode degradation and establishes the framework for the design of durable low Pt-loaded PEM fuel cells.

End-of-life care for the devout Jewish patient.

The Joint Commission emphasizes the importance of cultural competence and effective communication in quality medical care, particularly during end-of-life (EOL), when decisions are influenced by diverse cultural and religious backgrounds. For Orthodox Jewish patients, the philosophical framework used for EOL decision-making may conflict with that used in traditional Western medical ethics. In this paper, we explore the complexities of EOL decision-making for devout Jewish patients and highlight how approaches may differ from a Western ethical framework. This paper aims to familiarize clinicians with EOL preferences of Orthodox Jewish patients, organized into an ethical framework called 'casuistic deontology'. Leading with an open-minded approach emphasizing cultural humility, we explore ways in which integrating this perspective can allow for culturally appropriate and compassionate EOL care. Using a case study methodology, we focus on a 79-year-old Orthodox Jewish male hospitalized with severe injuries. The patient's medical course is analyzed, highlighting how the decisions made by his family in consultation with their Rabbi may differ from the decisions made with a philosophy of a Western ethical framework. This case illustrates the ethical tensions that may arise when Western medical practices intersect with Orthodox Jewish beliefs, particularly regarding brain death, resuscitation, and artificial nutrition. We underscore the need for cultural sensitivity when approaching EOL decision-making, allowing for compassionate and comprehensive care that respects religious perspectives. This paper helps provide a structure for clinicians to navigate the complex EOL care needs for the devout Jewish patient in a manner consistent with their cultural and religious identity.

Compassionate Ventilator Release in Patients With Neuromuscular Disease: A Two-Case Comparison

Dyspnea, the subjective sensation of breathlessness, is a distressing and potentially traumatic symptom. Dyspnea associated with mechanical ventilation may contribute to intensive care unit (ICU) associated post-traumatic stress disorder and impaired quality of life. Dyspnea is both difficult to alleviate and a cause of significant distress to patients, their loved ones, and care providers People living with neuromuscular disease, such as amyotrophic lateral sclerosis (ALS) or myasthenia gravis (MG), often rely on a ventilator at late stages of illness due to complications of progressive respiratory muscle weakness and paralysis. When unable to wean from the ventilator, conversations turn towards goals of care and release from the ventilator for comfort and end of life (EOL). Patients with and without neuromuscular disease have high risk for dyspnea at EOL upon ventilator liberation. Although limited recommendations have been published specific to patients with ALS, no guidelines currently exist for the terminal liberation from mechanical ventilation in patients experiencing respiratory muscle insufficiency from a neuromuscular disease. Further research on this topic is needed, including creation of a protocol for ventilator release in patients with neuromuscular disease. The following case reports detail the dissimilar EOL experiences of two patients with different forms of neuromuscular disease.