Quality Of Dying Research Articles

Adapting and Using the Quality of Dying and Death Questionnaire.

Adapting and Using the Quality of Dying and Death Questionnaire.

The quality of death and dying of patients under at home palliative care, evaluated by family and friends of the patient

INTRODUCTION: In Poland, there are no studies on the quality of dying and the moment of death. Studies described in the literature involve mostly the quality of life, care and treatment. Results of public surveys show that people have a lot of expectations of both the process and the moment of death. People pay attention to more and more widely known phenomenon of “good death and quality of dying”, especially in patients whose prognosis is not positive and the causative treatment process was terminated. The main objective of the work was to research the quality of the process of dying, and the moment of death within patients in terminal state, that were under free, at-home palliative care. MATERIAL AND METHODS: Study material was gathered with a validated, translated into polish language, anonymous sheet QODD — The Quality of Dying and Death. The group of recipients are families and friends who took care of a dying patient, who was taken care of by a Home Hospice Centre of the Congregation of Marian Fathers in Warsaw. Research material was being gathered since the beginning of 2016–2018. The original QODD questionnaire consists of 31 questions, although modified versions with 17 questions exist. The questionnaire with 31 questions was used in the research. RESULTS: 150 questionnaires were collected (150 deceased people). The vast majority, i.e. 78 (52%) of the group were women, the remaining percentage of 72 (48%) were men. The patients very often controlled the situation they were in, were able to independently consume a meal. In most cases they did not feel dyspnoea, which is a measurable indicator of symptom control and improves the quality of life. Very frequently the patients were not at peace with death, but in most cases, they did not feel fear. Very frequently spent time with spouses, close ones and children. In most cases, the patients did not want to talk about the funeral ceremony but mostly they got to say goodbye to their loved ones. In most cases the patients never felt the need to hurry the process of death, but they also did not want to use life-supporting options. Regardless of their awareness of death the patients still had a purpose in life. CONCLUSIONS: There are a lot of advantages coming from the research. They can be separated into two areas: Medical: improving the quality of life, ability to contract benefits as a result of an evaluation of the care process in at-home palliative care. Research: comparison of the quality of dying in patients of at-home palliative care with stationary care, comparison of individual providers among each other, researching the quality of death within various illnesses, researching the quality of death and dying in children.

Families' Experiences With End-of-Life Care in Nursing Homes and Associations With Dying Peacefully With Dementia

ObjectivesTo examine family caregivers' experiences with end-of-life care for nursing home residents with dementia and associations with the residents dying peacefully. DesignA secondary data analysis of family caregiver data collected in the observational Dutch End of Life in Dementia (DEOLD) study between 2007 and 2010. Setting and participantsData were collected at 34 Dutch nursing homes (2799 beds) representing the nation. We included 252 reports from bereaved family members of nursing home residents with dementia. MeasuresThe primary outcome was dying peacefully, assessed by family members using an item from the Quality of Dying in Long-term Care instrument. Unpleasant experiences with end-of-life care were investigated using open-ended questions. Overall satisfaction with end-of-life care was assessed with the End-of-Life Satisfaction With Care (EOLD-SWC) scale, and families' appraisal of decision making was measured with the Decision Satisfaction Inventory. Associations were investigated with multilevel linear regression analyses using generalized estimating equations. ResultsFamilies' reports of unpleasant experiences translated into 2 themes: neglect and lack of respect. Neglect involved facing inaccessibility, disinterest, or discontinuity of relations, and negligence in tailored care and information. Lack of respect involved perceptions of being purposefully disregarded, an insensitive approach towards resident and family, noncompliance with agreements, and violations of privacy. Unpleasant experiences with end-of-life care were negatively associated with families' perceptions of the resident dying peacefully. Families' assessment of their relative dying peacefully was positively associated with satisfaction with end-of-life care and decision making. Conclusions/ImplicationsFamilies' reports of unpleasant experiences with end-of-life care may inform practice to improve perceived quality of dying of their loved ones. Humane and compassionate care and attention from physicians and other staff for resident and family may facilitate recollections of a peaceful death.

Comparative Study of Quality of End of Life Between LGBTQ and Non-LGBTQ Hospice Patients (TH340B)

•List the similarities and differences in the quality of dying and death in LGBTQ and non-LGBTQ individuals receiving hospice care.•Describe the need for research in LGBTQ experiences in hospice care.•Discuss need for incorporating LGBTQ training for hospice providers. While there is evidence that lesbian, gay, bisexual, transgender, and queer (LGBTQ) people experience health inequities when compared to the non-LGBTQ population, this phenomenon has not been adequately explored in hospice care. Understanding whether disparities exist at the end of life may assist health care providers in supporting LGBTQ patients and family members. The purpose of this study was to compare the quality of dying and death of LGBTQ people with non-LGBTQ people in order to determine whether the inequities found in other healthcare settings extend to hospice. A primarily quantitative comparative descriptive study was implemented to explore the difference between groups. The Quality of Dying and Death Version 3.2a Family Member/Friend After-Death Self-Administered Questionnaire was modified to exclude ICU-specific instructions to collect quantitative data via online surveys. This instrument contains 22 items measuring aspects of the end-of-life experience (QODD-22) and an additional single item rating the overall quality of dying and death (QODD-1). Family members and close friends of adults who died under hospice care in the previous five years were recruited. A total of 122 data sets (66 from family members of non-LGBTQ individuals and 56 from family members of LGBTQ individuals) were included in the final analysis. These results are from preliminary analysis, final analysis will be completed by February 2019. The non-LGBTQ group had eleven QODD-22 mean scores higher than the highest QODD-22 mean score in the LGBTQ group, indicating better quality of dying and death in the non-LGBTQ group across numerous aspects of the end-of-life experience. A comparison of QODD-1 scores between the LGBTQ and non-LGBTQ groups revealed statistically significant differences (p=0.035). Based on these findings, there is evidence that LGBTQ individuals experience a poorer quality end of life than non-LGBTQ individuals.

Correction: Palliative care team consultation and quality of death and dying in a university hospital: A secondary analysis of a prospective study.

[This corrects the article DOI: 10.1371/journal.pone.0201191.].

Quality of dying and quality of end-of-life care of nursing home residents in six countries: An epidemiological study

Background: Nursing homes are among the most common places of death in many countries. Aim: To determine the quality of dying and end-of-life care of nursing home residents in six European countries. Design: Epidemiological survey in a proportionally stratified random sample of nursing homes. We identified all deaths of residents of the preceding 3-month period. Main outcomes: quality of dying in the last week of life (measured using End-of-Life in Dementia Scales – Comfort Assessment while Dying (EOLD-CAD)); quality of end-of-life care in the last month of life (measured using Quality of Dying in Long-Term Care (QoD-LTC) scale). Higher scores indicate better quality. Setting/participants: Three hundred and twenty-two nursing homes in Belgium, Finland, Italy, the Netherlands, Poland and England. Participants were staff (nurses or care assistants) most involved in each resident’s care. Results: Staff returned questionnaires regarding 1384 (81.6%) of 1696 deceased residents. The End-of-Life in Dementia Scales – Comfort Assessment while Dying mean score (95% confidence interval) (theoretical 14–42) ranged from 29.9 (27.6; 32.2) in Italy to 33.9 (31.5; 36.3) in England. The Quality of Dying in Long-Term Care mean score (95% confidence interval) (theoretical 11–55) ranged from 35.0 (31.8; 38.3) in Italy to 44.1 (40.7; 47.4) in England. A higher End-of-Life in Dementia Scales – Comfort Assessment while Dying score was associated with country (p = 0.027), older age (p = 0.012), length of stay ⩾1 year (p = 0.034), higher functional status (p < 0.001). A higher Quality of Dying in Long-Term Care score was associated with country (p < 0.001), older age (p < 0.001), length of stay ⩾1 year (p < 0.001), higher functional status (p = 0.002), absence of dementia (p = 0.001), death in nursing home (p = 0.033). Conclusion: The quality of dying and quality of end-of-life care in nursing homes in the countries studied are not optimal. This includes countries with high levels of palliative care development in nursing homes such as Belgium, the Netherlands and England.

Technical-efficiency analysis of end-of-life care in long-term care facilities within Europe: A cross-sectional study of deceased residents in 6 EU countries (PACE).

BackgroundAn ageing population in the EU leads to a higher need of long-term institutional care at the end of life. At the same time, healthcare costs rise while resources remain limited. Consequently, an urgency to extend our knowledge on factors affecting efficiency of long-term care facilities (LTCFs) arises. This study aims to investigate and explain variation in technical efficiency of end-of-life care within and between LTCFs of six EU countries: Belgium (Flanders), England, Finland, Italy, the Netherlands and Poland. In this study, technical efficiency reflects the LTCFs’ ability to obtain maximal quality of life (QoL) and quality of dying (QoD) for residents from a given set of resource inputs (personnel and capacity).MethodsCross-sectional data were collected by means of questionnaires on deceased residents identified by LTCFs over a three-month period. An output-oriented data-envelopment analysis (DEA) was performed, producing efficiency scores, incorporating personnel and capacity as input and QoL and QoD as output. Scenario analysis was conducted. Regression analysis was performed on explanatory (country, LTCF type, ownership, availability of palliative care and opioids) and case mix (disease severity) variables.Results133 LTCFs of only one type (onsite nurses and offsite GPs) were considered in order to reduce heterogeneity. Variation in LTCF efficiency was found across as well as within countries. This variation was not explained by country, ownership, availability of palliative care or opioids. However, in the ‘hands-on care at the bedside’ scenario, i.e. only taking into account nursing and care assistants as input, Poland (p = 0.00) and Finland (p = 0.04) seemed to be most efficient.ConclusionsEfficiency of LTCFs differed extensively across as well as within countries, indicating room for considerable efficiency improvement. Our findings should be interpreted cautiously, as comprehensive comparative EU-wide research is challenging as it is influenced by many factors.

Palliative care team consultation and quality of death and dying in a university hospital: A secondary analysis of a prospective study.

PurposeInvolvement of palliative care experts improves the quality of life and satisfaction with care of patients who are in the last stage of life. However, little is known about the relation between palliative care expert involvement and quality of dying (QOD) in the hospital. We studied the association between palliative care team (PCT) consultation and QOD in the hospital as experienced by relatives.MethodsWe conducted a secondary analysis of data from a prospective study among relatives of patients who died from cancer in a university hospital and compared characteristics and QOD of patients for whom the PCT was or was not consulted.Results175 out of 343 (51%) relatives responded to the questionnaire. In multivariable linear regression PCT was associated with a 1.0 point better QOD (95% CI 0.07–1.96). In most of the subdomains of QOD, we found a non-significant trend towards a more favorable outcome for patients for whom the PCT was consulted. Patients for whom the PCT was consulted had more often discussed their preferences for medical treatment, had more often been aware of their imminent death and had more often been at peace with their imminent death. Further, patients for whom the PCT was consulted and their relatives had more often been able to say goodbye. Relatives had also more often been present at the moment of death when a PCT had been consulted.ConclusionFor patients dying in the hospital, palliative care consultation is associated with a favorable QOD.

Informal Caregiving Networks for Hospice Patients With Cancer and Their Impact on Outcomes: A Brief Report.

This prospective study investigates informal care networks and their impact on hospice outcomes. Primary caregivers (N = 47) were the main source of data from 2 time points: within a week of enrollment in hospice and bereavement. Data were also collected from 42 secondary caregivers. Intraclass correlation coefficients (ICCs) determined correspondence between primary and secondary caregivers regarding informal care network size. Correlations were used to test associations between variables. Nonparametric paired sample tests were used to analyze change in anger and guilt. The ICC found poor correspondence (-0.13) between primary and secondary caregivers' network descriptions. Correlational analyses found a strong/moderate negative association between quality of dying (QOD) and grief (r = -0.605, P < .05). Study participants reported increased anger (0.4, P < .05, range 1-5) and guilt (0.4, P < .05, range 1-5), particularly among caregivers with high levels of support. Findings suggest that improving QOD may facilitate postdeath coping for caregivers.

The Quality of Dying and Death in a Residential Hospice

ContextResidential hospices may be an optimal compromise between home and hospital settings for end-of-life care, but there has been little systematic research regarding the quality of dying and death in such locations. ObjectivesThe objective of this study was to assess the quality of dying and death of patients who received end-of-life care in a residential hospice and its relationship to hospice length of stay (LOS) and prior receipt of palliative care. MethodsA total of 100 caregivers of patients who died in a residential hospice in downtown Toronto, Canada, were recruited four to six months after patient's death. The quality of dying and death was measured, based on interviews with bereaved caregivers, using the Quality of Dying and Death (QODD) questionnaire. ResultsThe overall mean QODD score was 68.85 ± 11.62, which is in the intermediate (“neither good nor bad”) range (30–70) of the scale. The lowest QODD subscale score was on the Transcendence subscale, which evaluates death-related concerns; this was 59.48 ± 25.37, with ratings in 14.6% of the sample in the “terrible to poor” (0–29) range. QODD scores were higher for patients with hospice LOS of more than one week (72.21 ± 9.64) than for those with a shorter LOS (60.38 ± 11.92) (P < 0.001). ConclusionOverall quality of dying and death was perceived as average to above average, in an urban residential hospice, although death-related distress was present in a substantial minority of patients. The association of better QODD with hospice LOS of more than one week may be due to better clinical status on admission and/or longer duration of time that is needed to achieve optimal outcomes.

AVALIAÇÃO DA SATISFAÇÃO DE FAMILIARES DE PACIENTES ATENDIDOS EM UNIDADES DE TERAPIA INTENSIVA: REVISÃO INTEGRATIVA

RESUMO Objetivo: analisar a produção científica relacionada às evidências acerca da satisfação de familiares de pacientes de UTI e os instrumentos utilizados para sua avaliação. Metodo: revisão integrativa na qual foram analisados artigos publicados entre 2005 e 2015, em inglês, português ou espanhol, nas bases de dados PUBMED/MEDLINE e LILACS e a biblioteca SciELO. Utilizou-se como estratégia de busca: personal satisfactional OR satisfaction AND family. Para coleta de dados dos artigos elaborou-se um instrumento com informações como: título, autores, ano de publicação e revista, objetivo do estudo, delineamento, participantes, local da pesquisa, temática principal e resultados. Resultados: atenderam aos critérios de inclusão 27 produções. Foram identificados quatro instrumentos utilizados para avaliar a satisfação de familiares de pacientes na UTI o Critical Care Family Satisfaction Survey, Family Satisfaction in the Intensive Care Unit, Critical Care Family Needs Inventory e o Quality of Dying and Death. Os estudos abordaram a satisfação dos familiares em relação às suas necessidades e tomadas de decisão, satisfação quanto a cuidados paliativos, evidenciou-se, ainda, estudos de adaptação transcultural e validação de instrumentos. Quanto ao nível de evidência, os estudos se concentram nos níveis II a VI. Conclusão: a análise da produção científica sobre a satisfação de familiares de pacientes de UTI permitiu evidenciar que o fator que mais contribui na promoção da satisfação da família foi a qualidade do atendimento.

Objective Functions for the Shape Optimization of Temperature Control Channels in High‐Pressure Die Casting

AbstractIn high‐pressure die casting, the quality of the produced cast parts highly depends on the die quality. One die component are temperature control channels. The state‐of‐the art approach for the temperature control channels are boreholes drilled from the sides into the die that are afterwards formed into a closed flow channel by inserting plugs.Since additive manufacturing methods are available to manufacture the dies, an obvious step is to construct more advanced temperature control channels. The shape of these free‐form channels can be obtained by numerical optimization.To find the optimal shape of the channels, appropriate objective functions are required. This contribution is focused on such objective functions. (© 2017 Wiley‐VCH Verlag GmbH &amp; Co. KGaA, Weinheim)

End-of-Life Care and Quality of Dying in 23 Acute Geriatric Hospital Wards in Flanders, Belgium

ObjectivesTo describe the nursing and medical interventions performed in the last 48 hours of life and the quality of dying of patients dying in acute geriatric hospital wards. MethodsCross-sectional descriptive study between October 1, 2012 and September 30, 2013. Twenty-three acute geriatric wards in 13 hospitals in Flanders, Belgium. Patients hospitalized for more than 48 hours before dying in the participating wards. Structured after-death questionnaires, filled out by the nurse, the physician, and the family carer most involved in end-of-life care. Main outcome measures were several nursing and medical interventions reported to be performed in the last 48 hours of life and the quality of dying. ResultsOf 993 patients, we included 338 (mean age 85.7 years; 173 women). Almost 58% had dementia and nearly half were unable to communicate in the last 48 hours of their life. The most frequently continued or started nursing and medical interventions in the last 48 hours of life were measuring temperature (91.6%), repositioning (83.3%), washing (89.5%), oxygen therapy (49.7%), and intravenous fluids and nutrition (30%). Shortness of breath, lack of serenity, lack of peace, and lack of calm were symptoms reported most frequently by nurses and family carers. ConclusionMany nursing and medical interventions are continued or started in the last hours of a patient's life, which may not always be in their best interests. Furthermore, patients dying in acute geriatric wards are often affected by several symptoms.

Comparing Quality of Dying and Death Perceived by Family Members and Nurses for Patients Dying in US and Dutch ICUs

The Quality of Dying and Death (QODD) questionnaire is used as a self-reported measure to allow families and clinicians to assess patients' quality of dying and death. We evaluated end-of-life (EOL) experiences as measured by the QODD completed by families and nurses in the United States and the Netherlands to explore similarities and differences in these experiences and identify opportunities for improving EOL care. Questionnaire data were gathered from family members of patients dying in the ICU and nurses caring for these patients. In The Netherlands, data were gathered in three teaching hospitals, and data was gathered from 12 sites participating in a randomized trial in the United States. The QODD consists of 25 items and has been validated in the United States. Data from 446 patients were analyzed (346 in the United States and 100 in the Netherlands). Dutch patients were older than those in the United States (72+ 10.2 years vs65+ 16.0 years; P< .0025). The family-assessed overall QODD score was the same in both countries: the Netherlands= median, 9; interquartile range (IQR), 8-10 and the United States= median, 8; IQR, 5-10. US family members rated the quality of two items higher than did the Netherlands families: "time spent with loved ones" and "time spent alone." Nurse-assessed QODD ratings varied: the single-item QODD summary score was significantly higher in the Netherlands (the Netherlands: median, 9; IQR, 8-10 vsthe United States: median, 7; IQR, 5-8; P< .0025), whereas the QODD total score was higher in the United States (the Netherlands: median, 6.9; IQR, 5.5-7.6 vsthe United States: median, 7.1; IQR, 5.8-8.4; P= .014), although it did not meet our criteria for statistical significance. Of the 22 nurse-assessed items, 10 were significantly different between the Netherlands and the United States, with eight having higher scores in the United States and 2 having higher scores in the Netherlands. The QODD was rated similarly by family members in the United States and the Netherlands but varied when assessed by nurses. These differences may be due to organizational or cultural differences between the two countries or to expectations of respondents.

An Observational Study to Explore the Feasibility of Assessing Bereaved Relatives' Experiences Before and After a Quality Improvement Project to Improve Care of Dying Medical Inpatients.

Although hospitals are the most likely place of death, the quality of care received by dying inpatients remains variable. This is concerning for both the dying person and their relatives, with poorer bereavement outcomes likely for those who perceived their family member suffered unduly. There is a real need to consider how this situation can be improved. This work was conducted with the aim of exploring the feasibility of including bereaved relatives' experiences as part of a larger project exploring the use of a care bundle to improve care of the dying inpatients. Fifty relatives of inpatients who had died previously in hospital were contacted by letter with a request for interview before the implementation of a care bundle for the dying, with a care bundle being a collection of care processes that are implemented together. After this project had been in place for 6 months, a further 50 families were contacted who had died on the bundle. Ten families responded initially to the first request and 10 the second, with the interviews based on the Quality of Dying and Death (QODD) tool and a final open-ended question. Although all families who agree to be interviewed completed the session, with regard to the QODD, some families indicated that they would rather talk than provide numeric scores. No major differences in the prescores and postscores were noted. When invited to share their experiences, without prompting, families spoke of consistent concerns that included communication, place of death, and symptom control. This work confirms that it is highly feasible to incorporate assessments of bereaved family members' opinions as part of the wider assessment of research into end-of-life care.

Families' experiences of intensive care unit quality of care: Development and validation of a European questionnaire (euroQ2)

PurposeThe purpose of the study is to adapt and provide preliminary validation for questionnaires evaluating families' experiences of quality of care for critically ill patients in the intensive care unit (ICU). Materials and methodsThis study took place in 2 European ICUs. Based on literature and qualitative interviews, we adapted 2 previously validated North American questionnaires: “Family Satisfaction with the ICU” and “Quality of Dying and Death.” Family members were asked to assess relevance and understandability of each question. Validation also included test-retest reliability and construct validity. ResultsA total of 110 family members participated. Response rate was 87%. For all questions, a median of 97% (94%-99%) was assessed as relevant, and a median of 98% (97%-100%), as understandable. Median ceiling effect was 41% (30%-47%). There was a median of 0% missing data (0%-1%). Test-retest reliability showed a median weighted κ of 0.69 (0.53-0.83). Validation showed significant correlation between total scores and key questions. ConclusionsThe questions were assessed as relevant and understandable, providing high face and content validity. Ceiling effects were comparable to similar instruments; missing data, low; and test-retest reliability, acceptable. These measures are promising for use in research, but further validation is needed before they can be recommended for routine clinical use.

Concordance between Experiences of Bereaved Relatives, Physicians, and Nurses with Hospital End-of-Life Care: Everyone Has Their “Own Truth”

When patients die relatives and healthcare professionals may appreciate the quality of the dying phase differently, but comparisons are rare. In a cross-sectional study (June 2009–July 2012) the experiences of bereaved relatives, physicians, and nurses concerning the quality of dying in a large Dutch university hospital were compared, and the relation to communication was explored. Measurements were concordance on the quality of dying (QOD) (0–10 scale), awareness of impending death, and end-of-life communication. Results. Data on all three perspectives were available for 200 patients. Concordance in general was poor. Relatives’ scores for QOD (median 7; IQR 5–8) were lower than physicians and nurses’ (both median 7; IQR 6–8) (P=0.002). 48% of the relatives, 77% of the physicians, and 73% of the nurses had been aware of impending death. Physicians more often reported to have informed patients and relatives of end-of-life issues than relatives reported. When both physicians and relatives reported about such discussion, relatives’ awareness of impending death and presence at the patient’s deathbed were more likely. Conclusion. Relatives, physicians, and nurses seem to have their “own truth” about the dying phase. Professionals should put more emphasis on the collaboration with relatives and on verification of relative’s understanding.

Physical and Psychological Distress Are Related to Dying Peacefully in Residents With Dementia in Long-Term Care Facilities

ContextAlthough dying peacefully is considered an important outcome of high-quality palliative care, large-scale quantitative research on dying peacefully and the factors associated with a peaceful death is lacking. ObjectivesTo gain insight into how many residents with dementia in long-term care facilities die peacefully, according to their relatives, and whether that assessment is correlated with observed physical and psychological distress. MethodsThis was a retrospective cross-sectional study of deceased nursing home residents in a representative sample of long-term care facilities in Flanders, Belgium (2010). Structured post-mortem questionnaires were completed by relatives of the resident, who were asked to what extent they agreed that the resident “appeared to be at peace” during the dying process. Spearman correlation coefficients gave the correlations between physical and psychological distress (as measured using the Symptom Management at the End of Life with Dementia and Comfort Assessment in Dying at the End of Life with Dementia scales) and dying peacefully (as measured using the Quality of Dying in Long Term Care instrument). ResultsThe sample comprised 92 relatives of deceased residents with dementia. In 54% of cases, relatives indicated that the resident died peacefully. Weak-to-moderate correlations (0.2–0.57) were found between dying peacefully and physical distress in the last week of life. Regarding psychological distress, weak-to-moderate correlations were found for both the last week (0.33–0.44) and last month of life (0.28–0.47). ConclusionOnly half of the residents with dementia died peacefully as perceived by their relatives. Relatives' assessment of whether death was peaceful is related to both physical and psychological distress. Further qualitative research is recommended to gain more in-depth insights into the aspects on which relatives base their judgment of dying peacefully.

Medical Ethical Principles may Drive Improvement of Quality of Dying in Hong Kong

Population ageing raises concern regarding the quality of end of life care (EOLC), not only for people with cancer but for all dying of end stage chronic diseases, particularly for dementia. Medical ethical principles, legal and cultural factors affect the quality of end of life care. This article discusses how these three factors currently contribute to EOLC in Hong Kong, in the context of differing trajectories of development in China, other Asian countries, and the USA. EOLC for non cancer patients has only recently been highlighted, where ethical, legal, and cultural issues are being debated. Although there is no statute or case law that directly govern the legal status of advance directives in Hong Kong, a validly made advance directive is generally recognized at common law. However, there is a range of other legal barriers to providing EOLC according to medical ethical principles. There is little discussion among health care providers or the public regarding advance directives, euthanasia, physician assisted suicide, or withdrawal of life support, particularly for those with dementia. It is hoped that a continuing medical ethics discourse regarding EOLC issues may provide momentum to overcome current inertia or avoidance of EOLC issues, such that population aging may not be accompanied by increasingly poor quality of care in the dying process.

Characterization Methods for Ultrathin Wafer and Die Quality: A Review

Ultrathin silicon die is a key enabler for high performance semiconductor devices and ultrathin packaging. The quality of ultrathin wafers and dies has a significant influence on packaging assembly yield and device reliability. The key quality characteristics of ultrathin wafers and dies are bow/warpage, total thickness variation (TTV), subsurface damage (SSD), surface roughness, and mechanical strength. Wafer and die bow/warpage cause handling and processing problems in manufacturing processes, and induce defects during various packaging assembly processes that eventually lead to device reliability issues. The wafer TTV requirement is becoming more stringent for new generations of thin and 3-D packages. SSD, surface roughness, and dicing defects have adverse effects on die mechanical strength and reliability. Therefore, characterization methods are needed for these quality characteristics to control the manufacturing processes for ultrathin wafers and dies to ensure good device performance and reliability. The following ultrathin wafer and die characterization techniques are discussed in this paper: noncontact bow/warp/TTV measurement, materialographic analysis with optical and electron microscopy, high-resolution X-ray diffraction, micro-Raman spectroscopy, scanning infrared depolarization, optical profilometry, atomic force microscopy, and uniaxial/biaxial bending tests.