text:
Advance care planning with people with dementia: a process evaluation of an educational intervention for general practitioners
Bram Tilburgs ORCID: orcid.org/0000-0003-1588-004X1,
Raymond Koopmans2,3,4,
Henk Schers2,
Carolien Smits5,
Myrra Vernooij-Dassen1,
Marieke Perry2,3,6 na1 &
Yvonne Engels7 na1
General practitioners (GPs) are advised to offer advance care planning (ACP) to people with dementia (PWD). In a randomized controlled trial, an educational intervention for GPs aimed at initiating and optimizing ACP proved to be effective. During the intervention most GPs were accompanied by their practice nurse (PN). To provide insights into the intervention's successful components and what could be improved, we conducted a process evaluation and explored implementation, mechanisms of impact and contextual factors.
We used the Medical Research Council guidance for process evaluations. Implementation was explored identifying reach and acceptability. We performed descriptive analyses of participants' characteristics; selection, inclusion and intervention attendance; a GP post-intervention survey on initiating ACP; a post intervention focus group with trainers of the intervention.
Mechanisms of impact were explored identifying adoption and appropriateness. We used: participants' intervention ratings; a GP post-intervention survey on conducting ACP; ACP documentation in PWD's medical files; post-intervention interviews with PWD/FC dyads. All data was used to identify contextual factors.
The intervention was implemented by a small percentage of the total Dutch GP population invited, who mostly included motivated PWD/FC dyads with relatively little burden, and PWD with limited cognitive decline. The mechanisms of impact for GPs were: interactively learning to initiate ACP with training actors with a heterogeneous group of GPs and PNs. For PWD/FCs dyads, discussing non-medical preferences was most essential regarding their SDM experience and QoL. Some dyads however found ACP stressful and not feasible. Younger female GPs more often initiated ACP. Male PWD and those with mild dementia more often had had ACP. These characteristics and the safe and intimate training setting, were important contextual facilitators.
We recommend Interventions aimed at improving ACP initiation with PWD by GPs to include interactive components and discussion of non-medical preferences. A safe environment and a heterogeneous group of participants facilitates such interventions. However, in practice not all FC/PWD dyads will be ready to start. Therefore, it is necessary to check their willingness when ACP is offered.
Dementia is a life limiting syndrome with a worldwide rising number of people being diagnosed per year [1, 2]. Earlier research advised dementia care to be proactive, person-centred and to focus on living and dying well [3, 4]. All these aspects of care can be improved with advance care planning (ACP) [5, 6]. ACP has recently been defined as: "the process which enables individuals to define goals and preferences for future care with family and healthcare professionals and to record and review these preferences when appropriate" [7]. ACP thereby focuses on medical and non-medical care preferences, and should not be restricted to end of life care [7,8,9]. Particularly in dementia, because of the deteriorating cognition, it is advised to start ACP timely. As most people with dementia (PWD) live in the community, ACP initiation by general practitioners (GPs) is most appropriate [2, 10, 11]. However, this hardly takes place.
To train GPs in timely initiating ACP with PWD, we developed an interactive educational intervention, which we evaluated in a cluster randomised controlled trial (RCT) with 38 GPs. The 19 GPs in the intervention group initiated ACP significantly more often and discussed a statistically significant larger number of medical and non-medical preferences than those in the control group. No effects were found on patient-related secondary outcome measures, such as quality of life (QoL), shared decision making (SDM), and family caregivers' (FCs) competence [12].
The educational intervention under study consisted of multiple components [13]. For such a complex intervention, a process evaluation can help healthcare professionals, researchers and policy makers to understand what contributes to the intervention's success, and what can be improved. In addition, a process evaluation can provide insights into the intervention's mechanisms of impact on everyday life by exploring if study participants adopted the trained skills in daily practice and if all stakeholders found these skills appropriate [14, 15].
Also, recruiting GPs, PWD and FCs for research is challenging and often has low GPs' participation rates and high PWD/FC dropout rates [16, 17].
It is therefore essential to identify the population reached by the educational intervention and investigate if the intervention was found acceptable for both GPs and PWD/FC dyads [18,19,20].
For those reasons, we aimed to explore the implementation of the educational intervention by focussing on reach and acceptability. We also aimed to explore the impact of the intervention's mechanisms on everyday life by focussing on the adoption and appropriateness of ACP in daily practice, including the experiences of GPs, PWD and their FCs. We also defined contextual factors important to both implementation and the mechanisms of impact.
We used a mixed methods approach and followed the Medical Research Council (MRC) guidance for process evaluations [19]. We addressed the intervention's implementation, mechanisms of impact on everyday life and relevant contextual factors. With regard to implementation, we focussed on reach and acceptability. Reach was defined as the educational intervention having reached the intended stakeholders. For GPs this meant that they participated in the training. For PWD/FC dyads this meant that they participated in at least one ACP conversation with their GP. Acceptability was defined as the educational intervention being acceptable, as experienced by the stakeholders [19,20,21]. With regard to the intervention's mechanisms of impact in daily practice we focussed on adoption and appropriateness. Adoption was defined as the participants' intention or initial decision to employ ACP in practice. Appropriateness was defined as participants perceiving ACP relevant in daily primary care practice [19,20,21]. As for contextual factors, we focussed on the setting of the intervention and the characteristics of the study participants. Contextual factors can influence both implementation and mechanisms of impact [19].
Ethical consent
The study was approved by the medical ethics committee (CMO) of the region Arnhem-Nijmegen in accordance with the Medical Research Involving Human Subjects Acts and the declaration of Helsinki (NL52613.091.15). Anonymity was assured by removing all participant information that could lead to identification from this manuscript.
The educational intervention
Between March and June 2016, we trained 19 GPs in initiating ACP with PWD during two workshops in a small theatre. We hypothesised that first discussing near future non-medical preferences (e.g. housing, daily activities) before preferences on medical scenarios (e.g. hospital admission, or resuscitation) were discussed, would facilitate PWD's engagement in ACP [8, 9, 22]. Discussing such preferences was therefore included in the training.
We used role playing exercises with training actors, combined with other didactic and interactive, proven effective strategies [23]. A model for shared decision making (SDM) with frail elderly was introduced by a GP specialised in this topic and was used to guide the ACP conversations [24]. Barriers and facilitators (e.g. a trust-based relationship with the GP, engaging all stakeholders, GPs' proactive attitude, starting timely and regularly reviewing ACP) were addressed by a GP specialized in elderly care (MP) [8, 9]. Participating GPs were invited to bring a practice nurse (PN), as PNs have an important role in dementia care communication in primary care [8, 9]. A full description of the intervention is published elsewhere [12].
Process evaluation participants
The study population consisted of GPs, PNs and PWD/FCs dyads who participated in the RCT, and all trainers who provided the educational intervention. We purposefully selected dyads from different GP practices in order to include participants with characteristics that allowed answering our research questions. Besides, we aimed to include female and male PWD and female and male FCs who had had at least one ACP conversation after their GP was trained.
Data collection on reach and acceptability
With regard to the intervention's reach we used the following information. Regarding GPs we registered numbers of those invited to the cluster RCT and characteristics of those who decided to participate. We documented which GP included a PN as well as GPs' and PNs' workshop attendance. Six months after the intervention, all intervention group GPs were invited to complete an 8-item survey. The first item explored reach as it addressed barriers to include PWD and FCs in the study, using a five-point Likert-scale (totally disagree (1) – totally agree (5)). From PWD and FCs, we registered numbers of those invited to the cluster RCT and characteristics of those who decided to participate. When PWD and FCs decided not to participate they were asked for their reasons.
With regard to exploring the acceptability of the educational intervention we used the following information. GPs and PNs were asked to complete an evaluation form after each of both workshops. This evaluation form consisted of 10 items. Nine items used a five-point Likert-scale (totally disagree (1) - totally agree (5)), rating separate training elements (e.g. the use of training actors; the heterogeneity of the group, meaning that the group consisted of GPs and PNs with different levels of experience). We considered a rating positive when participants agreed or totally agreed with an item. With the last item of the evaluation form, participants were asked to rate the complete workshop (1–10). From all trainers who provided the educational intervention we gathered qualitative data. They took part in a focus group interview, 9 months after the intervention. All were asked for written informed consent. The topic list used was established during several meetings with the research team (BT, MP, YE, RK, MVD) (Supplementary file 1). A researcher (YE), trained in interviewing, chaired the focus group.
Data collection on adoption and appropriateness
With respect to adoption we used the following information. From GPs we used documented ACP conversations in the medical files of included PWD to determine per GP if they initiated ACP discussions. Six months after the intervention, the medical files were analysed retrospectively by two researchers who were blinded to study allocation [12]. We also used item 2 of the GP survey, addressing barriers to initiate ACP with PWD.
With respect to appropriateness we used items 3 to 8 of the GP survey and qualitative data from PWD and FCs. We invited PWD/FCs dyads from the intervention condition to participate in a semi-structured interview. All participants were asked for written informed consent. A researcher (BT), trained in interviewing, conducted each interview at PWD's homes, assisted by a research assistant. To guide the interviews, a topic list, constructed during several meetings with the research team (BT, MP, YE, RK, MVD) was used. (Supplementary file 2). Data collected are shown in Table 1.
Table 1 Data used to answer our research questions.
From all participants, demographic characteristics were collected at baseline.
For all quantitative data we used descriptive statistics. With regard to reach we compared the characteristics of PWD, FCs, PNs and GPs who participated in the RCT or who declined. In addition, we analysed the first item of the GP survey on barriers for the inclusion of PWD/FC dyads.
For acceptability, we analysed PNs' and GPs' workshop attendance and evaluation. The focus group was audio-taped, transcribed verbatim and analysed with content analysis separately by at least two researchers using Atlas. Ti version 7 software [25]. Text fragments related to our research aim were coded. After each interview, codes from both researchers were compared and merged and a codebook was created. As a next step, the codes were combined into categories and eventually themes. Disagreements during this process were discussed with other members of the research team (MP, YE) [25].
With regard to adoption we compared GPs who did or did not conduct ACP with PWD and FCs. ACP conversations documented in the PWD's medical file and item 2 of the GP survey were used as our source of data.
For appropriateness, we analysed items 3 to 8 of the GP survey. To analyse the interviews with PWD and FCs, we used content analyses as described above [25].
Implementation of the educational intervention
We invited 1313 GPs by mail of whom 36 GPs (2.7%) agreed to participate. Characteristics of GPs who declined are unknown. Before randomisation, participating GPs contacted 182 PWD/FCs dyads. Of those, 140 dyads, (78%) gave informed consent (mean age PWD 82y, 58% female; mean age FC 69y, 65% female). For those who declined (n = 42; 22%; mean age PWD 84y, 56% female; mean age FC 76y, 65% female) the expected burden of participation was the most frequently mentioned reason (n = 10).
Item 1 of the survey was completed by 16 (84%) of the 19 GPs from the intervention group. Thirteen (68%) GPs stated they did not invite all PWD who met the inclusion criteria (age ≥ 65, any stage of dementia, FC also participating in the study) to participate. (supplementary file 3) Several reasons for this were mentioned: dementia severity (n = 4); PWD's/FCs' lack of motivation to discuss ACP (n = 11), PWD/ FCs not being aware or accepting the dementia diagnosis (n = 5), PWD/FCs denying possible future problems (n = 4).
Acceptability
Of the 19 GPs in the intervention group (range age 36-63y, 8 females), 16 (84%) attended both workshops, and three (16%) attended one workshop. Reasons for non-attendance were: lack of time (n = 2) and illness (n = 1). Of the 18 practice nurses, 15 (83%) attended both workshops. Three (17%) attended only one workshop due to time constraints.
Twenty-six participants (GPs and PNs) completed the workshop's evaluation form. All were positive about practicing ACP with training actors. All but one (96%) were positive about the workshops' relevance and alignment with daily practice. Twenty-one (81%) were positive about the presentations on ACP and the SDM model with frail elderly. Twenty-two (85%) were positive about the location of the workshops. Fifteen (58%) were positive about the presentation given by a FC. The workshops received a mean overall rating of 8.1 (out of 10).
The focus group interview with the seven trainers (range age 40-66y, four women) took place in November 2017 at the Radboud University Medical Centre. Data analyses resulted in two themes (the workshops' successful elements and elements which could be improved; contextual factors) and five categories (communicating goals during ACP; from theory to practice; workshop components which could be improved; the heterogeneity of the workshop participants; the workshop environment). (Table 2).
Table 2 Categories and codes from the focus group interviews with trainers and training actors.
Theme 1: the workshops' successful elements and elements which could be improved
The trainers found practicing ACP with training actors and starting ACP with non-medical preferences currently important to the PWD's QoL, the most successful workshop elements. In addition, the trainers stated that they demonstrated that for ACP it is important to establish a personal relationship with the person with dementia and FC. Such a relationship creates an atmosphere where difficult issues concerning care preferences and maintaining a dignified remaining phase of life with optimal quality can be discussed. Balancing theoretical and interactive exercises was also considered a successful element.
"When there was more tranquillity during an ACP conversation, and we (trainers who acted as PWD) were given the time to tell things, we actually won time and were able to discuss difficult subjects...... When a GP was rushed, you (training actor) became restless or confused. When there is tranquillity and time is taken, you get a completely different conversation which is also more pleasant."
Trainers stated that each participant (GPs and PNs) had a different learning curve and that their experiences with PWD and ACP prior to the training differed. This heterogeneity made the workshops challenging. Nevertheless, trainers preferred such a heterogeneous group because participants then also learned from each other.
"I (trainer) have to say... when a group is more diverse, it gets more interesting, especially when a group is not that big, diversity is nice. To me it is not that interesting whether a participant is a PN or a GP. I just see 15 people who want to learn from each other."
According to the trainers, the presentation given by a FC left room for improvement, as this did not fully address the complexity of caring for a person with dementia. Looking back, the trainers found that they had not discussed the aims of her presentation thoroughly enough with the FC.
Theme 2: contextual factors
According to the trainers, the workshop location (a small theatre) and the limited number of participants (maximum of 15 participants with four trainers), created an intimate and safe setting. As a result, trainers were able to give sufficient personal attention and feedback and participants dared to experiment when practicing ACP conversations.
Mechanisms of impact on everyday life
Review of the medical records showed that 16 (84%) of the 19 GPs in the intervention group had had at least one ACP conversation with at least one person with dementia during the 6 months after the intervention. Nine GPs (47%) had had at least one ACP conversation with more than half of the included PWD from their practice. These GPs were younger (45.1 vs. 51.7 years) and more often female (7 out of 9 vs. 3 out of 10) compared to the 10 (53%) GPs who had had ACP conversations with less than half of the PWD from their practice. (Supplementary file 3).
In the GP survey, thirteen (68%) GPs stated they had initiated ACP with all included PWD. (Supplementary file 3) Those who did not, stated that a lack of time and dementia severity were the main reasons for not having initiated ACP.
PWD who had had at least one ACP conversation during the 6 months after the intervention were more often male (71% male vs. 29% female) compared to those who had not had ACP 53% male vs. 47% female). In addition PWD who had ACP more often had very mild dementia (14%) compared to those who had not had ACP (3%). (Table 3).
Table 3 Characteristics of PWD and FCs who had ACP or had no ACP.
Most GPs (57%) found it important to start ACP with discussing non-medical preferences of PWD. All GPs stated that continuing ACP about medical scenarios became easier after these non-medical preferences were known. Fifteen (78%) GPs wanted to start ACP early in the disease trajectory and found engaging FCs not difficult. Nine GPs (47%) found engaging PWD not difficult (Supplementary file 3).
Ten FCs (range age 70-84y, 6 females) and two PWD (age 70 and 84y, both female) were interviewed between January and June 2017. The first two interviews, with PWD, showed that PWD had trouble remembering ACP conversations and were not able to provide information concerning our research aims. We therefore decided to conduct the remaining interviews by telephone with only the FC. After eight interviews no new codes emerged and two more interviews were conducted to confirm saturation. Two themes (experiences with discussing goals, making timely shared decisions) including four categories (discussing medical and non-medical issues, additional ACP outcomes, shared decision making, proactive behavior) were derived. (Table 4).
Table 4 Appropriateness: Categories and codes from the interviews with family caregivers and people with dementia.
Theme 1: experiences with discussing preferences
Most FCs indicated that starting ACP with near future non-medical care preferences suited the PWD's needs as these preferences importantly influenced their current situation and QoL.
"I really liked the fact that not only medical issues were discussed. I always say: when discussing well-being, all aspects of the person have to be discussed".
Some FCs however stated that ACP had mostly focused on the PWD's illness and medical preferences. According to them, this was a missed opportunity. Capabilities of PWD and non-medical issues should have been addressed as well.
Most FCs found ACP important as it provided tranquility, clarity, increased their knowledge about dementia, improved the contact with their GP and increased trust in healthcare professionals. FCs also stated that the GP gained more insight in their living situation. Some FCs however found discussing future preferences confronting, stressful and not useful. These FCs only wanted to discuss care when a problem actually arose.
Theme 2: making timely shared decisions
FCs appreciated that they, with the person with dementia, were engaged in ACP conversations. They could both participate and co-decide. FCs felt no hierarchy between them and the GP.
"I really felt we could co-decide. She (GP) would put it on the table, so to speak and then we start talking about it......"
Most FCs appreciated the GPs' proactive behaviour as FCs would not have initiated ACP themselves.
Some FCs doubted if engaging PWD in ACP was possible because of their memory problems or limited insights. If PWD were unable to make decisions themselves, FCs decided for them, which they found difficult. Most FCs found an annual evaluation of ACP sufficient, while some wanted this at least twice a year. One FC stated that during ACP, the GP gave little opportunity for SDM.
In this process evaluation we aimed to explore the implementation of an educational intervention for GPs and PNs about ACP with PWD and their FCS, and the intervention's mechanisms' impact including important contextual factors.
The intervention was implemented by a small part of the invited GPs. The participating GPs mostly reached PWD/FC dyads who were motivated and experienced relatively little burden. The intervention's most successful elements were practicing and experiencing timely ACP with training actors in a heterogeneous group, with near future non-medical preferences and improving QoL as the starting point. The highly appreciated training was acceptable to all stakeholders. The intimate and safe environment appeared to be an important contextual factor.
Most GPs adopted ACP in daily practice. With regard to appropriateness, GPs stated that an early start of ACP including non-medical preferences facilitated ACP. PWD/FCs dyads stated that ACP, including non-medical preferences, improved SDM and was important to PWD's current QoL. Some FCs doubted the feasibility of ACP. ACP was more often applied by younger female GPs. Male PWD and persons with mild dementia more often had ACP. We therefore consider gender of professionals, PWD and FCs, and dementia severity important contextual factors.
Interpretation of the study in comparison with other literature
Training healthcare professionals in communication skills regarding future care has been shown effective before [26,27,28]. Using role models, simulations and mixed interactive and didactic education in a small and safe environment, as we did, are thereby the most effective approaches [23, 29,30,31,32,33]. Although a Cochrane review concluded that the overall effects of training healthcare professionals are limited, [23] our study showed that education on professional behaviour in performing ACP in daily primary care practice can be substantial. Nevertheless, a maximum implementation degree was not reached [12, 23].
It is not surprising that GPs included PWD/FC dyads of whom they thought to be capable and willing to participate in ACP [7, 34]. ACP and SDM, when aimed at deciding on future medical preferences, require the ability to imagine future scenario's, which is difficult for PWD, especially when dementia is severe. In addition, willingness and motivation depend on the right timing, perceived barriers and subjects discussed, and are therefore not fixed states assessable at one time point [8, 35, 36]. Regularly checking PWD/FCs dyads' willingness and motivation, and customizing ACP to the needs and capabilities of those involved, leads to more dyads being engaged and prevents that ACP is experienced as stressful or not feasible [37,38,39,40,41]. In addition, taking in account the role of FCs, as cognitive decline progresses and FCs are deemed to decide for PWD, is thus important [40]. As shown in our results and earlier research, including non-medical preferences in ACP facilitates ACP as these are important to PWD's current QoL and SDM [8, 9, 42]. To provide appropriate ACP in primary care, we recommend to include such non-medical aspects in future educational interventions.
Our research showed that gender of GPs and PWD are important contextual factors. Younger female GPs more often initiated ACP than their male and older colleagues. This is congruent with previous studies which showed that younger female GPs have more knowledge and more positive attitudes towards dementia care management [43]. We also showed that male PWD more often had had ACP than female PWD. This contrasts with earlier research which found that females are more active in decision making, are more inclined to discuss a wider variety of preferences for future care, feel more empowered by discussing care preferences and believe preferences will be granted when documented [44, 45]. On the other hand, as these characteristics also apply to FCs, the mostly female FCs of the male PWD in our study will have had an important role in initiating ACP in dementia.
In contrast to the secondary outcomes of the cluster RCT, this process evaluation shows that ACP, in which discussing nearby non-medical preferences has a central role, has an impact on experienced involvement in decision making and is important to QoL. This contrast can be explained by the fact that quantitative measurements of QoL do not properly reflect those aspects of daily life individuals find important and appraise for their QoL [46,47,48,49]. Also, earlier research indicated that PWD and FCs find qualitative research methods more appropriate to assess important aspects related to their QoL [50]. Given the above, we emphasize the importance of future research on PWD's, FCs' and GPs' gender, GPs' age, and relevant more personalised measurements of QoL for PWD.
Study strengths and limitations
This study has several strengths. With the MRC guidance for the process evaluation of complex interventions we were able to provide insights into the effective working mechanisms of the multiple components of the educational intervention and the experiences of stakeholders when gained skills were applied in daily practice [19]. We used a mixed-methods approach, included the views of PWD, FC, GPs and trainers, and included researchers with a wide range of expertise. As a result, triangulation and in-depth understanding of our research findings was achieved [51].
Our study also has some limitations. Recruiting GPs for palliative care education research is known to be difficult and in this study only a small percentage decided to participate [17]. It is known that GPs mainly participate in research they personally find important or valuable for the medical profession as a whole [52, 53]. In addition, part of the GPs doubt the feasibility of ACP in daily practice and are uncertain about how to discuss end-of-life preferences [8, 9]. This might have contributed to the GPs' low participation rate. However, interventions aimed at relatively new and complex skills are often implemented first in a small group of motivated professionals and from there on spread to the rest of the target population [54].
We were not able to retrieve characteristics of GPs who did not respond or declined to participate. Hence, we were not able to determine if these GPs differed from the participating GPs and could not further explore possible consequences for the intervention's external validity.
As we did not confront GPs with the difference between the mentioned and documented ACP conversations, we were not able to explain why this discrepancy was found. This can be caused by incomplete medical records which do not reflect actual medical performance [55]. It can also be caused by GPs giving socially desirable answers in the survey.
As PWD were not able to remember ACP conversations, we may not have a complete view of how ACP was applied and experienced in daily practice.
We recommend to include interactive and didactic elements in future educational interventions on ACP with PWD in primary care, and focus on practicing ACP with non-medical preferences aimed at remaining QoL as a starting point. A safe learning environment and heterogeneous groups will increase learning effects. GPs' younger age and female gender, and PWD's male gender may positively influence ACP initiation.
In daily practice, ACP can be experienced as stressful and not feasible by some PWD. GPs should therefore check PWD/FC dyads' willingness to be engaged and only start when they are ready. Future research on interventions to increase engagement of PWD and FCs in ACP is recommended.
We also advise future research to include a broad sample of GPs, PWD and FCs and to take into account how gender of both the professional and patient, and age of healthcare professionals, influences ACP application in daily practice. To improve further initiation of ACP in dementia, we suggest a wider implementation of our educational intervention.
ACP:
SDM:
People with dementia
FC:
Family caregiver
GP:
MRC:
QoL:
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Berkhof M, van Rijssen HJ, Schellart AJM, Anema JR, van der Beek AJ. Effective training strategies for teaching communication skills to physicians: An overview of systematic reviews. Patient Educ Couns. 2011;84(2):152–62.
Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361–7.
Mullick A, Martin J, Sallnow L. An introduction to advance care planning in practice. BMJ. 2013;347(7930):28–32.
van der Steen JT, van Soest-Poortvliet MC, Hallie-Heierman M, Onwuteaka-Philipsen BD, Deliens L, de Boer ME, et al. Factors associated with initiation of advance care planning in dementia: a systematic review. J Alzheimers Dis. 2014;40(3):743–57.
Politi MC. importance of clarifying patients desired role in shared decision making to match their level of engagement with their preferences. BMJ. 2013;347:7066.
Elwyn G, Durand MA, Song J, Aarts J, Barr PJ, Berger Z, et al. A three-talk model for shared decision making: multistage consultation process. BMJ. 2017;359.
Fried TR, Bullock K, Iannone L, O'Leary JR. Understanding Advance Care Planning as a Process of Health Behavior Change. J Am Geriatr Soc. 2009;57(9):1547–55.
Groen-van de Ven L, Smits C, Span M, Jukema J, Coppoolse K, de Lange J, et al. The challenges of shared decision making in dementia care networks. Int Psychogeriatr. 2016:1–15.
Glaudemans JJ, Moll van Charante EP, Willems DL. Advance care planning in primary care, only for severely ill patients? A structured review. Fam Pract. 2015;32(1):16–26.
Mignani V, Ingravallo F, Mariani E, Chattat R. Perspectives of older people living in long-term care facilities and of their family members toward advance care planning discussions: a systematic review and thematic synthesis. Clinical Interv Aging. 2017;12:475–84.
Turner S, Iliffe S, Downs M, Wilcock J, Bryans M, Levin E, et al. General practitioners' knowledge, confidence and attitudes in the diagnosis and management of dementia. Age Ageing. 2004;33(5):461–7.
Perkins HS, Hazuda HP, Cortez JD. Advance Care Planning: Does Patient Gender Make a Difference? Am J Med Sci. 2004;327(1):25–32.
Arora NK, McHorney CA. Patient preferences for medical decision making: who really wants to participate? Med Care. 2000;38.
Muldoon MF, Barger SD, Flory JD, Manuck SB. What are quality of life measurements measuring? BMJ. 1998;316(7130):542–5.
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Bowling A, Rowe G, Adams S, Sands P, Samsi K, Crane M, et al. Quality of life in dementia: a systematically conducted narrative review of dementia-specific measurement scales. Aging Ment Health. 2015;19(1):13–31.
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Kuper A. An introduction to reading and appraising qualitative research. BMJ. 2008;337(7666):404.
Heywood A, Mudge P, Ring I, Sanson-Fisher R. Reducing systematic bias in studies of general practitioners: the use of a medical peer in the recruitment of general practitioners in research. Fam Pract. 1995;12(2):227–31.
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Chan KS, Fowles JB, Weiner JP. Review: Electronic Health Records and the Reliability and Validity of Quality Measures: A Review of the Literature. Med Care Res Rev. 2010;67(5):503–27.
The author(s) disclose receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the ZonMw Memorabel program, project number 79–73305–98-420. The funders had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.
Marieke Perry and Yvonne Engels contributed equally to this work.
Department of IQ Healthcare, Radboudumc, Nijmegen, The Netherlands
Bram Tilburgs & Myrra Vernooij-Dassen
Department of primary and community care, Radboudumc, Nijmegen, The Netherlands
Raymond Koopmans, Henk Schers & Marieke Perry
Radboudumc Alzheimer Centre, Nijmegen, The Netherlands
Raymond Koopmans & Marieke Perry
Joachim en Anna, Centre for specialized geriatric care, Nijmegen, The Netherlands
Raymond Koopmans
Research Group Innovating with Older Adults, Windesheim University of Applied Sciences, Zwolle, The Netherlands
Carolien Smits
Department of geriatric medicine, Radboudumc, Nijmegen, The Netherlands
Marieke Perry
Department of anesthesiology, pain and palliative medicine, Radboudumc, Nijmegen, The Netherlands
Yvonne Engels
Bram Tilburgs
Henk Schers
Myrra Vernooij-Dassen
BT: contributed to the conception and design, data analysis and data interpretation, writing of the manuscript. RK: contributed to the design, data analysis, data interpretation and writing of the manuscript. MvD: contributed to the design, data interpretation and writing of the manuscript. HS: contributed to data interpretation and writing of the manuscript. CS: contributed to data interpretation and writing of the manuscript. YE: contributed to the design, data analysis, data interpretation and writing of the manuscript. MP: contributed to the design, data analysis, data interpretation and writing of the manuscript. All authors have read and approved the manuscript.
Correspondence to Bram Tilburgs.
The study was approved by the research ethics committee (CMO) of the region Arnhem-Nijmegen in accordance with the Medical Research Involving Human Subjects Acts and the declaration of Helsinki (NL52613.091.15). Anonymity was assured by removing all participant information that could lead to identification from the transcripts. Written consent was obtained from all participants. The family caregiver gave consent on behalf of the person with dementia.
Additional file 1: Supplementary file 1.
Topic list focus group interview with workshop trainers.
Additional file 2: Supplementary file 2
. Topic list interviews with people with dementia and family care givers.
Characteristics of GPs who did or did not have ACP and the items of the GP survey.
Tilburgs, B., Koopmans, R., Schers, H. et al. Advance care planning with people with dementia: a process evaluation of an educational intervention for general practitioners. BMC Fam Pract 21, 199 (2020). https://doi.org/10.1186/s12875-020-01265-z

redpajama_set_name: RedPajamaCommonCrawl


text:
Q: Difference between setTranslationX/Y and offsetLeftAndRight/offsetTopAndBottom? I'm working with a CoordinatorLayout in which child views positions are being animated with the ViewCompat.offsetLeftAndRight and ViewCompact.offsetTopAndBottom APIs.
When a child view is added or removed from the CoordinatorLayout, the layout operation resets the position of each child to the top left corner of the screen, i.e. without any offset.
This article provides a solution, by setting a layout listener on the child view and restoring old positions.
I noticed that using the setTranslationX and setTranslationY APIs, this problem does not occur. Children keep their position after parent layout events.
How should I decide between these two sets of APIs for arranging my views on screen? I'm wary of using either without understanding their differences. I did not get a good understanding by reading the official documentation.

A: Quite old question after many months I have few explanations:
First things first. Offset will move the view horizontally or vertically similarly to translate but it's used for permanent results.
When you use View#offsetTopAndBottom(int offset) then internally it has these functionality:
mTop += offset;
mBottom += offset;

On the other hand tranlate is an variable which is calculated in addition to this top/bottom/left/right positions and mostly handy in animations.
Both methods will trigger a layout refresh if needed.
More have been explained by Nick Butcher in this nice video: https://www.youtube.com/watch?v=86p1GPEv_fY&t=5m42s
Regarding CoordinatorLayout are you by any change setting margins to the children? E.g. BottomSheetBehavior does not work well with margins since it ignores them. I think this might be the case for you.

redpajama_set_name: RedPajamaStackExchange


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text:
Integrations & API
Services provider & Telecom operator
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text:
The ABCs of Why We Need Electric School Buses
Patty Buchanan — August 4, 2021
Founding member of Croton100 and Co-Chair of Climate Reality Project, Westchester Chapter
In a historic development, the Croton Harmon School District is moving forward with plans to purchase electric school buses. In May, the community voted overwhelmingly to authorize funds to purchase three electric school buses, contingent on receipt of grants from New York State.
The School Transportation Department, which manages its own student transportation fleet, is working to finalize the New York State subsidy funding to get electric school bus wheels on the road in this fiscal year.
For well over a year, the School District heard from climate crisis advocacy groups, including Croton100 and Mothers Out Front, about the perils of particulate pollution emissions from fossil fuel buses that cause asthma and cancers.
'Electrifying transportation is necessary to protect the health and safety of children and future generations.' – Kristy Cohen, Volunteer, Mothers Out Front
These school buses also emit greenhouse gases that are warming the atmosphere, which causes glacial ice melt, sea level rise, unprecedented heat, droughts, wildfires, hurricanes and floods.
Mothers Out Front Volunteer Kristy Cohen stresses, "The need to stop buying fossil fuel vehicles now is clear. Electrifying transportation is necessary to protect the health and safety of children and future generations."
The challenges in mobilizing electric school buses are the costs and the discomfort with new technology. Electric school buses cost about two to three times that of fossil fuel buses.
Croton100 led the case for understanding available subsidies and explaining that the higher purchase price of electric buses is offset over time by savings on operation (fuel) and lower maintenance.
Electric motors are three times more efficient in converting fuel (i.e., electricity) into locomotion than internal combustion engines, which waste energy in the form of heat, sound, smoke and incomplete combustion when fossil fuel is burned.
Additionally, a unit of electricity costs less than a unit of fossil fuel energy. Electric motors are more efficient because their regenerative braking systems recapture kinetic energy to recharge the battery as the bus is slowing. Because electric motors are as simple as a battery on wheels, electric vehicles do not have all the expenses of maintenance, such as oil, oil filters, spark plugs, hoses, belts, radiators, carburetors, mufflers, tailpipes, and transmissions.
In addition to saving money on replacement parts, related labor costs for all this maintenance are eliminated with electric vehicles. The higher electric motor efficiency plus reduced energy costs and lower maintenance adds up to lower Total Costs of Ownership (TCO) over time.
As part of its advocacy campaign, Croton100 presented the School District with a TCO analysis and it shared its work with the community. Croton100's Chandu Visweswariah created a tool that easily calculates and displays a TCO graph that any school district can use to understand the cost and carbon comparisons between electric school buses and fossil fuel school buses, with about a dozen variables that affect TCO.
This Bus Electrification for Student Transportation ("BEST") framework is an Excel spreadsheet with cost formulas and resources built into the tool. It is freely available on the website of Croton100's umbrella organization CURE100.org/resources (Communities United to Reduce Emissions 100%), along with many other electric school bus resources.
"The mindset change necessary for school bus electrification requires quantification of TCO," said Chandu. "The BEST framework we offer serves the dual purpose of educating school districts and stakeholders about electric buses while providing a customizable TCO calculator."
School Board President Sarah Carrier says, "The Croton Harmon schools have a long history of focusing on sustainability. We are proud of our work towards this initiative and are very proud to be among the first school districts in New York to begin the transition to electric school buses."
Croton100.org
About the Author: Patty Buchanan


Hello Flo... Just thinking about you and wondering how you are feeling now that you've been home for a few weeks. I sincerely hope that everything is going well and that your recovery is on track. Check in with us if you have time during this busy time of the year.
Flo..did they give you more than one drain when you left the hospital? I had an extra as i had to clean out one every day..put a little soap in it and run water through it and hang on a towel rack to dry naturally. I had a long drain and large bag for night time and a shorter one for my leg bag which i wore during the day. You've got a lot of mucus in there which might be clogging it up.
As far as sitting on the toilet and thinking you have to pee that still sometimes happens to me 8 yrs later. Its hysterical..there must be some memory cells in there!! We've all done it!!
You are an inspiration to everyone on this site! There are certainly people reading your posts who can find hope in their futures! I, and all who read your posts, are encouraged by your "never Quit" attitude!
You know this is a team situation. The Dr. is important. But you also give great kudos to your husband(he is going through this just like you) the nurses, your friends, the hospital support staff( I had a special relationship with the cleaning people) and everyone who touched your life in this war.
Get well! I know you need a Big Cheer!
Welcome home, Flo. I'm so happy you have reached this milestone. Things from here out should only continue to get better, maybe with some minor bumps in the road, but hopefully they will be few and far between.
Well it is 6 days post op and all is going well. yes Sara Anne you really never know how many people truely care about you until something like this happens yes you know you have friends but the ones that stand by you through something like this are your true friends. And yes the Hubby is pretty darn amazing praise be to God on that one cause he and he alone has given Hubby the strength to put up with me for 29 years and still say he likes me.
Went home yesterday, never new how far it was from Nashville to Crofton Ky, okay I new just did not know that 80 miles could seem like an eternity, stopped at a rest area to walk for a few minutes could not stand sitting any longer felt things were backing up knew I would prolong the trip but also knew I had to get out of that car and walk a few minutes. Felt much better for doing so. Got all the drains out except 2 the stoma tube which is clapped off and the malecot cath. So it is vry strange to me to be encouraged to pass gas girls don't do that so my husband has had a good laugh lately with some of the things I have said about passing gas. I don't know if I am the only weird one out there but it is like I have to sit on the potty to really be successful (I know TMI)so I find myself sitting on the potty for this purpose but then other times I think my brain has not 100% accepted the fact that I do not have a bladder and I think I have to pee is this totally weird or what? The other thing is how do u ever feel like you have finished your business if u don't pee I mean they go hand in hand?


Gamma Technologies, in cooperation with Sendyne Corp., is introducing an advanced technology platform for comprehensive electric and hybrid vehicle simulation that combines Gamma's GT-Suite vehicle simulator with Sendyne's CellMod CPM and RTSim real-time solver. This new platform provides total electric and hybrid vehicle multi-physics simulation including engine, vehicle, electric machines, cooling, and aftertreatment systems, along with a Compact Physical Model (CPM)-based virtual battery pack.
Total vehicle simulation can reduce time to market, improve performance and cut costs by aiding in the optimization of the power delivery system. In order to ensure high accuracy of complete hybrid powertrain simulations, it is important that models capture the temperature-sensitive behavior of the involved components and the flow of energy between subsystems.
By coupling a battery CPM with a hybrid electric vehicle model that includes the propulsion system and the thermal aspect of its components, as well as the entire cooling system, GT-SUITE becomes the first simulator tool accurately to predict the interactions between various subsystems and numerous energy paths, Gamma says. Thus, it can be used to reduce battery pack overdesign, as well as for thermal management analysis and control strategy optimization.
To aid in battery pack system design, each cell in the xEV's battery pack is modeled individually to reflect statistical variations among cells. Thermal interactions among adjacent cells are also modeled. Simulation time is quick; for a battery pack consisting of 100 series connected individual cells, simulation output is produced 20 times faster than simulated time.
Typically, battery simulation for hybrid and electric vehicles is performed through the use of look-up tables and uncoupled equivalent-circuit and thermal models, neither of which can provide a reliable level of accuracy.
Sendyne's CellMod, while compact, is based on physics as well as measured data. It provides macroscopic behavior modeling of all relevant observable phenomena, including their derivatives and interdependencies, and thus provides good predictability and overall accuracy.
The new technology will be presented at the IEEE Transportation and Electrification Conference iTEC2014 on 15-18 June 2014.
Gamma Technologies GT-SUITE is a leading tool for total vehicle simulation. Selected by Robert Bosch GmbH as its preferred tool, Gamma was recently presented with a Supplier Innovation Award for Transmission and Driveline Engineering by Chrysler at its 2014 Innovation Awards ceremony. Sendyne, whose technology was nominated for a 2014 EE Times and EDN ACE Award, provides its CellMod CPM and RTSim real time solver to enable interactive and detailed simulation of the battery pack to the rest of the vehicle systems.


mode	  Specifies a symbolic constant	indicating the desired behavior.
GL_FASTEST, GL_NICEST, and GL_DONT_CARE are accepted.
GL_FASTEST	      The most efficient option	should be chosen.
GL_DONT_CARE	      The client doesn't have a	preference.
GL_LINE_SMOOTH_HINT Indicates	the sampling quality of	antialiased lines.
Indicates	the sampling quality of	antialiased points.
Indicates	the sampling quality of	antialiased polygons.


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This system is called The 12 Pillars of Peak Performance.
You may have seen my new fictional storybooks on each of the 12 Pillars… These are a great way to learn and grasp the concepts within each Pillar..
But now you want more… You want to go deeper… You want a easy to use, step-by-step framework that you can use with your team at your own pace..
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text:
Digest of United States Practice in International Law
for Compliance with the Continental Shelf Fisheries Resources section of the Bartlett Act, 78 Stat. 194 (16 U.S.C. 1081-1086). The Standards, which constitute 50 Code of Federal Regulations Part 295, include in the regulations a list of Continental Shelf Fisheries Resources of the United States and set forth prohibited acts and a procedure for enforcing those portions of the Bartlett Act which make it unlawful for any vessel except a vessel of the United States, or any person in charge of such vessel, to engage in the taking of any Continental Shelf fishery resource except as provided by the Act or an international agreement to which the United States is a party. The enforcement procedures subject any vessel engaging in fishing to boarding by an enforcement officer when that officer has reason to believe such vessel is engaged in the taking of any Continental Shelf fishery resource appertaining to the United States.
The species listed in the regulations have been found to constitute a Continental Shelf fishery resource by either (1) the Offshore Shrimp Fisheries Act of 1973 (87 Stat. 1061), or (2) the Secretary of Commerce, in consultation with the Secretary of State.
Fed. Reg., Vol. 41, No. 123, June 24, 1976, pp. 26019-26020.
Secretary of State Henry A. Kissinger presented, on April 8, 1976, a series of proposals regarding deep sea mining, aimed at contributing to a solution of the problem by the United Nations Conference on the Law of the Sea. In a statement delivered in New York, he proposed, inter alia, a system of parallel access to seabed resources, under which, whenever a deep seabed mining site is set aside for state or private exploitation, a similar site would be set aside for the international community. He also suggested a temporary limit on production of seabed minerals, which would be tied to the projected growth in the world nickel market, currently estimated to be about 6 percent a year, that would in effect limit production of other minerals contained in deep seabed nodules, such as copper. Portions of his statement devoted to the deep seabeds follow:
First, to ensure an equitable decisionmaking system, the United States continues to believe that the Treaty should authorize the formation of an International Seabed Resource Authority to supervise exploration and development of the deep seabeds. The Authority would be comprised of four principal organs:
-An Assembly of all member states, to give general policy guidance;
-A Council, to serve as the executive, policy-level and main decisionmaking forum, setting operational and environmental rules for mining, and supervising the contracts for deep seabed mining;
-A Tribunal, to resolve disputes through legal processes; and --A Secretariat, to carry out the day-to-day administrative activities of the Authority.
The United States proposes
-that the power of the Authority be carefully detailed by the Treaty in order to preserve all those rights regarding the uses of the seas which fall outside the competence of the Authority, and to avoid any jurisdictional overlap with other international organizations;
-that the composition and structure of the Council reflect the producer and consumer interests of those states most concerned with seabed mining. All nations whose vital national concerns are affected by decisions of the Authority must have a voice and influence in the Council commensurate with their interests; -that the proposed permanent seabed Tribunal adjudicate questions of interpretation of the Treaty and of the powers of the International Authority raised by parties to the Treaty or by private companies engaged in seabed mining. Without a Tribunal, unresolved contention is a certainty. Such a body will be necessary if any seabed proposal is to win wide acceptance.
Second, to ensure that all nations, developed and developing, have adequate access to seabed mining sites:
-The United States proposes that the Treaty should guarantee nondiscriminatory access for states and their nationals to deep seabed resources under specified and reasonable conditions. The requirement of guaranteed access will not be met if the Treaty contains arbitrary or restrictive limitations on the number of mine sites which any nation might exploit. And such restrictions are unnecessary because deep seabed mining cannot be monopolized; there are many more productive seabed mining sites than conceivably can be mined for centuries to come.
-The United States accepts that an "Enterprise" should be established as part of the International Seabed Resource Authority and given the right to exploit the deep seabeds under the same conditions as apply to all mining.
-The United States could accept as part of an overall settlement, a system in which prime mining sites are reserved for exclusive exploitation by the Enterprise or by the developing countries directly-if this approach meets with broad support. Under this system, each individual contractor would propose two mine sites for exploitation. The Authority would then select one of these sites which would be mined by the Authority directly or made available to developing countries at its discretion. The other site would be mined by the contractor on his own.
-The United States proposes that the International Authority should supervise a system of revenue sharing from mining activities for the use of the international community, primarily for the needs of the poorest countries. These revenues will not only
advance the growth of developing countries; they will provide tangible evidence that a fair share in global economic activity can be achieved by a policy of cooperation. Revenue sharing could be based either on royalties or on a system of profit sharing from contract mining. Such a system would give reality to the designation of the deep seabeds as the common heritage of all mankind. -Finally, the United States is prepared to make a major effort to enhance the skills and access of developing countries to advanced deep seabed mining technology in order to assist their capabilities in this field. For example, incentives should be established for private companies to participate in agreements to share technology and train personnel from developing countries. Third, in response to the legitimate concerns of land-based producers of minerals found in the deep seabeds, we offer the following steps as an additional major contribution to the negotiations:
-The United States is prepared to accept a temporary limitation, for a period fixed in the Treaty on production of the seabed minerals tied to the projected growth in the world nickel market, currently estimated to be about 6 percent a year. This would in effect limit production of other minerals contained in deep seabed nodules, including copper. After this period, the seabed production should be governed by overall market conditions.
-The United States proposes that the International Seabed Authority have the right to participate in any international agreements on seabed-produced commodities in accordance with the amount of production for which it is directly responsible. The United States is prepared to examine with flexibility the details of arrangements concerning the relationships between the Authority and any eventual commodity agreements.
-The United States proposes that some of the revenues of the International Seabed Resource Authority be used for adjustment assistance and that the World Bank, regional development banks, and other international institutions assist countries to improve their competitiveness or diversify into other kinds of production if they are seriously injured by production from the deep seabeds. An urgent task of the International Authority, when it is established, will be to devise an adjustment assistance program in collaboration with other international institutions for countries which suffer economic dislocations as a result of deep seabed mining.
The United States believes that the world community has before it a grave responsibility. Our country cannot delay in its efforts to develop an assured supply of critical resources through our deep seabed mining projects. We strongly prefer an international agreement to provide a stable legal environment before such development begins, one that ensures that all resources are managed for the good of the global community and that all can participate. But if an agreement is not reached this year it will be increasingly difficult to resist pressure to proceed unilaterally
Dept. of State Bulletin, Vol. LXXIV, No. 1922, Apr. 26, 1976, pp. 533-542.
Permanent Regime
The United States put forward significant new proposals on the deep seabeds at the resumed session of the Third U.N. Conference on the Law of the Sea, which met in New York August 26-September 17, 1976. It indicated its readiness to agree to a financing arrangement for the proposed Enterprise (the independent operating arm of the International Seabed Authority) designed to enable the Enterprise to begin mining operations within a reasonable time span. The United States further proposed that there could be a review, possibly in 25 years, to determine if the provisions of the treaty regarding the system of seabed exploitation were working adequately. Secretary of State Kissinger described the U.S. initiatives, in a statement to heads of delegations at the Conference, on September 1, 1976, as follows:
At the last session, the United States proposed the system of parallel access in which, concurrently with any state or private mining of the deep seabeds, a similar site would have to be set aside for the international community to be exploited or mined by the international community . . .
On reflection, many countries have expressed reservations about this concept on many grounds. . .one of the principal grounds was that it did no good to set aside a part of the mining sites for the international community if the international community did not possess the financial resources with which to mine or to put its Enterprise into business and if there were no provisions for the transfer of technology to the international community.
We have taken these views into serious consideration. And. therefore, on the occasion of my meeting with some of the members of Committee I, I proposed on behalf of the U.S. Government that the United States would be prepared to agree to a means of financing the Enterprise in such a manner that the Enterprise could begin its mining operation either concurrently with the mining of state or private enterprises or within an agreed timespan that was practically concurrent.
We proposed also that this would include agreed provisions for the transfer of technology so that the existing advantage of certain industrial states would be equalized over a period of time.
We have also taken into account the views that have been expressed by some delegates that it might be premature to establish a permanent regime for the deep seabeds, for the exploitation of the deep seabeds, at the beginning of a process of technology and to freeze it for an indefinite period.
For this reason we have proposed today that there could be periodic review conferences at intervals to be negotiated-for example, 25 years-in which the methods by which mining in the deep seabeds takes place and the apportionment between various sectors could be periodically reexamined.
The United States has made its proposals, which represent significant restrictions on our freedom of action, for the sake of international peace and international harmony and for the purpose of demonstrating that in this new area of mankind's activities we will make every effort to avoid the sort of rivalries that characterized colonial exploitations of the 19th century.
But there are limits beyond which no American leader can go. And if those limits are attempted to be exceeded, then we will find ourselves in the regrettable and tragic situation where at sea-just as previously on land-unilateralism will reign supreme.
We in the United States would not, in the short term, have any disadvantages from this-quite the contrary. But we are part of mankind, and we believe that an opportunity would be lost that may not come again.
Dept. of State Bulletin, Vol. LXXV, No. 1944, Sept. 27, 1976, pp. 397-399.
Regime of Transit Passage
The straits articles set forth in the revised single negotiating text (RSNT) submitted by the Chairman of the Second Committee at the fourth session of the Third U.N. Conference on the Law of the Sea, March 15-May 7, 1976, provide for the regime of transit passage considered by the United States to be an essential element in the adoption of a 12-mile maximum breadth of the territorial seas. U.S. delegations to the 1976 sessions of the Conference reported general agreement among states on the subject, although noting that a small number of states sought changes, varying according to their geographical location and configuration.
Ch. 2 of the Second Committee's text, entitled "Straits used for international navigation," follows:
SECTION 1. GENERAL
Juridical status of waters forming straits used for
international navigation
1. The regime of passage through straits used for international navigation established in this chapter shall not in other respects affect the status of the waters forming such straits nor the exercise by the states bordering the straits of their sovereignty or jurisdiction over such waters and their air space, bed and subsoil. 2. The sovereignty or jurisdiction of the states bordering the straits is exercised subject to this chapter and to other rules of international law.
Nothing in this chapter shall affect:
(a) Any areas of internal waters within a strait, except where the establishment of a straight baseline in accordance with article 6 has the effect of enclosing as internal waters areas which had not previously been considered as such;
(b) The status of the waters beyond the territorial seas of states bordering straits as exclusive economic zones or high seas, or


Like Conor McPherson's Dublin Carol, produced upstairs at Steppenwolf last month (my review) , his longer, more fanciful Seafarer centers on drunken Irish failures in frantic need of a second chance on Christmas Eve. A former alcoholic, McPherson has seen the bottom of many bottles and sent back postcards. His surrogate Sharky (Francis Guinan), an accident-prone, guilt-ridden loser who singlehandedly justifies the saddest Irish stereotypes, is consumed with self-loathing. He boozes with his censorious and now-blind brother Richard (John Mahoney), his hen-pecked chum Ivan (Alan Wilder), and Nicky (Randall Newsome), his ex-wife's stew-faced new husband. Each has enough troubles to require local anesthetics acquired through pub crawling or just consumption out of a brown paper bag.
In the first act they indulge in male-bonding strategies of dominance and submission, with Richard particularly astute at passive-aggressive insults masquerading as simple observations. But, as if to raise small talk to big stakes, Nicky has brought along Mr. Lockhart (Tom Irwin). This nattily dressed stranger turns out to be the devil, eager to play cards for Sharky's soul because of an unresolved match-up they'd had a quarter century before. In the play's best passage, Lockhart secretly describes the rather unconventional hell that he will take Sharky to (through a tavern conveniently called The Hole in The Wall). It's a kind of eternal cold storage where no one will love him and he'll lack the "peace of mind" that pervades heaven.
As in The Devil and Daniel Webster, the intrigue is how Sharky can save his soul from this convivial devil who hates music but not Irish whiskey. As it turns out, the crowd-pleasing, cleverly compassionate ending, based on an implausible shift in the game's outcome, delivers the wishful thinking of A Christmas Carol. But it's too contrived to convince. The devil deserves better.
Saving the show from its script, Randall Arney's Steppenwolf staging delivers performances that are dead reckoning. Despite the shaky accents, this ensemble adeptly capture the sloppy intimacy of old friends lubricating themselves into oblivion. They all work together. -Mahoney's sly digs as the control-freak brother, Wilder's paralyzed look as Ivan considers the angry wife from whom he's temporarily escaped, and Newsome's clumsy attempts to lift idiotic anecdotes into shared legends. In contrast, there's Guinan's glum-pussed Sharky, whose lack of connections defines him more than the others' feckless bonhomie.
Finally, Irwin's loud, humorless and ultimately lonely Lockhart acts as a walking curse intent on putting Sharky out of his misery into a worse one. ("I've seen all those hopeless thoughts, buried there, in your stupid scrunched-up face." ) They deserve each other, perhaps more than the audience does this uncomfortably devout piece of sympathy for a sinner.
Links to Other McPherson Plays reviewed at Curtainup including The Seafarer in New York where many critics were ecstatic about it.


There is an inexcusable and disheartening silence from white evangelical Christians over the unprovoked killing of Richard Collins III at the University of Maryland over the weekend.
Collins, 23, was a member of the ROTC. He was recently commissioned as a second lieutenant in the Army and was scheduled to graduate from Bowie State University on Tuesday. His father, a military veteran, said his son loved lacrosse, soccer, and was a runner.
Collins was African American. His alleged killer, Sean Christopher Urbanski, 22, appears to be a white nationalist, a member of a Facebook group called "Alt-Reich Nation." Urbanski was charged with murder and assault for the attack that University of Maryland Police Chief David Mitchell called "totally unprovoked."
"He is an absolute danger to the community," she said.
I believe that the real "danger to the community" about which the judge spoke does not just apply to the alleged killer. It also applies to white evangelical Christians, professing a faith rooted in justice for the oppressed, but whose silence over America's "open season" on black lives can only be read as consent.
Repeatedly, black pain over escalating killings has been met by silence of the white evangelical community.
Tragically, the same excuse was made by white evangelicals each time a black person, mostly unarmed men and boys, were killed by cops. Sadly, we have heard these names and too many others: Jordan Edwards, Trayvon Martin, Michael Brown, Tamir Rice, Jordan Davis, Eric Garner, Alton Sterling, Laquan McDonald, Walter Scott. The list goes on of those struck down by police.
Repeatedly, black community pain, outrage, and resistance over these escalating killings have been met by the silence of the white evangelical community. These killings have taken place mostly without a word, even from often outspoken white evangelicals. Perhaps something about the victims made them unworthy of compassion, outrage, or speaking out. She had a police record. He was selling untaxed cigarettes. He had a busted taillight. He was reported to have had a weapon. She resisted arrest. He was running from the police. The excuses are varied, but no less painful.
This is a cost too high for the people of God to continue to tolerate.
The Collins murder reminds us that whether or not an African American is an upstanding citizen, doing all the right things, or has a flawed background, their killing is sill met with the same silence, not the least bit of outrage.
Richard Collins III was a soldier, an honor student, just three days short of graduating from college. Not even these extraordinary attributes and accomplishments were enough to provoke Christ-like compassion and outrage from white evangelicals. His life did not matter to them, any more than those who were considered too imperfect to elicit any measure of moral indignation.
Studies confirm that African Americans are more likely to be stopped, frisked, arrested, and abused by the police than white citizens, even for the same crimes. Therefore, the biblical call to protect and cover the weakest parts of the body, is a call that makes silence an inexcusable and troubling response to the escalating attacks on black lives.


text:
Iyanla on the Importance of Boundaries Between Exes
Aired on 03/31/2018 | CC tv-14
Reality star Trina Braxton has been divorced from her ex-husband, Gabe, for a few years, but the two still can't seem to make a clean break from each other. In the time since their divorce was finalized, Trina has nursed Gabe back to health after surgery, allowed him to live with her, supported him through a recent breakup with another woman and even slept with Gabe while on a recent family vacation. It's as if Trina is Gabe's "wife on the other side of the divorce," Iyanla says, which is unhealthy if they want to move forward.
"I have an ex-husband, and he don't come to my house after he has surgery. And we are dear friends, but he don't come sleep up in my guesthouse 'cause he ain't got nowhere to live. But that's just me," Iyanla says. "Boundaries."
Tune in Saturday, March 31, at 9/8c.
Farewell Special -- Part 2
Open Letter to All Black Men
99 Problems and My Mom Is One
Marriage Is Not Our Business
LisaRaye: Queen of De-Nial
When Dirty Laundry Goes Viral
All Aboard the Trauma Train
Home Invasion Horror Story
LisaRaye McCoy
Biological Mama Drama
The Masks We Wear
House of Chaos
Shay Johnson: "BLEEP Your Process!"
Where Are They Now: Fix My Overweight Family
Where Are They Now: Fix My Abusive Marriage
Pride vs. Prejudice (Part 2)
Iyanla: "My Relationship With Motherhood Was Complicated
Iyanla Explains The Origin Of Her Name
Iyanla Recalls Her Favorite One-Liners That Became Memes
Digital Exclusive: Iyanla on the Power Of a Hug
The Iyanla: Fix My Life Farewell Special Airs Saturday
Iyanla Shows David Jr. That He's on the Pipeline to Prison
A Son on His Widowed Father: "We Broke This Man Down"
Dr. Steve Perry On The School-To-Prison Pipeline


text:
Assessing administrative costs of mental health and substance abuse services
Robert W. Broyles, Lutchmie Narine, Madeline J. Robertson
Increasing competition in the market for mental health and substance abuse MHSA services and the potential to realize significant administrative savings have created an imperative to monitor, evaluate, and control spending on administrative functions. This paper develops a generic model that evaluates spending on administrative personnel by a group of providers. The precision of the model is demonstrated by examining a set of data assembled from five MHSA service providers. The model examines a differential cost construction derived from inter-facility comparisons of administrative expenses. After controlling for the scale of operations, the results enable MHSA programs to control the efficiency of administrative personnel and related rates of compensation. The results indicate that the efficiency of using the administrative complement and the scale of operations represent the lion's share of the total differential cost. The analysis also indicates that a modest improvement in the use of administrative personnel results in substantial cost savings, an increase in the net cash flow derived from operations, an improvement in the fiscal performance of the provider, and a decline in opportunity costs that assume the form of foregone direct patient care.
Administration and Policy in Mental Health
https://doi.org/10.1023/B:APIH.0000034416.45790.a3
personnel costs
Phychiatric Mental Health
10.1023/B:APIH.0000034416.45790.a3
Fingerprint Dive into the research topics of 'Assessing administrative costs of mental health and substance abuse services'. Together they form a unique fingerprint.
Administrative Personnel Medicine & Life Sciences
Substance-Related Disorders Medicine & Life Sciences
Mental Health Medicine & Life Sciences
Organizational Efficiency Medicine & Life Sciences
Compensation and Redress Medicine & Life Sciences
Cost Savings Medicine & Life Sciences
Efficiency Medicine & Life Sciences
Broyles, R. W., Narine, L., & Robertson, M. J. (2004). Assessing administrative costs of mental health and substance abuse services. Administration and Policy in Mental Health, 31(5), 393-408. https://doi.org/10.1023/B:APIH.0000034416.45790.a3
Assessing administrative costs of mental health and substance abuse services. / Broyles, Robert W.; Narine, Lutchmie; Robertson, Madeline J.
In: Administration and Policy in Mental Health, Vol. 31, No. 5, 01.05.2004, p. 393-408.
Broyles, RW, Narine, L & Robertson, MJ 2004, 'Assessing administrative costs of mental health and substance abuse services', Administration and Policy in Mental Health, vol. 31, no. 5, pp. 393-408. https://doi.org/10.1023/B:APIH.0000034416.45790.a3
Broyles RW, Narine L, Robertson MJ. Assessing administrative costs of mental health and substance abuse services. Administration and Policy in Mental Health. 2004 May 1;31(5):393-408. https://doi.org/10.1023/B:APIH.0000034416.45790.a3
Broyles, Robert W. ; Narine, Lutchmie ; Robertson, Madeline J. / Assessing administrative costs of mental health and substance abuse services. In: Administration and Policy in Mental Health. 2004 ; Vol. 31, No. 5. pp. 393-408.
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title = "Assessing administrative costs of mental health and substance abuse services",
abstract = "Increasing competition in the market for mental health and substance abuse MHSA services and the potential to realize significant administrative savings have created an imperative to monitor, evaluate, and control spending on administrative functions. This paper develops a generic model that evaluates spending on administrative personnel by a group of providers. The precision of the model is demonstrated by examining a set of data assembled from five MHSA service providers. The model examines a differential cost construction derived from inter-facility comparisons of administrative expenses. After controlling for the scale of operations, the results enable MHSA programs to control the efficiency of administrative personnel and related rates of compensation. The results indicate that the efficiency of using the administrative complement and the scale of operations represent the lion's share of the total differential cost. The analysis also indicates that a modest improvement in the use of administrative personnel results in substantial cost savings, an increase in the net cash flow derived from operations, an improvement in the fiscal performance of the provider, and a decline in opportunity costs that assume the form of foregone direct patient care.",
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AB - Increasing competition in the market for mental health and substance abuse MHSA services and the potential to realize significant administrative savings have created an imperative to monitor, evaluate, and control spending on administrative functions. This paper develops a generic model that evaluates spending on administrative personnel by a group of providers. The precision of the model is demonstrated by examining a set of data assembled from five MHSA service providers. The model examines a differential cost construction derived from inter-facility comparisons of administrative expenses. After controlling for the scale of operations, the results enable MHSA programs to control the efficiency of administrative personnel and related rates of compensation. The results indicate that the efficiency of using the administrative complement and the scale of operations represent the lion's share of the total differential cost. The analysis also indicates that a modest improvement in the use of administrative personnel results in substantial cost savings, an increase in the net cash flow derived from operations, an improvement in the fiscal performance of the provider, and a decline in opportunity costs that assume the form of foregone direct patient care.
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text:
Vaal University of Technology School Fees 2022/2023
The Vaal University of Technology school fees schedule for fresh and returning undergraduate students for the 2022/2023 academic year has been published.
The management of the Vaal University of Technology (VUT) has published the school fees schedule for newly admitted students and returning students for the 2022/2023 academic session.
The university reserves the right to change fees without prior notice to the student. However, fee changes are subject to approval by the Governing Council.
This post contains the breakdown of tuition fees to be paid by undergraduate students of the Vaal University of Technology.
Vaal University of Technology School Fees
CLICK HERE to view or download the Vaal University of Technology (VUT) School Fees Schedule.
Visit the school website to get more information…
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Related Topics:Vaal University of Technology | www.vut.ac.za
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Situated at only 4km from Bergerac, it has a dominant river position. This is a special 350m2 one level house, inside of a 2 hectare forest park. This house has a 51m2 living room with beautiful wood walls. The 29m2 living room has a wonderful view over the Dordogne's river. It also has one office, six rooms (two of them are renovated), three 1/2 bathrooms, kitchen and a small storage room. There is a big parking place, and a 12X6 swimming pool with salt treatment.
- Storeroom with an stone fire place.
- 4 carpeted rooms, 2 of them are suites.
- There is a kitchen that has to be renovated.
- 51m2 marbled room, it has a wood fire place, and it is oriented towards the south.
- 29m2 living room (carpet), it is oriented towards the west, and it has an unrestricted view over the Dordogne's river.
- 4 years Heat boiler Viesmann brand.
- There is one 15m2 room that needs to be renovated.
- There is an stone room that is used as a technical room for the pool.
- wells, that helps to irrigate the park and the pool.
- double glazing on the west side of the house.
- Wood Doubled glazing windows on the west part.
- The airport is at 5 min.
- Dominant view over the Dordogne's river.


text:
package implementation

import (
	plannercore "github.com/pingcap/tidb/planner/core"
	"github.com/pingcap/tidb/planner/memo"
)

// HashJoinImpl is the implementation for PhysicalHashJoin.
type HashJoinImpl struct {
	baseImpl
}

// CalcCost implements Implementation CalcCost interface.
func (impl *HashJoinImpl) CalcCost(outCount float64, children ...memo.Implementation) float64 {
	hashJoin := impl.plan.(*plannercore.PhysicalHashJoin)
	// The children here are only used to calculate the cost.
	hashJoin.SetChildren(children[0].GetPlan(), children[1].GetPlan())
	selfCost := hashJoin.GetCost(children[0].GetPlan().StatsCount(), children[1].GetPlan().StatsCount())
	impl.cost = selfCost + children[0].GetCost() + children[1].GetCost()
	return impl.cost
}

// AttachChildren implements Implementation AttachChildren interface.
func (impl *HashJoinImpl) AttachChildren(children ...memo.Implementation) memo.Implementation {
	hashJoin := impl.plan.(*plannercore.PhysicalHashJoin)
	hashJoin.SetChildren(children[0].GetPlan(), children[1].GetPlan())
	return impl
}

// NewHashJoinImpl creates a new HashJoinImpl.
func NewHashJoinImpl(hashJoin *plannercore.PhysicalHashJoin) *HashJoinImpl {
	return &HashJoinImpl{baseImpl{plan: hashJoin}}
}

// MergeJoinImpl is the implementation for PhysicalMergeJoin.
type MergeJoinImpl struct {
	baseImpl
}

// CalcCost implements Implementation CalcCost interface.
func (impl *MergeJoinImpl) CalcCost(outCount float64, children ...memo.Implementation) float64 {
	mergeJoin := impl.plan.(*plannercore.PhysicalMergeJoin)
	// The children here are only used to calculate the cost.
	mergeJoin.SetChildren(children[0].GetPlan(), children[1].GetPlan())
	selfCost := mergeJoin.GetCost(children[0].GetPlan().StatsCount(), children[1].GetPlan().StatsCount())
	impl.cost = selfCost + children[0].GetCost() + children[1].GetCost()
	return impl.cost
}

// AttachChildren implements Implementation AttachChildren interface.
func (impl *MergeJoinImpl) AttachChildren(children ...memo.Implementation) memo.Implementation {
	mergeJoin := impl.plan.(*plannercore.PhysicalMergeJoin)
	mergeJoin.SetChildren(children[0].GetPlan(), children[1].GetPlan())
	return impl
}

// NewMergeJoinImpl creates a new MergeJoinImpl.
func NewMergeJoinImpl(mergeJoin *plannercore.PhysicalMergeJoin) *MergeJoinImpl {
	return &MergeJoinImpl{baseImpl{plan: mergeJoin}}
}

redpajama_set_name: RedPajamaGithub