The View from Hillview | Look out Europe, The Carmichaels are Coming!
Look out Europe, The Carmichaels are Coming!
It seems obvious, doesn't it? A move to a new country will bring along a whole new world of stress. Which it does, but how we each deal with the stress of change, unfamiliarity, fitting in, new schools, jobs, and communities is as individual as we are each individuals. Hmmm, a bit wordy, but you understand, yes?
Our largest concern was for our daughters.
They actually don't go to school in a castle. But they could. This is England, after all.
How did we help them prepare for school?
Brought them with us on the initial house and school hunting trip. This helped them feel part of the process, which was important as the decision to move was largely done without their input. Of course we considered their feelings, however the opportunity this move provided for all of us was the deciding factor.
Scheduled a one-on-one school meeting once we returned to England. This allowed them another view of the school and to get all their questions answered; when was lunch, how will they find their way around school, and what courses should they select?
Validated their fears and talked them through them. They were scared. This was normal and letting kids feel those feelings, but not wallow in them is important. Together we helped them imagine the first day and how it would unfold. We did some light role-playing, to get them thinking about how to start conversations with other students. We told them to smile and be themselves.
We knew that one of their greatest fears was to have the "wrong" bag or socks or pencil-case. We made right anything we got wrong the first time through.
We scheduled appointments with teachers to understand how the English school system worked in terms of grading, "sets", and the all-encompassing GCSE exams. I will deal with the confusing U.K. school system, as far as I understand it, in a later post. I may need to create visuals.
How did we help them to settle in and deal with homesickness?
Exploration. Whether on foot, cab, bus, or train, we set out each day to explore our neighbourhood, when we first moved to Hertford. We now continue to journey further and further across England and of course we take many, many trips to London.
Skype sessions with family and friends. Keeping in contact with grandparents and friends has been crucial for the girls. With the internet there is no reason we can't keep in close contact all our loved ones in Canada. This is helping ground them and not feel so alone.
Cooking and baking comfort foods. There is nothing like coming home from school to a steaming bowl of "Gramma soup" and a plate of Granny's freshly baked chocolate chip cookies to make a kid feel at home.
Validating their feelings. This continues to be a bumpy transition and we need to be ready with lots of hugs, back rubs, and chocolate chip banana bread.
On the most part we have adjusted fairly well, however, we too have had our share of homesickness.
Engaged a relocation company. This was crucial. I am not sure how we would've moved as seamlessly as we did without them. They helped us find a house, school, grocery store, furniture, a doctor's office, and even assisted with understanding train schedules.
We researched online and asked a lot of questions of friends who also had made transatlantic moves. Thanks to a Canadian friend in Australia, we had insights into what should be included in an expat package, what mementos to bring, and what to expect upon arrival.
The Drew came over a few weeks before the kids and I to purchase some basic furniture, food, and everyday supplies so when we arrived we weren't met with a cold and empty home. Finding things like pictures, clothes, bedding, and even towels from home waiting for us was comforting and made our house feel more homey.
We are now slowly making friends ourselves. I am part of my street's book club, we joined a local gym, and Drew has done the pub crawl with some dads from the girls' football teams. And just like the kids we are learning that making friends takes time and effort.
It took a good 3 months for the extreme homesickness to slip away and the kids still have roller coaster moody moments, but life is full of kids' moody moments.
Would we do it all again? You betcha. It was the wildest, bravest, craziest, and smartest decision we have ever made.
The world is there to discover.
Moody nightfall – King's College.
Our kids are constantly surprising us. They keep rising to the occasion that is "explore every inch of our new homeland" with enthusiasm.
They were excited about the Eiffel Tower, the nuclear bomb shelter in Essex, and the London Science Museum. However, we have been holding off on medieval churches, garden tours, and old estate grounds, sensing these are places not typically filled with secondary school students. At least not when not on a school led outing.
Or maybe it was just, "Okay. Cool." Details schmetails.
What matters is they were on board, which as every parent knows, is the key to a successful family road trip.
Getting lost has never been such fun.
Drew and I had on our agenda a tour of King's College, St. Mary's Cathedral, and a stroll along the streets, taking in the vibe of this university town that dates back to 1209. We are history buffs, so walking the same streets of Lord Byron, Charles Darwin, and Stephen Hawking was thrilling. Even more thrilling was that the girls' were almost as excited as us.
Yes, that is correct. Somehow we stumbled across a mall, hidden in the heart of Cambridge. Emma was in awe. Starbucks, New Look, and John Lewis greeted us as we followed Em's beeline to The Little Cupcake stall.
Filled with mocha frappuccinos, lattes, and decadent treats we made our way to St. Mary's Catherderal. We trekked up the bell tower – all 123 winding stairs – and were rewarded with breathtaking views of Cambridge. Sarah took those narrow stairs two at a time on the way down, which was only just this side of heart stopping. I followed much slower, my aging knees groaning as I gripped the hand rail to steady my decent.
King's College or drum store? Choices, choices.
Next up was King's College, where we were eager to see where some of the best minds in science, maths, and literature had gone to school. Sadly, the college was closed to the public that day, however our disappointment quickly faded as we turned the corner to find…a music store… a music store filled with drum kits.
Sarah was in Nirvana. Literally.
Our budding photographer a.k.a. a miraculous moment of sibling civility.
Although our kids are catching our history bug, they are still kids, and weaving kid friendly attractions into our adventures keeps their interest. What we have quickly learned is to balance our adventures between adult and child friendly events. This keeps the peace and nourishes family harmony.
Our next stop: Birling Gap & Brighton to see the sea.
*Cambridge Tip: Do NOT drive into the town. It is a congested one way street nightmare. Make use of the Park and Ride bus service for easy and stress free access.
Yup, the drums found a new home. That's right, she is drumming in her Halloween costume as all famous drummers are prone to do. Just ask Phil Collins.
For close to a decade we have spent Thanksgiving at our cottage on Lake Winnipeg with our family crowded around tables, elbows knocking, as we gave our thanks.
This year we had to tweak our old traditions. We ate chicken rather than turkey, chocolate cake in place of Gramma's pumpkin pie, and the rolling hills of Hertford replaced the sandy shores of Ponemah.
The ill-named bunker near Chipping Ongar.
Rather than spending the day raking leaves at the lake and preparing a 15 pound turkey with all the trimmings, we spent a better part of Sunday exploring a decommissioned nuclear bunker.
It was strangely cool, yet it contributed to our family's "out of sorts" kind of day. It was similar to that feeling when you wear an ill-fitting pair of pants trousers, that cover your rumpus, but when you sit down the button flies off. Or like when you are truly jonesing for a McDonald's Big Mac and have to settle for a Hardee's cheese burger, except neither roasted chicken or turkey will give you severe indigestion and chronic heart disease. Things are familiar, but not quite right.
There is a book for everything.
The first year after any life changing event is supposed to be difficult. Everyone says so. There are even books that help you transition from the old and familiar to the new and unknown.
The newness of our first holiday celebration away from Canada, hit hardest when skyping with our family. Earlier in the evening we chatted with my parents, catching up and giving virtual hugs and discussing future travel plans. It was sad, but we muddled through.
Things went pear-shaped as we huddled on the sofa after dinner to skype with Clan Carmichael. It was great to see the Aunties, Uncles, Cousins, Gramma, and of course our beloved and sorely missed Zoe-Zoe Dog. However, it was also heart wrenching not being able to hug them, or taste a bite of my sister-in-law's famous sweet potato pie, or to sip mulled wine around our cottage campfire, between games of bacci ball and roof ball. Sarah crumpled first, followed by me, then Emma, and finally Drew.
Thanksgiving left us all in a funk, allowing homesickness to slip in and set up camp in our front living room. However, it is time for a fall clean, and that room is next on my list.
We shall push those sad feelings out the front door, down the hill, and focus on our next European trip. Surely discussions of where to spend New Years will be spirit lifting for each one of us.
And who could remain glum when Zurich, Salzburg, and Barcelona are less than 3 hours away?
Europe at our back door.
This ancient cedar canopies the graves around its roots.
In the past, I've always found them extremely spooky. Until recently. I'm not sure what changed. Maybe my curiosity with who has come before has been dialed up the older I get. Or perhaps the older I get, the closer I am to becoming a permanent cemetary resident. Most likely much has to do with moving to England, a country full of old, creepy, and beautiful graveyards.
As I wandered through the St. Andrew's cemetery, my mind was full of questions. Who lived here before? What were their lives like? How did they die? Many of the tombstones are worn away, the writing erased from our sight, but still remains the marker of a person who once walked through the same streets I do. A person who loved and was loved, with dreams and aspirations. Likely they lived a harder life. One full of challenges and disappointments, limits placed on them due to status and privilege.
St. Andrews Church yard in Hertford.
Writing historical fiction has always intrigued me, and as I craft the story behind my middle grade novel set in 1944, I am left to dream of other tales that can be found hiding in the past.
So where will I roam next?
Shall I visit Bunhill Fields in the London Borough of Islington, where John Bunyan, author of The Pilgrim's Progress, Daniel Defoe, who wrote Robinson Crusoe, and the poet and artist William Blake rest in peace.
Perhaps I will meander through the Royal Burial Ground, Frogmore, Berkshire where Queen Victoria and Prince Albert are buried.
Or what about visiting the tomb of Karl Marx in The Highgate Cemetery in London? This is also where painter Dante Gabriel Rossetti's wife Elizabeth Siddal (d. 1862) is buried. Apparently he had her grave opened in 1869 to retrieve a book of poems he had placed in her coffin. Morbidly cool fact.
We are planning a trip to Scotland so we should probably include the Iona Abbey on the list. Duncan, the Scottish king murdered by Macbeth in 1140, is reputed to be buried here, along with 47 other Scottish kings and a number of Scottish saints.
Hope to see you soon, lurking behind a crumbling mausoleum.
The perfect latte swirl at The Bebo Cafe.
After my shameful admission of passing over fine local cafes for the super chain coffee-house, Starbucks, I decided I can and must do better.
Me, my coffee addiction appreciation, and my future Hertford happiness is dependent upon it. A ginormous exaggeration, but still.
Fountain in Salisbury Square celebrating the four rivers in Hertford; The Lee, Mimram, Beane, and Rib.
Yesterday my café research took me to The Bebo Café which is right in the heart of Hertford. Their front doors open onto Salisbury Square where the sounds and smells of The Hertford Farmers' Market overtake your senses each weekend. Here you will hear the call of "Three quid for two pounds of fresh strawberries" while smells of seafood and fresh pastries fight for your attention and the fishmonger and baker vie to make a sale. All while you stroll along the cobblestone pedestrian-only paths.
A quiet writing and people watching nook.
Autumn is in the air in Hertford, so I sat inside, down a few steps still facing the front door which was a perfect place to write and when words alluded me; people watch. The coffee shop was full of moms with young kids, their conversation revolved largely around their children. I didn't intend to eavesdrop, but the rhythm and cadence of English accents still catches me up, interrupting my thoughts. It seemed much of their concern was centered on their children's happiness; are they making friends, are they adjusting to new schools and teachers, and will they cope well with more demanding homework expectations.
I found this extremely comforting. Not that the mothers were worried about their children, as that would be somewhat sadistic, but that their concerns are nearly identical to my own worries for my children.
World Wide Community of Mums.
It seems wherever you go, the world over, concerns of mothers are nearly identical. Are our children happy? And wherever you go, you always remain a member of the Mother Community – in a very broad sense.
There is more to a town than its shops, restaurants, and schools. Those are important and make a place interesting and unique, but it is the people who fill the cafes, markets, and houses that make a town feel like home.
Sitting in that cafe, feeling part of that Mother Community, made me feel connected to my new neighbours, even if they didn't know that I have moved into a house on the tippy-top of a hill, that has a most spectacular view.
It also let me feel more at ease than I have in quite some time, allowing my mind to drift back to story building and creative thoughts, and to that exquisite latte, with the swirl of foam and that perfectly flaky cinnamon brioche.
Sitting just at street level, providing a unique view of the town.
The search for the familiar grounds us, make us feel connected to our environment. Some people crave it like a chocolate addict craves a life-sized Coffee Crisp. Others are only slightly affected by the unknown and unfamiliar. Perhaps they crave all things new to the same extent that same chocolate lover wants his Oh Henry bar. I have no scientific proof to back me up, only hunches, intuition, and personal experience.
I land somewhere in between those extremes. Which seems a bit of a flip-flop in my quick adoption of English life when I consider my last post of feeling at home only last week. Then, all seemed grand, easy, and vaguely familiar.
As my time in a foreign land lengthens and the reality that we are not on some great family holiday sinks in, I am hit face first with all that is different. And I am feeling ungrounded. And overwhelmed. And lonely.
My daughters are now back to school, both with hearts sick for home, friends, and family. Since I need to be their solid rock of confidence I have worn a brave mom face. To borrow from an English friend, I am practicing my stiff upper lip. My lip may be quivering like an autumn leaf on a tree, but stiff my lips (both upper and lower for safe measure) have become.
Now that I am alone and taken to wandering Hertford Town streets, I find myself searching for the familiar, looking to get grounded.
This is just like my walk through Hertford. Except it was a bright sun-shining day, and that's a dude in a hoody, and my stroll was far less scary and way more cobble-stone quaint. Besides that, could be my doppelgänger.
And where did my feet take me today?
Hertford Starbucks, where every latte tastes the same.
Past Costa's Coffee and Nero's Café and well past the Turkish coffee shop and wound their way along cobblestone avenues to Starbucks. Yes, Starbucks. Almost embarrassingly typical for a North American.
When every store around you is unfamiliar and it is hard to find chocolate chips, pot barley, wheat thins, cream cheese, golden mushroom soup, and so many more foods your family is demanding asking for so sweetly, you get a bit overwhelmed. If you then top that off with the realization that you can't buy Melatonin in the UK and you've had your last blessed pill the night before, you might panic a tiny bit thinking you will be awake for the next two years straight.
So can a person fault themselves for aching for the familiarity of a Starbucks?
"No!" I say with conviction (fueled by caffeine).
So I sit here, surrounded by coffee lovers; couples, moms with tots, and the solo acts who sit at their laptops furiously tapping.
The writer in me is curious to know if they too are writers. The Canadian in me is too polite to ask. The foreigner in me is delighted to just sit back in the deep-seated faux leather sofa and people watch while drinking in an hour of familiarity, sipping on her wet latte, and write.
Oh right. Not everything is the same in the Starbucks UK.
A wet latte = a latte, no foam.
I know it has only been a little over one week, but I have fallen head over heels for this country.
It is familiar, yet different.
Is this feeling of familiarity a result of us moving to an English-speaking country? Is it because the UK system of government, health care, and views on socialism are similar to my Canadian experience? Or could this familiarity be at a more cellular level?
Bear with me while I explore this thought.
On both sides of my family my ancestors immigrated to Canada from the British Isles; Wales, Scotland, and Ireland. My granddad was born in London in 1904 while his Welsh family was in the process of immigrating to Canada.
I have never lived anywhere but Winnipeg, and our Winnipeg house is only a mile from my childhood home. Being in a familiar environment has always been comforting and the thought of moving anywhere far from family and friends brought me mild to extreme waves of anxiety, yet now that I am 3,900 miles from my Winnipeg front door I feel at home.
A few days ago I ventured out to explore Hertford with my youngest. I let my 11-year-old dictate our destinations as I want the kids to become as comfortable with their new town as I am. We got lost, found our way back home, and in the process discovered two more candy stores (we are now up to four and the girls are in sweets heaven), the pet store, a WH Smith bookstore, a fish monger, and of course a castle.
We are in England after all.
On Saturday we went to the town centre farmer's market, registered with a surgery to get a National Health Services number, searched out a clothes dryer (as stiff undies, t-shirts, and jeans are not as cozy as they sound), and ventured to the metropolis of Welwyn Garden City to get shirts, skirts, shoes, and trousers to complete the girls' school uniforms.
Oh, and did I mention I DROVE for my first time?
The mini. My dream car. Helmet on. Ready to ride!
*Humidity, damp, rain, and more rain to be explored in a later post, because…England. And rain is a thing here. Just like how Canadians do snow and cold, the English do rain and cool.
They say with every big move there will be some bumps. Small hurdles. Hiccups that interrupt your acclimation to your new environment.
How does this correlate to Murphy's Law? It doesn't until you consider the Carmichael Family Crest is a hand holding a broken spear. In other words, we're ready for a fight yet we come to the battlefield with a broken weapon. My day was sort of like that. I had great intentions of accomplishing everything on my to-do list, and ended up tearing it up into teensy, tiny microscopic pieces by half past noon.
People are very helpful when you show up announced at a ritzy golf club seeking a landlady named Jo.
Neighbours have an understanding smile, directions (albeit without street names), and a cup of tea at the ready.
English front house doors automatically lock when closed. Without fail.
After a very sudden and intense wave of 7am home-sickness, I pulled myself together, wiped my tears, and stiffed my upper lip to hit the moving boxes with a renewed determination. I was also buoyed by the news that my step-mom was coming for a visit at 12:00. Our plan was to get the girls' school uniforms, have lunch, and leisurely stroll along the canal that runs through Hertford. Deeeelightful. When Judith's rappa-tap-tap sounded at the door, we raced outside to greet her. Me in my sturdy fashionista runners, Sarah in her socks, and finally Emma in her bare feet.
No phone. No money. No shoes. Fantastic.
Thankfully a neighbor a few doors down recalled that our landlady, Jo (last name at this point unknown) also managed a golf course and quickly gave us directions. Unfortunately we didn't have the exact name of the course, however, we weren't concerned. How hard could this be, we reasoned. England is a small country after all.
England has a lot of golf courses. In close proximity to each other.
What a way to treat newcomers to a country. I highly recommend Brickendon Golf Club if you are ever in Hertfordshire.
And a huge thanks to Dave, who treated us like royalty, proving that settling in Hertford was the right decision for us.
Only 5 more sleeps until our transatlantic move.
Overseas. Living in Europe. Neighbors with the Queen. Okay the last is a stretch, but it still counts. If Elizabeth the Second was in a pinch and needed a place for a quiet cup of tea, at least my reception room is on the same continent, not 3 time zones away smack dab in the middle of Canada.
And yes, that's right I said reception room, not living room. I am practicing my "British" as the kids call it. I believe the actual British call it "proper English." However you phrase it, we have a lot to learn about our new country, beyond driving on the other side of the road, becoming tea aficionados, and mastering school tie-tying so 10 stripes show. Drew will be working in Dublin every second week and since he is currently our sole tie wearer and tie-tyer, we'll be on our own for much of the time. I predict this skill to shoot to first place on our Top 10 England Adaption list, pronto.
This final week is full of final moments.
Today we say farewell to our beloved cottage, Stone's Throw for the final time before we move. For the past 13 years, we have spent every summer here; skipping over sandbars, toasting burning marshmallows in our fire pit, and watching our "Hartmichael"* girls make up dances, gymnastics routines, and film movies with seemingly endless energy. Every moment creating another cherished summer memory. Leaving with another summer full of fresh fun is likely the best way our family can leave Canada. We will reminisce about days of sand, swimming, and s'mores with friends at the cottage while we fly over the Atlantic.
This week we jam and cram as much time in with friends and family. How easy it is to take those dearest to you for granted, until you have a dwindling number of days, hours, and finally minutes with them. We are so fortunate to have caring grandparents, aunties, uncles, and cousins that will be greatly missed.
Favourite lake side writing spot.
But right now, I am typing this curled up in my favorite wicker chair in my front porch, looking out on sparkling Lake Winnipeg. Puffy white clouds drift across the pale blue prairie sky, the pier at Nelson's beach inviting me for one last swim. And why not? Can anyone have too many beach days?
Tomorrow or the next, I'll write about farewell parties, final packing, and furry creatures. Yup. Alliteration at its finest.
*Hartmichaels is our blended last name of Hartley and Carmichael; together we become…The Hartmichaels! We have gone on numerous adventures together and the girls are like cousins. Together they will conquer the world.
There have been so many firsts for The Carmichael Clan over the past 6 months.
First time we've taken the girls overseas. The first time the girls have seen Big Ben, Piccadilly Circus, and The Harry Potter Studios. And the first time we've both rented a house and became landlords; almost at the exact same moment.
It was actually easier to find a house in Hertford than it was to choose a tenant for our own Wildwood Park home. Maybe because there were only 13 houses available to rent in the entire Hertford town proper (and we viewed each one), or perhaps because we fell in love with the first Hertford home we saw. More likely it was because we were throwing caution to the wind and embracing that adventurous spirit that drove us to make such a big move to the U.K.
What I am certain of, is renting our own home in Wildwood Park was extremely difficult. Partly because "The Park" is the most special place we have ever lived. Living here is not just about the house itself, but the community into which you become enveloped. The selection process for a tenant was made more difficult because we had four renters who each would have been a wonderful fit for us and the neighbourhood. This really surprised me.
Ultimately, we came down to being fair and chose the renter who had given us all the background information we requested quickest. Much like Michael Phelps and all his Olympic Golds, we held a timed race to see who the "winner" would be.
Now the hard part. Telling the other three families they will have to continue their search for their Winnipeg home. With one potential tenant in particular this will be extra hard to do, as we bonded through her delightful friends who viewed our house on her behalf and through email; she in Wales and me in Winnipeg – both of us with ties to Cardiff. It is a small world after all. I imagine it feels a bit like an editor must when sending out a rejection letter to a writer…not a great feeling.
Wish me luck as I break the news.


Recent pediatric literature and studies by independent journals recommend key functions that should be part of a neonatal EMR, including those that enhance data management and improve patient safety and care.
First and foremost, the EMR should be designed specifically for neonatologists. This user-centered design is crucial to making a software program that works for the intended audience.
Join us this winter at the world's largest pediatric education event! We'll be showing pediatricians and other health professionals how to make strides in their NICU operations with the benefits and ease of use PediNotes.


text:
Video decision support...
Video decision support tool for advance care planning in dementia: randomised controlled trial
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b2159 (Published 28 May 2009) Cite this as: BMJ 2009;338:b2159
Errata - June 10, 2009
Angelo E Volandes, instructor1,
Michael K Paasche-Orlow, associate professor2,
Michael J Barry, professor1,
Muriel R Gillick, professor3,
Kenneth L Minaker, professor1,
Yuchiao Chang, senior statistician1,
E Francis Cook, professor4,
Elmer D Abbo, assistant professor5,
Areej El-Jawahri, research fellow1,
Susan L Mitchell, associate professor 6
1General Medicine Unit, Department of Medicine, Massachusetts General Hospital, 50 Staniford Street, Boston, MA 02114, USA
2Department of Medicine, Boston University School of Medicine, 715 Albany Street, Boston, MA 02118, USA
3Department of Ambulatory Care and Prevention, Harvard Medical School/Harvard Pilgrim, 133 Brookline Ave, Boston, MA 02215, USA
4Department of Medicine, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA 02115, USA
5Department of Medicine, University of Chicago, 5801 South Ellis, Chicago, IL 60637, USA
6Hebrew SeniorLife, 1200 Centre Street, Boston, MA 02131, USA
Correspondence to: A E Volandes avolandes{at}partners.org
Accepted 3 February 2009
Objective To evaluate the effect of a video decision support tool on the preferences for future medical care in older people if they develop advanced dementia, and the stability of those preferences after six weeks.
Design Randomised controlled trial conducted between 1 September 2007 and 30 May 2008.
Setting Four primary care clinics (two geriatric and two adult medicine) affiliated with three academic medical centres in Boston.
Participants Convenience sample of 200 older people (≥65 years) living in the community with previously scheduled appointments at one of the clinics. Mean age was 75 and 58% were women.
Intervention Verbal narrative alone (n=106) or with a video decision support tool (n=94).
Main outcome measures Preferred goal of care: life prolonging care (cardiopulmonary resuscitation, mechanical ventilation), limited care (admission to hospital, antibiotics, but not cardiopulmonary resuscitation), or comfort care (treatment only to relieve symptoms). Preferences after six weeks. The principal category for analysis was the difference in proportions of participants in each group who preferred comfort care.
Results Among participants receiving the verbal narrative alone, 68 (64%) chose comfort care, 20 (19%) chose limited care, 15 (14%) chose life prolonging care, and three (3%) were uncertain. In the video group, 81 (86%) chose comfort care, eight (9%) chose limited care, four (4%) chose life prolonging care, and one (1%) was uncertain (χ2=13.0, df=3, P=0.003). Among all participants the factors associated with a greater likelihood of opting for comfort care were being a college graduate or higher, good or better health status, greater health literacy, white race, and randomisation to the video arm. In multivariable analysis, participants in the video group were more likely to prefer comfort care than those in the verbal group (adjusted odds ratio 3.9, 95% confidence interval 1.8 to 8.6). Participants were re-interviewed after six weeks. Among the 94/106 (89%) participants re-interviewed in the verbal group, 27 (29%) changed their preferences (κ=0.35). Among the 84/94 (89%) participants re-interviewed in the video group, five (6%) changed their preferences (κ=0.79) (P<0.001 for difference).
Conclusion Older people who view a video depiction of a patient with advanced dementia after hearing a verbal description of the condition are more likely to opt for comfort as their goal of care compared with those who solely listen to a verbal description. They also have more stable preferences over time.
Trial registration Clinicaltrials.gov NCT00704886.
Respecting patients' preferences for treatment is a key component of high quality end of life care.1 2 3 4 Traditionally, physicians help patients to engage in advance care planning for future health states by describing hypothetical situations such as advanced dementia and by exploring possible goals of care.5 6 This traditional approach is limited because it is challenging to realistically envision hypothetical future disease states such as dementia from verbal descriptions,7 descriptions are inconsistent among providers,8 9 10 11 12 13 14 15 and the degree to which patients understand verbal descriptions of complex medical conditions depends on their level of health literacy.
Visual images can improve communication of complex health information16 17 18 19 and inform decision making at the end of life.20 21 22 In our previous investigations, a video decision support tool for advanced dementia seemed to improve communication and decision making for patients by helping them to visualise future health states.20 21 22 However, there were significant shortcomings to these studies: they were conducted in healthy middle aged patients; they used a before and after study design that did not allow comparison of the video to the standard advance care planning approach of a verbal narrative; they did not measure knowledge of the disease to test whether understanding of the disease improved; and they did not follow patients' preferences over time.
To address these shortcomings, we conducted a randomised controlled trial of the video decision support tool among a diverse group of older patients to study the video with a higher level of rigour. We hypothesised that compared with participants randomised to a verbal description of advanced dementia, those viewing the video decision support tool after listening to a verbal description would have greater knowledge of advanced dementia, be more likely to opt for comfort oriented care that focuses on the relief of symptoms, and would be less likely to change their preferences over time. A secondary, exploratory hypothesis was that the goals of care would be predicted by health literacy.
Advanced dementia is an excellent model on which to test the hypothesis that visualising a hypothetical health state improves decision making. Advanced dementia is an ultimately fatal, progressive, neurological disease in which the median survival after the onset of symptoms is three to six years.23 24 Patients with advanced dementia are at high risk of developing multiple yet predictable medical problems over the course of their illness, including aspiration pneumonia, pressure ulcers, and difficulty in swallowing. By virtue of their cognitive impairment, patients will seldom be able to participate in decisions about their care at the time problems develop. Healthy patients or patients in the early stages of dementia can, however, influence the treatment they will receive by exploring their goals of care with their physician. This entails deciding whether they would want specific interventions, such as cardiopulmonary resuscitation, intravenous antibiotics, or admission to hospital. This randomised controlled trial examined whether a video of a patient with advanced dementia could shape the choices made by people about the kind of care they would want in the future.
Participants were recruited from a convenience sample of patients cared for at four primary care clinics located at three teaching hospitals in the greater Boston area. These comprised an urban geriatric clinic, a suburban geriatric clinic, an urban adult primary care clinic, and a suburban adult primary care clinic. Recruitment occurred between 1 September 2007 and 30 May 2008. Clinic staff gave all scheduled English speaking patients aged 65 or over a leaflet outlining the study after patients registered for their clinic visit, which was scheduled as part of their usual care. At the end of the visit, clinic staff asked patients if they were interested in participating in the study. If patients indicated interest, the research team initially interviewed them for eligibility. Eligibility criteria included ability to communicate in English, ability to provide informed consent, and absence of moderate or severe cognitive impairment based on a short portable mental status questionnaire (SPMSQ) score of ≥7 (scores <7 indicate moderate or severe cognitive impairment).25
Study design and randomisation
After we obtained informed consent, all patients who met the eligibility criteria were randomised into one of two groups: listening to a verbal narrative describing advanced dementia (control group) or listening to the same verbal narrative followed by watching a two minute video depicting a patient with advanced dementia (intervention group). We used simple randomisation based on a computer generated scheme. Individual assignments were concealed in numbered envelopes, half of which were made available to each interviewer. One randomisation list was generated for all four clinics. At the end of the trial, the randomisation order of participants was checked against the computer generated list. A trained member of the research team followed a structured script to collect data in a quiet room in the clinic area.
For both groups, the interviewer read aloud the verbal narrative describing advanced dementia (see appendix on bmj.com). This description was based on the functional assessment staging (FAST) stage 7a.26 The FAST criteria include seven stages of dementia, with the later stages depicting more advanced disease. Stage 7 is further broken down into six substages (7a-7f). Stage 7a is generally considered the threshold for advanced dementia. The narrative states that advanced dementia is an incurable illness of the brain caused by many years of Alzheimer's disease or a series of strokes. Its salient features are the inability to communicate understandably with others, inability to walk without assistance, and inability to feed oneself.
Participants randomised to the intervention group viewed the video decision support tool on a portable computer after listening to the same verbal narrative.
The two minute video depicts the principal features of advanced dementia as described in the narrative. It presents an 80 year old female patient with advanced dementia together with her two daughters in the nursing home setting.
It is also available at www.ACPdecisions.com). The patient fails to respond to their attempts at conversation (inability to communicate). The patient is next shown being pushed in a wheelchair (inability to ambulate). Lastly, the patient is fed pureed food (inability to feed oneself). Before filming we obtained consent from her designated healthcare proxy to film the patient and to use the video for research purposes.
The development of the video followed a systematic approach,27 starting with a review of the literature on dementia and advance care planning. We then used a panel of physicians with an iterative process of comments to review the design, content, and structure of the video intervention. This panel included five geriatricians and five neurologists, all of whom specialise in the care of patients with dementia.
The video was filmed without the use of prompts or stage directions to convey a candid realism.28 The principal investigator (AEV) did all filming and editing, following previously published filming criteria.29 The video is accompanied by the same narration that was used in the verbal description arm of the study.
Data collection and other variables
At all four study sites, two members of the research team (AEV and AEJ), who were not blinded to the randomisation group, used structured questionnaires to interview participants before and after they listened to the verbal narrative alone or listened to the narrative and watched the video. At the baseline structured interview (15 minutes) we collected demographic data and data on health status and knowledge about advanced dementia. Sociodemographic data included age, race (self reported), sex, educational status, and marital status. Health status was self rated on a Likert scale as excellent, very good, good, fair, or poor. Participants were also asked if they had had a diagnosis of dementia and whether they had known a person with advanced dementia. We assessed knowledge of advanced dementia with five true/false questions that asked whether advanced dementia is curable and if patients with advanced dementia are able to communicate with others, recognise family members, ambulate, and feed themselves. Knowledge scores therefore ranged from 0-5, with higher scores indicating better knowledge.
Participants underwent a second structured interview (15 minutes) immediately after the intervention. This included knowledge of advanced dementia, preferences for goals of care, health literacy, and, for the video group, comfort with the video decision support tool. The knowledge questions were identical to those asked in the baseline interview.
There were three options for preferences for goals of care: life prolonging care, limited care, and comfort care (see appendix on bmj.com). Researchers verbally described examples of the kinds of care implied by each goal. The first option, life prolonging care, was described as aiming to prolong life at any cost. It translates into all potentially indicated medical care that is available in a modern hospital, including cardiopulmonary resuscitation and treatment in the intensive care unit. The second option, limited care, was described as aiming to maintain physical functioning. It includes treatments such as admission to hospital, intravenous fluids, and antibiotics but not attempted cardiopulmonary resuscitation and treatment in the intensive care unit. The third option, comfort care, was described as aiming to maximise comfort and to relieve pain. Only measures that provide comfort are performed. It is compatible with oxygen and analgesics but not with intravenous treatments and admission to hospital unless necessary to provide comfort. After these explanations, participants were asked about their preferences for care if they developed advanced dementia. Participants who were unable to select a level of care were considered "uncertain."
We assessed health literacy using the rapid estimate of adult literacy in medicine tool (REALM).30 This is a two to three minute English test of medically relevant vocabulary. It is a validated test of word pronunciation and has been shown to correlate well with tests that evaluate a range of literacy skills.30 As others have done, we defined three categories for health literacy based on the REALM scores: 6th grade and below (up to age 11; score 0-45); 7-8th grade (ages 12-13; 45-60); and 9th grade and above (age 14 and over; 61-66).31 32
For those participants randomised to the video intervention group, we used a four point Likert scale to assess the perceived value of the video by asking participants whether they had a better understanding of the disease after viewing the video, if they were comfortable watching the video, if they would recommend the video to others, and whether they thought videos would be helpful for eliciting preferences for care in other diseases like cancer.
One interviewer (AEV) contacted participants by telephone six weeks after the initial interview to determine again what their preferences would be if they had advanced dementia in exactly the same manner as the initial interview. We chose a follow-up period of six weeks to ensure that an adequate amount of time elapsed from exposure to the intervention and to assess whether the video had an enduring effect.
Our analyses were based on the decision making group to which participants were randomised. The primary outcome measure was preferences for care if they developed advanced dementia categorised as four options (life prolonging, limited, comfort, or uncertain). Additional outcomes included change in knowledge scores before and after the intervention and the stability of preferences after six weeks.
All characteristics of participants and outcomes were described by using proportions for categorical variables and means (SD) for continuous variables. We used χ2 tests to compare preferences for care (life prolonging, limited, comfort, or uncertain) between the two groups.
Two sample t tests compared change in knowledge scores before and after the intervention between the two groups. We used κ statistics to summarise the stability of preferences six weeks after the clinic interview for each group and compared the proportions who changed preferences with Pearson χ2 exact test between the two groups.
The measure for the primary outcome analysis was the unadjusted difference in proportions of participants preferring comfort care between the two study groups. We conducted secondary analyses to identify factors associated with a preference for comfort care among all participants. Bivariate analyses determined the association between individual characteristics of participants (age, sex, race, education, marital status, health status, personal history of dementia, previous relationship with a person with advanced dementia, health literacy, and randomisation group) and a preference for comfort care with Fisher's exact test. Multivariable logistic regression analyses were used to identify factors independently associated with preferences for comfort care. Factors significant at 0.10 in the bivariate analyses were entered into a stepwise algorithm, retaining factors in the model that were significant at the 0.05 level. We used the variance inflation factor to diagnose colinearity among potential predictors.
All reported P values are two sided, with P<0.05 considered as significant. The study was designed to detect a 25% difference in the proportion of participants choosing comfort care between the two groups, assuming the rate in the verbal group was 60%. With a target of 100 patients in each group, the power of the study was estimated to be >90%. Data were analysed with SAS software, version 9.1 (SAS Institute, Cary, NC).
Participant flow
We approached 225 consecutive and potentially eligible patients, of whom 205 (92%) agreed to be interviewed. Patients who declined did not differ significantly from the recruited participants in terms of age, sex, or race. The most common reason given for not participating was lack of time. Of the 205 recruited for the study, five were disqualified because their mental status questionnaire score was <7, resulting in a total of 200 study participants. Of these, 106 were randomised to the control group and 94 to the video intervention group (fig 1)⇓. Table 1 shows the baseline characteristics⇓. Despite the randomisation process there were some baseline differences in the two groups, including diagnosis of dementia and previous relationship with someone with dementia,.
Fig 1 Flow of participants through study
Characteristics of older people living in the community randomised to verbal description and video decision support groups. Figures are numbers (percentages) of participants unless stated otherwise
Among the 106 participants receiving only the verbal narrative, 68 (64%) chose comfort care, 20 (19%) chose limited care, 15 (14%) chose life prolonging care, and three (3%) were uncertain of their preferences. Among the 94 who also saw the video, 81 (86%) chose comfort care, eight (9%) chose limited care, four (4%) chose life prolonging care, and one (1%) was uncertain of her preferences (χ2=13.0, df=3; P=0.003). Thus a significantly greater proportion of participants in the video group opted for comfort care (difference 22%, 95% confidence interval 11% to 34%).
Mean knowledge scores (range 0-5) were significantly higher in the video group than in the control group (4.5 (SD 1.0) v 3.8 (SD 1.3), respectively; P<0.001). The mean increase in knowledge scores for the video group was 2.4 (2.1 to 2.7) and 1.5 (1.2 to 1.9) for the control group, which was significant (P<0.001).
Table 2 shows the unadjusted differences in proportions of participants and odds ratios preferring comfort care for each of the characteristics⇓. The factors associated with a greater likelihood of preferring comfort care among all participants were being a college graduate or higher, good or better health status, greater health literacy, white race, and randomisation to the video group. The first four factors were highly correlated: those with higher degree of education were more likely to have better health status, greater health literacy, and more likely to be white; those with better health status were more likely to have greater health literacy and were more likely to be white; and those with greater health literacy were more likely to be white (all with P<0.05). The variance inflation factors, however, were all less than 2.5 when we tested these four factors in the regression model, which indicated weak evidence of multicollinearity. After inclusion of these variables in a multivariable logistic regression model, participants randomised to the intervention group had a greater likelihood of opting for comfort care (adjusted odds ratio 3.9, 1.8 to 8.6). Other factors independently associated with opting for comfort care included a health literacy level of greater than 9th grade (4.1, 1.6 to 10.8) and white race (2.9, 1.3 to 6.6) (table 2).⇓
Unadjusted differences in proportions and multivariable analyses of associations with likelihood of choosing comfort care as primary goal of care
Six weeks after the initial clinic visit, we attempted to contact each participant by telephone. Among the 94 (89%) in the control group who could be contacted, 27 (29%) changed their preferences; the κ statistic for preference stability was 0.35 (0.15 to 0.54) (fig 2)⇓. Among the 84 (89%) participants contacted in the video group, five (6%) changed their preferences; the κ statistic for preference stability was 0.79 (0.62 to 0.98). After six weeks, the proportion of participants changing preferences was lower in the video group (P<0.001).
Fig 2 Initial preferences and stability of preferences after six weeks
The video decision support tool was highly acceptable to participants: 83 of 94 (88%) found the video "very helpful" or "somewhat helpful"; 80 (85%) said they were "very comfortable" or "somewhat comfortable" viewing the video; 89 (95%) said they would "definitely" or "probably" recommend the video to others; and 78 (83%) thought that using videos for other diseases (such as cancer) would be "very helpful" or "somewhat helpful." There were no adverse events in either group.
When presented with the possibility of developing advanced dementia, older patients living in the community are more likely to choose comfort as the primary goal of care after viewing a video of a patient with the disease and listening to a verbal description rather than just hearing a verbal description of advanced dementia. Moreover, viewing the video improved knowledge of advanced dementia and enhanced stability of preferences for treatment over time compared with hearing only the verbal narrative. Finally, health literacy seems to be associated with end of life preferences among older patients.
To the best of our knowledge, this study represents the first randomised controlled trial in a group of older patients of a video decision support tool for decision making at the end of life. In our previous before and after investigation of the advanced dementia video conducted in healthy middle aged participants, the video promoted preferences for comfort care, but it was not a randomised trial, was conducted with a younger healthy cohort, and did not follow the stability of preferences over time.20 Our current study extends this earlier work by showing the efficacy of the video in a randomised controlled trial among older patients. Moreover, the participants in the video group were more likely to have improved knowledge after the video and stable preferences over time. The stability of preferences is a critical consideration in evaluating preferences at the end of life33 34 35 36 37 38 39 40 and suggests a more accurate reflection of patients' values and wishes.
Our study has several important limitations and numerous strengths. Firstly, the research staff collecting data at baseline and at the immediate and six week follow-up interviews were not blinded to randomisation, which could have introduced bias into our findings. Previous randomised studies of interventions aimed at improving end of life decision making, however, have seldom been blinded because limiting the number of interviewers eases the burden on participants of addressing difficult and often painful subject matter.8 9 10 Furthermore, participants might disclose whether they viewed the video or not. We attempted to reduce the influence of this potential bias by using structured interviews and outcome measures. Secondly, despite randomisation there were some baseline differences between the two groups. This can be expected in a relatively small sample. Thirdly, videos can be manipulated to favour a particular perspective. Our study used one video of a white woman with dementia. We did not assess responses of participants to videos of people of different sex and race. Fourthly, we asked participants for their preferences in the context of a research study. The next step would be to investigate whether patients and physicians would document their preferences in the medical record or complete an advance directive.41 Finally, our sample was primarily white and African-American and drawn from primary care clinics in teaching hospitals in metropolitan Boston. Thus, our findings might not be generalisable to other minority groups (such as Latinos and Asian-Americans).
Policy implications and future research
Previous uses of video decision support tools have primarily focused on helping patients to make treatment or screening decisions.42 Our use of video redirects attention to the underlying health state by clarifying the nature of the condition about which patients are expected to make decisions. Our use of video portrays the illness to add a sense of verisimilitude that might be lacking in verbal descriptions. Moreover, these images might offer a more objective and straightforward approach to describe complex medical conditions, which is particularly pertinent to patients with low health literacy. In the US such patients are more likely to be elderly and African-American31 and are among the most vulnerable populations in our healthcare system. As the video led to better knowledge of advanced dementia, our study supports the claim made by others that pictorial or visual methods improve decision making processes.16 17 18 19 20 21 22
Previous studies have suggested that non-white people receive and opt for more aggressive end of life care.43 44 45 46 47 48 49 The reason for this observation is not well elucidated but might be, in part, because of variation in the quality of counselling they receive and their understanding of that counselling. As we have shown elsewhere,22 our study lends additional support to the notion that health literacy potentially mediates the role of race in end of life decision making, and video decision support tools offer an approach to circumvent this disparity. Future work is needed to explore this finding as health literacy was highly correlated with other variables and our study lacked adequate power to conduct detailed analyses of mediation.
The next step in using videos is to explore other diseases and the goals of care with video portrayals. We suspect that numerous other diseases and interventions, such as advanced cancer and cardiopulmonary resuscitation, would also be more accurately conveyed to patients through a visual medium than solely by verbal descriptions. As we have shown here and elsewhere,29 criteria regarding the necessary content and editing of each video portrayal must be carefully considered before clinical application of these videos.
Active debate exists surrounding the development of decision support technologies, especially when highly subjective content (patients' narratives and testimonials) and non-traditional media (video) are used.50 51 While important steps have been taken to develop objective criteria for the development and field testing of decision support tools,52 53 more research is needed particularly as they apply to the use of video.
Including patients in the decision making process has been an important yet complex advance in modern medical care. To secure the delivery of high quality end of life care, patients must be informed regarding their decision making. Education of patients using video decision support tools can improve their comprehension of disease states such as advanced dementia that are difficult to envision solely with words. Future work could extend the use of video decision support tools to other disease states such as advanced cancer and the goals of care. We have shown that video decision support tools enhance elderly patients' decision making by ensuring that it is both more informed and consistent over time.
What is already known on this topic
Advance care planning is a complex process involving communication of future health states such as advanced dementia
Visual images might be helpful to improve decision making and communication of complex information regarding what type of medical care patients would want at the end of life
What this study adds
Video images of advanced dementia improved knowledge for patients choosing the type of medical care they would like if they developed advanced dementia
Patients who viewed a video decision support tool of advanced dementia after hearing a verbal description were more likely to choose a comfort oriented approach compared with patients solely listening to a verbal narrative of the disease
Patients using the video decision support tool had more stable preferences for end of life care over time
Video decision support tools might be most useful for patients with low health literacy
Cite this as: BMJ 2009;338:b2159
We thank the patient and her family, who agreed to be filmed for the purposes of educating and improving decision making at the end of life for all patients. We also thank Claus Hamann, Katherine Hesse, Juergen Bludau, Laurel Yates, Peggy Edson, Ruth Kandel, and Aretha Delight Davis for their contribution to the project.
Contributors: AEV, MKP-O, MJB, MRG, EFC, EDA, and SLM were responsible for study concept and design. AEV and AE-J acquired the data, which was analysed and interpreted by AEV, MKP-O, YC, and SLM. AEV, MKP-O, MJB, MRG, EDA, and SLM drafted the manuscript. AEV, MKP-O, MJB, MRG, KLM, EFC, EDA, AE-J, and SLM supervised the study and critically revised the manuscript for important intellectual content. YC did the statistical analysis. AEV, MJB, MRG, and SLM obtained funding. AEV, MKP-O, MJB, KLM, EFC, EDA, AE-J, and SLM were responsible for administrative, technical, and material support. AEV is guarantor.
Funding: AEV was supported by a George Bennett Fellowship from the Foundation for Informed Medical Decision Making, a New Investigator Research Grant from the Alzheimer's Association, and a Center for Excellence Career Development Award from the Hartford Foundation.
Role of the sponsor: None of the foundations participated in the collection, analysis, or interpretation of the data or in preparation, review, or approval of the manuscript.
Competing interests: None declared.
Ethical approval: The protocol was approved by the institutional review board of each participating institution and all participants provided informed consent
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Lo B, Snyder L. Care at the end of life: guiding practice where there are no easy answers. Ann Intern Med1999;130:772-4.
Council on Scientific Affairs. Good care of the dying patient. American Medical Association. JAMA1996;275:474-8.
Lynn J. Measuring quality of care at the end of life: a statement of principles. J Am Geriatr Soc1997;45:526-7.
Sachs GA, Ahronheim JC, Rhymes JA, Volicer L, Lynn J. Good care of dying patients: the alternative to physician-assisted suicide and euthanasia. J Am Geriatr Soc1995;43:553-62.
Emanuel LL, Danis M, Pearlman RA, Singer PA. Advance care planning as a process: structuring the discussions in practice. J Am Geriatr Soc1995;43:440-6.
Gillick MR. A broader role for advance medical planning. Ann Intern Med1995;123:621-4.
Finucane TE, Shumway JM, Powers RL, D'Alessandri RM. Planning with elderly outpatients for contingencies of severe illness: a survey and clinical trial. J Gen Intern Med1988;3:322-5.
SUPPORT. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA1995;274:1591-8.
Hofmann JC, Wenger NS, Davis RB, Teno J, Connors AF Jr, Desbiens N, et al. Patient preferences for communication with physicians about end-of-life decisions. SUPPORT Investigators. Study to Understand Prognoses and Preference for Outcomes and Risks of Treatment. Ann Intern Med1997;127:1-12.
Covinsky KE, Fuller JD, Yaffe K, Johnston CB, Hamel MB, Lynn J, et al. Communication and decision-making in seriously ill patients: findings of the SUPPORT project. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. J Am Geriatr Soc2000;48(5 suppl):S187-93.
Tulsky JA, Fischer GS, Rose MR, Arnold RM. Opening the black box: how do physicians communicate about advance directives? Ann Intern Med1998;129:441-9.
Roter DL, Larson S, Fischer GS, Arnold RM, Tulsky JA. Experts practice what they preach: a descriptive study of best and normative practices in end-of-life discussions. Arch Intern Med2000;160:3477-85.
Smith AK, Ries AP, Zhang B, Tulsky JA, Prigerson HG, Block SD. Resident approaches to advance care planning on the day of hospital admission. Arch Intern Med2006;166:1597-602.
Tulsky JA, Chesney MA, Lo B. See one, do one, teach one? House staff experience discussing do-not-resuscitate orders. Arch Intern Med1996;156:1285-9.
Tulsky JA, Chesney MA, Lo B. How do medical residents discuss resuscitation with patients? J Gen Intern Med1995;10:436-42.
Frosch DL, Kaplan RM, Felitti VJ. A randomized controlled trial comparing internet and video to facilitate patient education for men considering the prostate specific antigen test. J Gen Intern Med2003;18:781-7.
Morgan MW, Deber RB, Llewellyn-Thomas HA, Gladstone P, Cusimano RJ, O'Rourke K, et al. Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease. J Gen Intern Med2000;15:685-93.
Edwards A, Elwyn G, Mulley A. Explaining risks: turning numerical data into meaningful pictures. BMJ2002;324:827-30.
Houts PS, Doak CC, Doak LG, Loscalzo MJ. The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence. Patient Educ Couns2006;61:173-90.
Volandes AE, Lehmann LS, Cook EF, Shaykevich S, Abbo ED, Gillick MR. Using video images of dementia in advance care planning. Arch Intern Med2007;167:828-33.
Volandes AE, Ariza M, Abbo ED, Paasche-Orlow M. Overcoming educational barriers for advance care planning in latinos with video images. J Palliat Med2008;11:700-6.
Volandes AE, Paasche-Orlow M, Gillick MR, Cook EF, Shaykevich S, Abbo ED, et al. Health literacy not race predicts end-of-life care preferences. J Palliat Med2008;11:754-62.
Wolfson C, Wolfson DB, Asgharian M, M'Lan CE, Ostbye T, Rockwood K, et al. A reevaluation of the duration of survival after the onset of dementia. N Engl J Med2001;344:1111-6.
Larson EB, Shadlen MF, Wang L, McCormick WC, Bowen JD, Teri L, et al. Survival after initial diagnosis of Alzheimer disease. Ann Intern Med2004;140:501-9.
Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc1975;23:433-41.
Sclan SG, Reisberg B. Functional assessment staging (FAST) in Alzheimer's disease: reliability, validity, and ordinality. Int Psychogeriatr1992;4(suppl 1):55-69.
National Cancer Institute. Making health communication programs work: a planner's guide. Bethesda, MD: US National Institutes of Health, 1997. www.cancer.gov/pinkbook.
Grant BK, Sloniowski J. Documenting the documentary: close readings of documentary film and video. Detroit: Wayne State University Press, 1998.
Gillick MR, Volandes AE. The psychology of using and creating video decision aids for advance care planning. In: Lynch TE, ed. Psychology of decision making in medicine and health care. New York, NY: Nova Science Publishers, 2007:193-206.
Davis TC, Long SW, Jackson RH, Mayeaux EJ, George RB, Murphy PW, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med1993;25:391-5.
Paasche-Orlow MK, Parker RM, Gazmararian JA, Nielsen-Bohlman LT, Rudd RR. The prevalence of limited health literacy. J Gen Intern Med2005;20:175-84.
Davis TC, Wolf MS, Bass PF 3rd, Thompson JA, Tilson HH, Neuberger M, et al. Literacy and misunderstanding prescription drug labels. Ann Intern Med2006;145:887-94.
Everhart MA, Pearlman RA. Stability of patient preferences regarding life-sustaining treatments. Chest1990;97:159-64.
Danis M, Garrett J, Harris R, Patrick DL. Stability of choices about life-sustaining treatments. Ann Intern Med1994;120:567-73.
Emanuel LL, Emanuel EJ, Stoeckle JD, Hummel LR, Barry MJ. Advance directives. Stability of patients' treatment choices. Arch Intern Med1994;154:209-17.
Carmel S, Mutran EJ. Stability of elderly persons' expressed preferences regarding the use of life-sustaining treatments. Soc Sci Med1999;49:303-11.
Rosenfeld KE, Wenger NS, Phillips RS, Connors AF, Dawson NV, Layde P, et al. Factors associated with change in resuscitation preference of seriously ill patients. The SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Arch Intern Med1996;156:1558-64.
Ditto PH, Smucker WD, Danks JH, Jacobson JA, Houts RM, Fagerlin A, et al. Stability of older adults' preferences for life-sustaining medical treatment. Health Psychol2003;22:605-15.
Straton JB, Wang NY, Meoni LA, Ford DE, Klag MJ, Casarett D, et al. Physical functioning, depression, and preferences for treatment at the end of life: the Johns Hopkins Precursors Study. J Am Geriatr Soc2004;52:577-82.
Lockhart LK, Ditto PH, Danks JH, Coppola KM, Smucker WD. The stability of older adults' judgments of fates better and worse than death. Death Stud2001;25:299-317.
Abbo ED, Sobotka S, Meltzer DO. Patient preferences in instructional advance directives. J Palliat Med2008;11:555-62.
O'Connor AM, Stacey D, Rovner D, Holmes-Rovner M, Tetroe J, Llewellyn-Thomas H, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev2001;(3):CD001431.
Garrett JM, Harris RP, Norburn JK, Patrick DL, Danis M. Life-sustaining treatments during terminal illness: who wants what? J Gen Intern Med1993;8:361-8.
Caralis PV, Davis B, Wright K, Marcial E. The influence of ethnicity and race on attitudes toward advance directives, life-prolonging treatments, and euthanasia. J Clin Ethics1993;4:155-65.
O'Brien LA, Grisso JA, Maislin G, LaPann K, Krotki KP, Greco PJ, et al. Nursing home residents' preferences for life-sustaining treatments. JAMA1995;274:1775-9.
Blackhall LJ, Frank G, Murphy ST, Michel V, Palmer JM, Azen SP. Ethnicity and attitudes towards life sustaining technology. Soc Sci Med1999;48:1779-89.
Crawley L, Payne R, Bolden J, Payne T, Washington P, Williams S. Palliative and end-of-life care in the African American community. JAMA2000;284:2518-21.
Hopp FP, Duffy SA. Racial variations in end-of-life care. J Am Geriatr Soc2000;48:658-63.
Klessig J. The effect of values and culture on life-support decisions. West J Med1992;157:316-22.
Khangura S, Bennett C, Stacey D, O'Connor AM. Personal stories in publicly available patient decision aids. Patient Educ Couns2008;73:456-64.
Winterbottom A, Bekker HL, Conner M, Mooney A. Does narrative information bias individual's decision making? A systematic review. Soc Sci Med2008;67:2079-88.
Elwyn G, O'Connor A, Stacey D, Volk R, Edwards A, Coulter A, et al. Developing a quality criteria framework for patient decision aids: online international Delphi consensus process. BMJ2006;333:417.
Evans R, Elwyn G, Edwards A, Watson E, Austoker J, Grol R. Toward a model for field-testing patient decision-support technologies: a qualitative field-testing study. J Med Internet Res2007;9:e21.
Data supplement
Angelo E Volandes instructor, Michael K Paasche-Orlow associate professor, Michael J Barry professor, Muriel R Gillick professor, Kenneth L Minaker professor, Yuchiao Chang senior statistician et al
Volandes A E, Paasche-Orlow M K, Barry M J, Gillick M R, Minaker K L, Chang Y et al.
Video decision support tool for advance care planning in dementia: randomised controlled trial BMJ 2009; 338 :b2159 doi:10.1136/bmj.b2159
Articles by Angelo E Volandes
Articles by Michael K Paasche-Orlow
Articles by Michael J Barry
Articles by Muriel R Gillick
Articles by Kenneth L Minaker
Articles by Yuchiao Chang
Articles by E Francis Cook
Articles by Elmer D Abbo
Articles by Areej El-Jawahri
Articles by Susan L Mitchell
You are going to email the following Video decision support tool for advance care planning in dementia: randomised controlled trial
Clinical trials (epidemiology)

redpajama_set_name: RedPajamaCommonCrawl


DOGBERT CONSULTS Dogbert: "To survive, you must create disruptive innovations that redefine the market." wally: "Does that mean the same thing as 'sell things people want'?" Dogbert: "There's one big difference." wally: "You only get paid if you say it in a funny way?" dogcart: "I like to think disruptively innovative."


Choosing the right addiction treatment program is an important step in the recovery process. The 10 best drug rehab centers in North Carolina cater to individuals with unique cultural, medical, and mental health needs. These facilities were chosen based on the services they offer, accreditation, positive reviews, and treatment effectiveness.
Settled in the Blue Ridge Mountains, Four Circles Recovery Center is a wilderness-based treatment program for men and women ages 18-28. This recovery center treats those with addictions, substance abuse problems, and co-occurring mental health issues by addressing the four circles of recovery—physical, mental, emotional, and spiritual.
Learn About Other Treatment Options In North Carolina Call: (800) 506-5834 To talk to a DrugRehab.org treatment specialist today Who Answers?
Founded by a group of individuals whose lives have been affected by addiction, the Wilmington Treatment Center is a facility for addiction recovery. As part of their treatment method, they see to help their clients by establishing improvement in feelings of self-worth, family interaction, a healthy lifestyle, interpersonal relationships, vocational productivity, and creating and attaining realistic life goals.
Located on the shoreline of the Outer Banks, Two Dreams Outer Banks is an addiction recovery center that treats individuals using a variety of methods, including continuous assessment, pharmacotherapy, personal training, nutritional planning, medical evaluations, recovery coaching, substance use monitoring, long-term continuing care, and more.
Pavillon is a center for alcoholism and drug addictions with treatment for men and women. Their programs include residential treatment, an extended care program, a 12-step treatment model, treatment for youth, and outpatient services located in South Carolina. Pavillon operates on a six to one patient to counselor ratio and has 50 beds in their residential facility and 24 beds in extended care.
Red Oak Recovery has gender-specific rehab programs based on the 12 steps to recovery. Treatment plans are created for each individual's needs and include cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT), motivational interviewing, nutrition, and mindfulness. This rehab center also provides dual diagnosis treatment and young adult programs.
Settled in the Blue Ridge Mountains, Phoenix Outdoor is a therapeutic wilderness program for teens struggling with substance abuse and co-occurring behavioral and mental health issues. They integrate wilderness therapy with clinical assessments, the 12-step model and transitional therapeutic interventions. Teens are separated from distractions like television, telephones, and visitors and instead learn to draw analogies to real life from wilderness experiences.
Unity Healing Center provides culturally sensitive treatment to Native American adolescents ages 13 to 18. The residential drug and alcohol rehab program maybe 80 to 90 days long and addresses the individual's mental, emotional, physical, and spiritual needs. Treatment methods include individual and group counseling, adventure, cultural programming, and continuing care.


The project involves upgrading existing US-77 to freeway standards from Saltillo Road to south of Van Dorn Street. This will include construction of a new interchange at the intersection of US-77 and Warlick Blvd.; construction of a new interchange at the intersection of US-77 and Pioneers Blvd.; and closing of the existing intersections at US-77 and Yankee Hill Road and at US-77 and Old Cheney Road. The work at the Warlick Interchange will include 1.06 miles of pavement reconstruction along Warlick Blvd./West Denton Road from Folsom Street to the Salt Creek Bridge. The work at the Pioneers Interchange will include 0.63 miles of pavement construction along Pioneers Blvd. from approximately 1000 feet west of Folsom Street to 300 feet west of South 1st Street.
A four-lane divided roadway section will be constructed along Warlick Blvd. through the limits of the interchange and east of US-77 to match the existing roadway. This typical section will have a 6-inch high integral curb at the raised median side of the driving lanes with surfacing and/or turf at the raised median. Ten foot wide shoulders, of which 8'-0" will be surfaced, are proposed at the outside of the driving lanes along this segment of Warlick Blvd. West of the new interchange the four-lane divided roadway section will transition to match the existing two-lane section along West Denton Road. A curbed urban roadway section will be constructed along Pioneers Blvd. through the limits of the interchange. One through lane will be provided for traffic in each direction along Pioneers with accommodations for dual left turn lanes and right turn lanes as required near the interchange. The paving will transition to match the existing two-lane section west of Folsom Street and the existing roadway section west of South 1st Street. The four-lane divided roadway section with depressed median will be perpetuated along US-77 through the limits of the project.
Roadway lighting will be provided along Warlick Blvd., Pioneers Blvd., and at the interchanges as part of this project. The project will also include traffic signals at the intersection of the interchange ramps and crossing roadways where warranted.
Acquisition of private property for highway right-of-way will be required for the project. One home and a number of commercial buildings must be acquired for construction of the Pioneers Interchange. Control of access near the new interchanges must be modified or acquired.
Construction of the Warlick Interchange will be phased to allow existing US-77 and Warlick Blvd. east of US-77 to remain open to traffic during construction. Traffic west of US-77 will be detoured during construction of the interchange at this location. Pioneers Blvd. will be closed between Folsom Street and South 1st Street during construction of the Pioneers Interchange and traffic will be detoured to Old Cheney Road. US-77 will remain open to traffic throughout the construction of the project.
The project is not in the Department's current five-year program and construction of the project will be dependent upon availability of future funds. The construction duration for the project will be approximately two years.
$15,700,000 (includes construction, right-of-way, utilities and engineering).


If you or a loved one is traveling in or out of Casper over the next day or two, expect significant delays or cancellations.
As of midday on Monday, all flights to and from Casper to Denver have been canceled due to weather conditions. Flights to Salt Lake City are also experiencing delays and cancellations.
For more information on flights coming into and leaving from Casper Natrona International Airport - Click Here.


If installing carpet is next on your DIY list, then look no further than Mohawk Air.o carpet flooring. Mohawk's Air.o carpet flooring will make installation a breeze and your new flooring will look amazing!
Mohawk has simplified the construction of carpeting. Air.o has a textile face, binder and cushioned backing that are all polyester. The parts are fusion-bonded together using a special welding process. This results in a flooring that is very strong, dimensionally stable, and resistant to buckling or wrinkling. Yet it is still light, soft and flexible.
Installation is easy. The use of knee kickers, tack strip or stretchers is not required. The only things needed are a cutting tool, T-square, and Mohawk branded double sided tape or adhesive.
Mohawk also makes it easy to install carpet flooring on stairs. It wraps effortlessly, you just need to trace, cut, and lay it right around the banister's edge.
Mohawk Air.o carpet flooring can be installed over any kind of substrate. It can be folded or rolled and will return to its original shape.
Hypoallergenic: Air.o's carpet fibers, backing or cushion do not absorb moisture, therefore helping to stop the growth of allergens and microbes. You don't need to worry about children or pets playing on the floor. It is VOC, latex and odor free, which is safe for everyone. This also eliminates that new carpet smell.
Easy to Clean: The non-woven cushioned backing permits more air flow for more thorough vacuuming to remove dirt and dust.
Environmentally Friendly: Mohawk Air.o carpet flooring is made with 100% recycled polyethylene terephthalate fiber (PET).
Original Flooring is Left Unharmed: The cushioned felt padding helps prevent damage to the original flooring.
Let your next DIY flooring project be an easy one. Stop by our Flooring Superstores in Grande Prairie, where our knowledgeable staff will help you choose the perfect Mohawk Air.o carpet flooring for your project.


Structurally, Centrophenoxine is closely related to Dimethylethanolamine (DMAE), which is produced in small quantities in our brain. Scientists suspect DMAE inhibits the metabolism of acetylcholine in the peripheral tissues of the brain, and by doing so the compound increases the levels of the neurotransmitter and thereby boosts various cognitive functions.
The second compound in Centrophenoxine, Parachlorphenoxyacetic (pCPA) is the synthetic version of plant grown hormones called Auxins. Binding with DMAE, pCPA increases the bioavailability of the nootropic supplement. Once the supplement crosses the Blood Brain Barrier (BBB), it's broken-down to pCPA and DMAE.
Apart from boosting acetylcholine levels in the brain, Centrophenoxine plays a major role as a neuroprotectant and brain energy booster. The supplement reduces accumulation of waste material inside the cells. As we age, more and more waste builds up inside the cells and causes liver spots on the skin. This is called as lipofuscin. Centrophenoxine removes 50% of the cellular waste in just eight weeks. In addition, the supplement increases oxygen and blood flow into the brain.
Centrophenoxine and ADHD: In the 1960's, Deanol, a prescription form of Dimethylethanolamine was used to treat ADHD. In a research study, 74 children were split into two groups. One group was given 500mg of Deanol, and the other was prescribed 40mg of Ritalin. After 3 months, it was found that DMAE was as effective as Ritalin in treating ADHD.
Centrophenoxine and Fluid Intelligence: A number of cognitive abilities can be bundled up to define the term fluid intelligence. Abilities such as working memory, logical thinking, problem-solving and other related faculties make up our fluid intelligence. It's believed that Centrophenoxine helps in the growth of new neurons and new brain synapses. The neurons and synapses fully develop in due course and enhance the overall cognitive functioning of the brain. The supplement also enhances creative thinking by increasing the communication between neurons in the two halves of the brain.
Centrophenoxine and Memory: Good memory is vital for everyone, not just those above the age of 60. A precursor of acetylcholine, Centrophenoxine is widely considered as one of the best choline sources currently available. The neurotransmitter acetylcholine plays a number of crucial roles in the brain, including the creation of new neurons and new synapses, controlling other neurotransmitters, memory formation, and promoting several cognitive processes. By increasing the levels of acetylcholine, Centrophenoxine helps improve reasoning and memory of the user.
Used in the treatment of ADHD, dementia, Alzheimer's, and age-related memory loss.


How to customize fields that Filebeat sends to Elasticsearch?
I have an ELK 6.5 server Debian 9 server (Bitnami build for Google Cloud Environment) to which I have to send my PostgreSQL 9.5 server (Debian 9) logs using Filebeat.
I chose to send data directly to Elasticsearch but I have a strange issue.
In the DB server, where Filebeat resides, I edited fields.yml and removed all groups but host, beats and postgres.
I also set filebeat to overwrite templates.


text:
Cranial Impalement är det amerikanska death metal-bandet Disgorges debutalbum, släppt januari 1999 av skivbolaget Extremities Productions. Albumet återutgavs augusti 2008 av Unique Leader Records.

Låtförteckning
 "Deranged Epidemic" – 3:07
 "Atonement" – 3:17
 "Cognitive Lust of Mutilation" – 2:41
 "Period of Agony" – 3:15
 "Cranial Impalement" – 3:02
 "Penetrate the Unfledged" – 2:57
 "Malodorous Oblation" – 2:42
 "Carnally Decimated" – 2:49
 "Outro" (instrumental) – 0:15

Medverkande
Musiker (Disgorge-medlemmar)
 Matti Way – sång
 John Remmen – gitarr (spår 1–4)
 Tony Freithoffer – gitarr (spår 1–4)
 David Hill – gitarr (spår 5–8)
 Ricky Myers – trummor
 Eric Flesley – basgitarr

Produktion
Jim Barnes – producent, ljudtekniker, ljudmix
Disgorge – producent
Jon Zig – omslagskonst

Referenser

Externa länkar
 Cranial Impalement på Encyclopaedia Metallum

Amerikanska debutalbum
Musikalbum 1999

redpajama_set_name: RedPajamaWikipedia


text:
Кошниця — вузька повітка для зберігання кукурудзи в качанах.

Топонім

 Кошниця — село в Смолянській області.

 Кошниця — село в Дубесарському районі.

 Кошниця — поселення в общині Шентюр, Савинський регіон.

 Кошниця — населений пункт у Крапинсько-Загорській жупанії.

Див. також
 Кошниця-при-Целю — поселення в общині Целє, Савинський регіон, Словенія.


Transportation, Meals, and Rooms | ThyCa: Thyroid Cancer Survivors' Association, Inc.
Our volunteers will add more information to this page from time to time.
Single, Double, Triple, or Quad Room: $99 plus tax for rooms reserved by the hotel's advance deadline, September 25.
Tell the reservation staff that you are making a reservation with the Thyroid Cancer Survivors' Conference.
Free shuttle to and from Lambert –St. Louis Airport, between 6:30 a.m. and 11 p.m. on the hour and half hour. Ask at the front desk for more details.
The sleeping room rate for conference attendees is $99 per night plus tax.
This rate is available for rooms reserved by October 14, 2008.
Make your reservations by telephone.
Be sure to say that you're attending the Thyroid Cancer Survivors' Conference, to get the special rate.
Shuttle that the Doubletree will provide.
There's a free airport shuttle to the Doubletree Hotel St. Louis at Westport.
At our conferences, many attendees arrange to share rides, rooms, or both with other thyroid cancer survivors met through support groups.
The Sheraton Westport Chalet Hotel St. Louis is located in St. Louis's impressive West Port Plaza area. It houses 300 guestrooms with wireless high-speed Internet access. The lobby area also has wireless Internet access.
The hotel is also conveniently located with access to more than 20 restaurants, exclusive shops, and entertainment.
Complimentary amenities include free shuttle service to Lambert-St. Louis International Airport and free self-parking at the hotel.
St. Louis is served by many airlines.
As noted above, the hotel has a free shuttle from and to Lambert-St. Louis International Airport.
Some people find that renting a car is the most convenient option when traveling. Car rentals are available online and at the airport.
Take Interstate 70 West to Interstate 270 South to Dorsett Road, Exit 17.
Turn left on Dorsett Road.
Turn right on Progress Parkway and continue straight ahead into West Port Plaza.
Take Interstate 64/Route 40 East to I-270 North to Dorsett Road, Exit 17.
Turn right on Dorsett Road, then turn right onto Progress Parkway.
Continue straight ahead into West Port Plaza.
Take Interstate 55 North to I-270 West/North.
Take Exit 17 onto Dorsett Road.
Make a right turn on Dorsett Road, then a right onto Progress Parkway.
Take Interstate 70 West to I-270 South, take Exit 17 to Dorsett Road.
Turn left on Dorsett Road, turn right on onto Progress Parkway.
Amtrak provides service to St. Louis.
Metro operates the St. Louis metropolitan region's public transportation system - - a multi-modal system that includes MetroBus and MetroLink light rail, as well as Metro Call-A-Ride paratransit system.


text:
NHL Great And Golf Nut Jeremy Roenick At Home 'Inside The Ropes'
NFL's Deal With DAZN To Stream Games Globally Said To Be Worth $1 Billion
Lionel Messi Camp Will 'Throw Out' FC Barcelona President Laporta If He Returns To Club, Says Brother
Global Cricket Stars Set To Be Part Of New American Pro T20 League's Upcoming Draft
Koeman Hails 'Amazing' FC Barcelona But Takes Dig At Successor Xavi And Accuses Messi Of Not Passing
FC Barcelona Survivors Of 2016 Near Collapse Warn Youngsters Not To Get Complacent With La Liga Points Lead
Mary Earps Becomes First English Goalkeeper Shortlisted For The Best FIFA Awards
Tyler Anderson, Sandy Alcantara Lead List Of MLB's Best Changeups
ForbesBusinessSportsMoney
Sasha Banks Will Reportedly Be At NJPW Wrestle Kingdom 17 As Potential AEW Debut Looms
Blake Oestriecher
Analyzing WWE, AEW and pro wrestling as a whole.
Dec 9, 2022, 07:20am EST |
WWE may lose one of its biggest stars in Sasha Banks. (AP Photo/Mary Schwalm)
The former Sasha Banks may have found her next stop in pro wrestling, and it's not WWE.
According to a report from PWInsider.com, "Merces Varnado aka WWE's Sasha Banks is expected to be at New Japan Pro-Wrestling's Wrestle Kingdom 17 event next month...While it is unknown whether Varnado will be appearing before the live crowd, we are told that NJPW is bringing Varnado in for the event."
Speculation has been running rampant about Varnado's future after she and tag team partner Naomi walked out of WWE back in May due, at least in part, to frustration with their booking. There hasn't been a definitive answer regarding Varnado's status with WWE since then. While PWInsider says she "has not been listed on WWE's internal roster for some time," there have been varying reports regarding her true status with WWE.
MORE FROM FORBESWWE Draft 2023: Becky Lynch To SmackDown And 5 Big Moves That Must Be MadeBy Blake Oestriecher
Varnado was at one point said to be released. Then, back in August, it was reported that she and Naomi had agreed to return to WWE. There was also buzz that her contract expired, but in late October, it was reported that she was still under contract with WWE. Most recently, it was noted that Varnado and WWE were discussing a new deal for a possible comeback but were far apart on money.
Whether or not Varnado eventually returns to WWE as Banks, the supremely talented star has clearly taken strides toward distancing herself from WWE and the Banks moniker.
The former Raw and SmackDown Women's Champion has altered all of her social media accounts, erasing Banks and instead utilizing her real name. In addition, Varnado has filed a number of trademarks—including one for the name "Mercedes Mone"—that indicate she will be leaving and working under a new name in the world of entertainment, though not necessarily in professional wrestling.
All of Varnado's recent actions would seemingly lead to the most obvious conclusion: Unless WWE is doing the unthinkable and also allowing her to work for NJPW, she's done with WWE for now but isn't leaving the squared circle altogether.
Varnado has been seen training in Mexico and has teased working for multiple promotions outside of WWE, including Stardom in Japan and even All Elite Wrestling. There have been multiple indications that AEW could be a potential landing spot for Varnado, who may be going by the Mercedes Mone moniker or some variation of that name post-WWE.
It was reported months ago Varnado would not be accepting bookings until 2023, which is when it appears that she will lace up the boots once again. AEW has teased that Varnado could potentially be coming in either for a feud with the undefeated and uber-marketable Jade Cargill, which certainly would be a dream match for many wrestling fans. In addition, the star once known as "The Boss" has been hinted at as a potential tag team partner for Saraya during Saraya's feud with Britt Baker and Jamie Hayter, with Saraya set to team with a mystery partner next month when Varnado is expected to return to wrestling.
There is a ton of history there, with Varnado working with Saraya, formerly Paige in WWE, in the match that ended Saraya's career there until Saraya's return to the ring in AEW after a five-year hiatus. Likewise, Baker has named Varnado as her dream opponent, and as AEW's top homegrown female star, she would obviously have to be considered for Varnado as a potential debut opponent.
No surprise here: According to Fightful Select (h/t PWMania), "Several AEW stars, on the other hand, are excited about the prospect of Banks joining the roster. One source quickly agreed that Banks appearing on weekly AEW programming as another 'anchor' for the women's division could spark interest and potentially increase viewership.
For now, though, Varnado isn't confirmed as going to AEW just yet, if ever. A known fan of Japanese wrestling, one of the best pure in-ring performers in the world and also one of pro wrestling's most marketable stars, Varnado leaving WWE and actually wrestling for another promotion would be a massive story in the pro wrestling and a game-changing one, too.
A huge star in the middle of their prime leaving WWE? This is a story that could have long-term ramifications in regards to the decisions that top superstars—especially women's wrestlers—make when it comes to their promotion of choice.
Given that NJPW is now a sister company of the all-female Stardom promotion, Varnado is a strong candidate to step into the ring overseas and absolutely set the wrestling world ablaze whenever she does.


What is the Rockford Woman's Club?
Rockford Woman's Club is a premier members club dedicated to the betterment of the Rockford Community and to enhancing the lives of its members through friendship, philanthropy and fun.
There are currently three departments within Rockford Woman's Club, Emerson-Lathrop, Marie T. Perry and Jessie I. Spafford, named after founding members. Each department meets monthly at the club for networking followed by a luncheon and a speaker. They also enjoy working on philanthropy projects, attending special events and attending monthly social activities. In addition, all-club events and philanthropic activities bring the entire membership together. We are ever-changing and evolving, bringing new members, new ideas, new programs and new energy into the club.
Rockford Woman's Club members share a commitment to the philanthropic causes we champion, and we share a commitment to each other. Because of that commitment, we have built a community of friendship and support. Much like a family. If you would like to join us in our commitment to our community and to each other, click below to learn more about the departments and then complete the application form for the department you wish to join.


text:
Sir Billy Connolly: a lifetime of helping others
Author: Roisin McCormackPublished: 9 January 2019
Following Sir Billy Connolly's moving appearance in the documentary 'Billy Connolly: Made in Scotland' on UK television channel BBC Two, we look back at the Glaswegian comedian's contributions to charity – and they're just as funny and heartwarming as the man himself
Sir Billy Connolly's recent TV appearance saw him reflect emotionally on his childhood, his half-century career in show business and the progression of his Parkinson's disease – which he said has left him feeling as if his life is "slipping away".
While being one of the most successful comedians in the world, 76-year-old Connolly has also worked tirelessly to help others, raising vital funds and awareness for charity. From running naked through the streets of London, UK, to visiting hospitals in Somalia, we look at some of the highlights of his philanthropic work over the years.
1985: 'Live Aid' appearance
Musicians from around the world came together to raise money to tackle famine in Ethiopia, a tragedy that led to an estimated 400,000 deaths. Concerts were held at both Wembley Stadium in London, England and the John F. Kennedy Stadium in Philadelphia, US. An abundance of musical talent played the venue in London including U2, Queen and David Bowie.
Leading the charge, Connolly, with his usual playful demeanour, took to the stage shouting, "Hello to everybody on earth!" before introducing pop icon Elton John.
1989: Visit to Mozambique
In the late eighties, Connolly visited the war-torn nation of Mozambique in southern Africa to demonstrate how the money raised from Comic Relief was being spent. Displaying his trademark grin, he told viewers how a donated fire engine had made a significant difference to the local fire service. The firemen told Connolly that before receiving the vehicle, they would have to hitchhike to an emergency and then use buckets of water to put out the fires.
2001: Billy Connolly streaks through central London
In a bid to encourage the general public to support Comic Relief, Connolly promised to streak through central London, UK, once they raised the first UK £1 million. Watching Billy run stark naked through the capital proved a powerful incentive for many viewers – the target was swiftly met and duly surpassed.
Despite facing some opposition along the way, with the police even threatening to stop the BBC filming the event, Connolly burst onto Piccadilly Circus, catching unsuspecting tourists off guard and leaving nothing to the imagination.
Watch it here.
2003: Visiting Somalia
Connolly visited Somalia, east Africa, to highlight the terrible conditions at the Hargeisa Hospital in Somaliland. The clip made for difficult viewing, showing how with so few resources, the hospital struggled to treat those in need. With his compassionate, caring charm Connolly skilfully guided the viewer through this emotional one-hour special.
2007: Appointed patron of the Celtic FC Foundation
Connolly was appointed as patron to the Celtic FC Foundation, a charity initiative backed by Scottish football team Celtic FC. Connolly, a lifelong Celtic fan, was given the role to raise awareness and help motivate others.
Billy Connolly leads the Celtic team out. pic.twitter.com/2wf5CAaQ
— BillyConnollyQuotes (@BigYinQuotes) February 16, 2013
2011: Helping flood victims in Australia
In the wake of the Queensland floods, which affected over 200,000 Australians, Connolly announced a special charity gig, with all proceeds going to the flood victims.
Connolly said: "I wanted to do what I do. Perform on stage, offer support that way."
2015: Statue in Glasgow, Scotland
Over the years Connolly's image has become synonymous with charity work and helping others. This was best symbolised in 2015 when a statue of Connolly was erected in his hometown of Glasgow, Scotland, to encourage the general public to donate to Comic Relief. Passersby could tap their contactless cards on Connolly's pocket and this would donate UK £1 to the cause.
UK-based readers can watch 'Billy Connolly: Made in Scotland' here.
Mother of schoolgirl who met Sir Billy Connolly "blown away" by daughter's selflessness
I've got Parkinson's and cancer: Billy Connolly's tear-jerking appeal
Penelope Shatford
It's 1.41 am Perth Australia time and I've w9ken from my sleep and I'm thinking of Billy Connolly…i want to help Luke the yodeller and regain life and moments and functions that are slipping away from what was given.
How can I contact him and Pamela. I'm a Kiwi through and through with Scottish descent and even if I didn't my pure driving force is to help give back. I'm far from normal and had such a funny yet sometimes very painful life but I do know what I'm capable of and that is to help.
My urgency here is to give hope and heal our dear Billy and not slip away but harness his inner Luke and grab him by his yodelling balls and set him as funny and carefree and so very far from Normal…your authentic original, candid, inspiring, loving flying funnyman Scotsman that we all live dearly.
I look up to you and it is so clear to me and I hope you that I am more than just a person and 1 woman in this life of ours…i have a fingerprint in life that can help others and I am drawn while heartedly to help you and my dear friend I will not give up on you cos you wouldn't on us. I can help not by a degree or to undermine Specialists in their field cos I know you've seen the best But you haven't seen my will and knowledge that I can help. How can I contact you ? It's 2.27 am now and I will find a way.
Your new/old friend and fan Penelope Shatford, Perth Australia
Watch: Icelandic football team takes to the pitch in Parkinson's tops
Parkinson's took centre stage in an international friendly against Ghana
5 awesome inventions to reduce troublesome Parkinson's tremors
Specially designed products to stabilise shaking hands
Timo's top 10 tips for travelling with Parkinson's
Interested in a Parkinson's event, but live far away? Read this