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Wrangler in Petticoats - eBook
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|Format: DRM Free ePub
Vendor: Barbour Publishing
Publication Date: 2010
Availability: In Stock
Series: Sophie's Daughters
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Petticoat Ranch, Lassoed in Texas Series #1 (rpkgd)Mary ConnealyBarbour Publishing / 2013 / Trade Paperback$5.99 Retail:
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Publisher's Description
Ride into the Rockies where love peaks between a tough Texas tomboy and a passionate artist. On her way to Montana, Sally McClellan's party is attacked and robbed. But then artist Logan McKenzie saves the badly wounded cowgirl who has been left for dead. Can this landscape painter tame the tomboy without breaking her spirit? Sally doesn't know much about ribbons and lace, but Logan's presence makes her want to connect with her feminine side. Will this fractured female discover a way to capture the artist's love—or find herself captured and killed by outlaws?
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Product Reviews
wfnrenSt Cloud, FLAge: 55-65Gender: female5 Stars Out Of 5Yet another book I didn't want to put down!April 22, 2014wfnrenSt Cloud, FLAge: 55-65Gender: femaleQuality: 5Value: 5Meets Expectations: 5Another great book by Mary, another book I didn't want to put down. I like the way she seems to make you feel you are right there in the action and believe me with these McClellan women there is action in what they do. If you haven't read any of her books you need to. Start with the Lassoed in Texas series, go on to the Montana Marriages series and end up with the Sophies's Daughers series. I have one book left in this series and then I don't know what I'll do!
C1 Stars Out Of 5Trashy. Has no place in a Christian marketplace.March 12, 2013CQuality: 1Value: 1Meets Expectations: 1The book begins with a murder scene that is very dark, beyond normal.
There is constast and intense disrespect for men that is not Godly or inspiring. Men are portrayed as weak and ignorant. The author does not encourage women in a difficult marriage to love their husbands, but to disrespect them. It glamorizes an attraction to a man that is not a woman's husband.
This book has no place in a Christian marketplace.
ladybadyClarksville, TNAge: 55-65Gender: female5 Stars Out Of 5Great read!December 4, 2012ladybadyClarksville, TNAge: 55-65Gender: femaleQuality: 5Value: 5Meets Expectations: 5One minute you'll be laughing, the next you'll be on the edge of your seat straining to read faster! Great story!
DeniseLangley, BCAge: 35-44Gender: female5 Stars Out Of 5This book holds humor and truths.May 9, 2012DeniseLangley, BCAge: 35-44Gender: femaleA fantastic book with a dry humor that kept me laughing nonstop. At the same time, this author hides truths that makes this book wonderfully down to earth revealing a God who accepts us flawed humans and loves us with our shortcomings.
juliebVancouver,WaAge: 55-65Gender: female3 Stars Out Of 5Strong women versus weak menApril 30, 2012juliebVancouver,WaAge: 55-65Gender: femaleQuality: 3Value: 4Meets Expectations: 3Even though this book is an easy read, it has a very unbelievable plot. The women are super heros, while the men are frequently depicted as weaklings, both spiritually and physically.
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Hand Towel with Gold Embroidery with Pouch
Share: Send to a friend:Product ID: WSC-JA-22853
A white hand towel with gold embroidery with Hebrew letters reading 'Al Netilat Yadayim' and a matching tie pouch made from organza. Read more
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THIS ITEM QUALIFIES FOR FREE SHIPPING With an order of $59 and over
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Product Description
This white hand towel is an essential addition to your Judaica collection. Use this lovely towel for Shabbat and holidays and an elegant decoration year round. Beautiful and pure in its design, this towel is a perfect way to represent the holiness of Shabbat and the holidays.
General Information
Dimensions 38cm x 70cm
Temporarily out of stock
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Resort Cotton Bath Towel 2302 2561
The Best Towels - Ever! I have purchased numerous brands of towels over the years. These are the best! February 10, 2010
After receiving and using these towels, my other towels seemed skimpy......so I put in a second order. They are so thick and luxurious. February 10, 2010
terrific towels Just received my towels with free personalized monograms. They are truely terrific. Super absorbent and generously sized. They realy add a high end look to my bathrooms. Thanks frontgate for such great quality products. February 10, 2010
Great,Great,Great I purchased these bath sheets and couldnt be happier. The only problem is folding them-they are so thick it nearly takes two people! Love-em February 10, 2010
Best Towels Everything I have ever bought from you has been excellent!! Love Frontgate products! February 10, 2010
Wish ALL our towels were this kind! Thought with the great price FRONTGATE was offering on the towels...we would ADD to our fine collection of towels. Ugh...now I wish ALL the towels in our home matched this quality and luxuriousness! One final word...BUY! February 10, 2010
Bath Towels High quality absorbent fluffy and extra large. We love them. February 10, 2010
Good quality and good value We have been very pleased with the towels we recently purchased. They are exceptional quality; great value for the reasonable price. February 10, 2010
Towel Review Saw the advertisement from Front Gate for their Bath Towels in The Wall Street Journal. I was truly impressed when the order arrived. The towels were better than I anticipated and the delivery time was also very prompt. I look forward to another occassion to purchase from Front Gate. February 10, 2010
Best Towels Ever We have been searching for the best towels for a while.We have bought towels from famous brands,upscale stores and still did not find what we would rate the best.My husband saw this add in the Wall Street Journal and we ordered the resort towels.These are the best towels ever!They are soft,thick and very absorbent.They feel and look great.We ended up ordering for all our bathrooms.Be careful with the colors as they look a little different on the screen. February 10, 2010
Great to Touch and See They are top quality - soft, thick, and plush. The monograms add a beautiful touch and have made my master bath look great. I'm going to order more for the other baths. February 9, 2010
Best Ever Great value, wonderful colors and the best towels ever. February 9, 2010
More Showers Please! These resort towels are so luscious, I only regret I don't have the time to take more showers! February 9, 2010
Resort Towels The towels are SO nice! They're thick & soft. We like the feel of them better than some other Turkish towels we purchased several months ago. February 8, 2010
at home spa! I love these soft, fluffy towels. They actually soak up the water-especially in my hair- and don't have that weird coating some towels have. It's like having a spa at home! Great deal for the price. February 8, 2010
Excellent Purchase One of the best purchases in a long while... after going around & around trying to find thick & absorbent towels, I have finally found them!!! Another bonus is, they even dry quickly! Now I know where I will continue to purchase my towels. February 8, 2010
Outstanding and Beautiful The towels are truly luxurious and beautiful quality. February 8, 2010
Fabulous! The bath towels we ordered are fabulous..soft, plush and feel as lush as some provided at a first class spa. Would highly recommend them! February 7, 2010
Finally - great towels! We've been looking for great resort quality towels for years. These towels exceeded are expectations and for a surprisingly affordable price. February 7, 2010
Wrap Yourself in Luxury These plush, ultra-soft towels will delight you when you wrap them around you after showering. They wash beautifully and have great absorbency. The monograms are quite attractive and stylish. A great buy! February 7, 2010
Great Towels I am very picky when it comes to towels. Being a frequent 5 star hotel guest, I have used my fair share of luxury towels. These are right up there with the finest. The monogramming is a nice touch. Good value. February 6, 2010
Fantastic Towels!! These towels proved to be everything the catalog described.Super soft and luxurious and they washed up beautifully. The finest towels I have ever purchased,I would strongly recommend these. February 6, 2010
Wonderful, thick towels. Best I've ever had. February 6, 2010
Best Towels This is the fourth set of these towels that we have purchased. They are the best. February 6, 2010
Luxury Abounds We ordered a complete set of towels in the seafoam color with a custom monogram. The thickness and softness of the towels is of a superior quality. The towels dry quickly after use and maintain their quality through machine washing. We will be ordering these as gifts in the future for family members. February 6, 2010
excellent quality & value Excellent quality & value.Finest bath towel I've ever bought.I plan on giving Frontgate website to friends & family. February 6, 2010
Best towel purchased yet I have ordered several towels recently from different companies and these towels are the most absorbent ones I have seen...right from the get-go...no prior washing necessary. I will order more in the future February 6, 2010
Wonderfully Plush towels We bought 2 of these towels about a year ago and loved them so much that we recently bought some more. They're super thick (my kids refuse to use any other towels now) and absorbent. It takes a couple of washings to work up to their full absorbency, but you'll love them. the color holds up very well with repeated washing too. February 6, 2010
Wonderful towels I love these towels. They absorb water and dry quickly. They are durable and soft...another great product from Frontgate. February 6, 2010
Best towels I have owed these towels are soooo soft and cushy. I just love them. Pretty and come in most colors that a person needs February 5, 2010
(57 Questions : 88 Answers)
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Resort Cotton Bath Towel
1 answer
In the picture of the 5 different colored towels - what is the darker blue color? French Blue?
Tampa, FL, USA
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Length of Ownership: < 1 year
2 weeks, 2 days ago
Tampa, FL, USA
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0out of 0found this question helpful.
Was this helpful?helpful0unhelpful0https://answers.frontgate.com/answers/0005/product/35398/question/1453375/undohelpfulness.djs?format=embeddedhtml&sessionparams=__BVSESSIONPARAMS__&return=__RETURN__&innerreturn=https%3A%2F%2Fanswers.frontgate.com%2Fanswers%2F0005%2Fproduct%2F35398%2Fquestions.djs%3Fformat%3Dembeddedhtml%26scrolltotop%3Dtrue%26expandquestion%3D1453375&user=__USERID__&authsourcetype=__AUTHTYPE__&submissionparams=__BVSUBMISSIONPARAMETERS__&submissionurl=__BVSUBMISSIONURL__
Answer:Thank you for your interest in the Resort Cotton Bath Towels. If you are referring the photo I have attached to this answer, the blues shown are Surf and Chambray.
1 week, 5 days ago
0out of 0found this answer helpful.
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Resort Cotton Bath Towel
1 answer
do any of the towels come in red. love the collection but not an option for red
Reno, NV, USA
Additional information about gige could not be loaded.
Length of Ownership: 2-5 years
1 month, 3 weeks ago
Reno, NV, USA
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0out of 0found this question helpful.
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Answer:The Resort Cotton Bath Towel is available in cabernet.
1 month, 2 weeks ago
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Resort Framed Memory Foam Rug
2 answers
Can the memory foam insert be removed for laundering? It seems like the foam would retain water and make drying the rug difficult. Thank you.
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1 week, 3 days ago
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0out of 0found this question helpful.
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Answer:Thank you for your interest in the Resort Framed Memory Foam Rug. We will look into this information for you. We sincerely apologize for any inconvenience this may cause.
1 week, 1 day ago
0out of 0found this answer helpful.
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Answer:The foam can not be removed for the Resort Framed Memory Foam Rug. To dry after washing we recommend tumble drying with extended dry time.
5 days ago
1out of 1found this answer helpful.
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Reversible Resort Cotton Bath Rug
1 answer
Ivory Color - yellowish?
Additional information about MrsTed could not be loaded.
The square showing sample color of Ivory looks like what I'd expect - however, the picture of the rug with turned-back corner in that color looks quite yellow. Which is more accurate?
1 week, 3 days ago
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0out of 0found this question helpful.
Was this helpful?helpful0unhelpful0https://answers.frontgate.com/answers/0005/product/66083/question/1457169/undohelpfulness.djs?format=embeddedhtml&sessionparams=__BVSESSIONPARAMS__&return=__RETURN__&innerreturn=https%3A%2F%2Fanswers.frontgate.com%2Fanswers%2F0005%2Fproduct%2F35398%2Fquestions.djs%3Fformat%3Dembeddedhtml%26scrolltotop%3Dtrue%26expandquestion%3D1457169&user=__USERID__&authsourcetype=__AUTHTYPE__&submissionparams=__BVSUBMISSIONPARAMETERS__&submissionurl=__BVSUBMISSIONURL__
Answer:Thank you for your interest in the Reversible Resort Cotton Bath Rug. The picture on the webpage that you are referring to is not ivory; it is Harvest.
1 week, 1 day ago
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Reversible Resort Cotton Bath Rug
1 answer
Seeking color like aqua
Additional information about MrsTed could not be loaded.
I'm looking for a light aqua color that is half blue and half green. Which of your color choices in this rug do you recommend?
1 week, 4 days ago
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Was this helpful?helpful0unhelpful0https://answers.frontgate.com/answers/0005/product/66083/question/1457163/undohelpfulness.djs?format=embeddedhtml&sessionparams=__BVSESSIONPARAMS__&return=__RETURN__&innerreturn=https%3A%2F%2Fanswers.frontgate.com%2Fanswers%2F0005%2Fproduct%2F35398%2Fquestions.djs%3Fformat%3Dembeddedhtml%26scrolltotop%3Dtrue%26expandquestion%3D1457163&user=__USERID__&authsourcetype=__AUTHTYPE__&submissionparams=__BVSUBMISSIONPARAMETERS__&submissionurl=__BVSUBMISSIONURL__
Answer:Thank you for your interest in the Reversible Resort Cotton Bath Rug. This item is currently availalbe in several sized in the Teal color.
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Food-handling safety risks at home are more common than you may think. The 4 easy lessons of this Be Foodsafe video are clean, separate, cook and chill. Read More
Vincent speaks with John Coffin about his career studying retroviruses, including working with Howard Temin, endogenous retroviruses, XMRV, chronic fatigue syndrome and prostate cancer, HIV/AIDS, and his interest in growing cranberries.
Host: Read More
Wow, the NEJM is really knocking out some great "perspectives" in their most recent issue.
The Internet has become a critical medium for clinicians, public health practitioners, and laypeople seeking health information. Data about diseases and outbreaks are disseminated not only through onli... Read More
Get grade school and middle school students excited about science! ASM has peer-reviewed classroom and outreach activities that can be utilized in K-12 classrooms. One such activity: Extract DNA from a banana. In under two hours, students can visibly see DNA extraction results from a small piece... Read More
Tara Smith joins the TWiEBOVsters to discuss the Ebola virus outbreak in west Africa, spread of the disease to and within the US, transmission of the virus, and much more.
Hosts: Vincent Racaniello, Read More
Dr, Francis Su is a mathematician at Harvey Mudd College in Southern California. Last week, he was honored with the prestigious Haimo Teaching Award of the Mathematics Association of America at the Join Math Meetings in San Diego. His acceptance speech is inspiring to any educator and any stud... Read More
Does a bacterium's cell wall, shape, way of moving, and environment really matter?
Yes! The more we know about bacteria, the more we are able to figure out how to make microbes work for us or stop dangerous ones from causing serious harm. And, for those of us who like to ponder more philosop... Read More
El podcast del microbio Nº 239 summarize the hypothesis published in "Astrobiology" about the possible role of pumice in the em... Read More
A slide-cast by Jonathan Eisen, Professor at UC Davis and Academic Editor in Chief of PLoS Biology, about open access publishing given at the Clinical and Translational Science Center at UC Davis (http://www.ucdmc.ucdavis.edu/ctsc). Read More
A general video from the The Royal College of Pathologists of Australasia featuring microbiologist Sally Roberts. Read More
Respected Sir,
Microbiology World is a bi-monthly e-magazine, which publish articles based on Microbiology and related fields of Life Sciences. Microbiology World has been established in 2013 and has been supported by several organizations.
I, editor in chief of this magazine, would be glad... Read More
Despite improvements in prevention, diagnosis and treatment, Lyme borreliosis (LB) is still the most common arthropod-borne disease in temperate regions of the northern hemisphere, with risk of infection associated with occupation (e.g. forestry work) and certain outdoor recreational activities ... Read More
When viruses come into contact with host cells, they trigger the cells to engulf them, or fuse themselves to the cell membrane so they can release their DNA into the cell.
Once inside a host cell, viruses take over its machinery to reproduce. Viruses override the host cell's normal functioni... Read More
Here is a transcript of TWiM episode #6, "Antibacterial therapy with bacteriophage: Fact or fiction?". Thanks to Steve Stokowski for transcription.
The transcript is also available as a pdf file - click here to download Read More
Click "source" to download a PowerPoint presentation on ASM's social media presence that I gave at the ASM General Meeting in San Diego on May 24, 2010. I was the first speaker.
The slides provide an overview of social media, its tools and the value proposition it might provide to microbio... Read More
Unable to embed Rapid1Pixelout audio player. Please double check that: 1)You have the latest version of Adobe Flash Player. 2)This web page does not have any fatal Javascript errors. 3)The audio-player.js file of Rapid1Pixelout has been included.
Hosts: Read More
Virginia Campbell,MD, host of the Brain Science Podcast, has published a very interesting interview with Dr. Paul Offit, author of the book Autism's False Prophets. In the interview, Campbell and Offit explore "the scientific evidence that vaccines DO NOT cause autism, but also examine why the c... Read More
El pocast del microbio Nº 221: Virología Ambiental y Microbioma (Environmental Virology and Microbiome)
El podcast del Microbio Nº 221 summarize the PLoS ONE paper by Krupovic and Forterre on the presence of microviridae provir... Read More
Microbes can tailor transcriptional responses to diverse environmental challenges despite having streamlined genomes and a limited number of regulators. We present data‐driven models that capture the dynamic interplay of the environment and genome‐encoded regulatory programs of two types of prok... Read More


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13 posts tagged with human and evolution.
Displaying 1 through 13 of 13. Subscribe:
Hominin paleoartistry
Élisabeth Daynès and John Gurche (not connected in any way, AFAIK) are among a few paleoartists who specialize in sculpting models of ancient hominin species, such as Sahelanthropus tchadensis (Daynes), Australopithecus boisei (Gurche), Australopithecus africanus (Daynes), Homo floresiensis (Gurche), and charismatic favorite Homo neanderthalensis (Daynes, Gurche). [more inside]
The Pit of Bones
Baffling 400,000-Year-Old Clue (NYT) to Human Origins: The pit of bones hides our oldest DNA.
The Soul Niche
Swimming around in a mixture of language and matter, humans occupy a particular evolutionary niche mediated by something we call 'consciousness'. To Professor Nicholas Humphrey we're made up of "soul dust": "a kind of theatre... an entertainment which we put on for ourselves inside our own heads." But just as that theatre is directed by the relationship between language and matter, it is also undermined by it. It all depends how you think it.
Young Indiana Jones Discovers Missing Link (maybe....)
"So I called my dad over and about five metres away he started swearing, and I was like 'what did I do wrong?' and he's like, 'nothing, nothing - you found a hominid'."The remarkable remains of two ancient human-like creatures (hominids) have been found in South Africa. Some researchers dispute that the fossils are of an unknown human species, but others say they may help fill a key gap in the fossil record of human evolution. [more inside]
More humans are alive today than had ever lived before 10,000 BC
Prometheus In The Kitchen
"Good, big ideas about evolution are rare." Simon Ings of the Independent reviews "Catching Fire: How Cooking Made Us Human" by Richard Wrangham. (via)
Secrets Of The Phallus
Why is the penis shaped like that? [T]he human penis is actually an impressive "tool" in the truest sense of the word, one manufactured by nature over hundreds of thousands of years of human evolution. You may be surprised to discover just how highly specialized a tool it is. Furthermore, you'd be amazed at what its appearance can tell us about the nature of our sexuality.
Neanderthal-Human Babies
Any admixture would have to be driven by male Neanderthals. Two years ago we discussed morphological evidence of nontrivial interbreeding. Since then Neanderthal DNA has been examined for genetic support for this model of human evolution, largely contradicting the belief in Neanderthal contribution to modern humanity. Indeed any contribution from the Neanderthal gene pool to the evolution of modern humans might be very rare and indeed it appears that the best candidate gene thus (MC1R) far likely was a result of convergent evolution. [more inside]
Australopithecus afarensis in the sky with diamonds
Lucy, one of the oldest and most complete fossilized hominid skeletons, is hitting the road. Although not without a little controversy. (And that's even before the creationists get wind of the tour!)
Life through time
The Simulacrisation of Technology into Life
As the Pentagon ousts plans to turn insects into cyber war machines you'd be forgiven for asking the question: Where does the real digital end and the faked life begin? Are we simulating life synthetically? or just speeding up an entirely natural process? Technologically engineered life is here to stay. Its not far fetched to speculate that simulacra may become all there is.
The concept of the Transhuman: human, the self, consciousness and their effects on the law
The first Transhuman Conference On the Law of Transhuman Persons: Whether or not you believe humans are set to evolve into gods, or AI is destined to achieve self-awareness the idea of the Transhuman is a thought provoking concept. Philosophers have debated the nature of the self, of the human for millennia. Is it time to start drafting new laws to govern all possible sentient beings on this planet? or is it all just a science of fiction? a comfortable humanist illusion?
Museum of the African Diaspora
MoAD is San Francisco's newest museum. The Museum of the African Diaspora is the latest addition to the SOMA neighborhood's expanding cultural riches, and promises to be fascinating (and, as far as I can tell, unique in the world). [more inside]
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text: TBS47589:House for sale in Village of Slaveyno Published by TBS Bgproperties on 2011-09-07 13:19:07 Code: TBS47589-231 Type: House Location: Slaveyno » Price: €19800.00 // Request Built area: 300.00 m2 Total area: 400.00 m2 Agency: TBS Bgproperties » If you are thinking to spend your holiday in a picturesque location, you should not miss this offer. The house we present to you is situated in a very calm region, and it is at the distance of 31 km from Smolyan city. The second largest city Plovdiv is disposed 84 km away from the village, and the famous ski resort Pamporovo stands at the distance of 26 km away. The property includes three storied house with total living area 300 sq. m, a parking lot and a garden vast 400 sq. m. Ground floor: Here you can find a basement. The walls of the house are made of stones, the flooring here is earth, and the frames of the windows are wooden. First floor: It consists of a corridor and three bedrooms. The flooring here is wooden, the walls are made of stones, again and the windows' frames are wooden. Second floor: Here are disposed a corridor and four rooms. The walls are made of stones. The flooring and the frames of the windows are wooden. The garden is a small one and planted with fruit trees, a trellis vine and flowers at the moment. There is also a well, which helps for the irrigation. The house is in basic condition and needs refreshment and renovation of the plasters and woodworks. There are some transposed roof tiles on one of the eaves. Some inner transformations are also possible, according to the clients' taste. The property is supplied with electricity and water –outside the dwelling. There is only one external toilet in the property. The road to the dwelling is an asphalt one and a gravel one, but easy accessible in the whole year. The village itself offers facilities like a shop, cafes, a church, a health service, a post office and regular bus transport to the towns and the villages in the vicinity. The region here gives good opportunities for fishing and hunting, as well as mountaineering, village tourism development and going sightseeing. So think about the possibility to become the new owner of that house. Website: http://www.tbsbgproperties.com/?pid=5&RefN=231 Contact TBS Bgproperties about this House - TBS47589-231 Your name Your Email Phone Your message to us Reset


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On her Answer Sheet blog Valerie Strauss highlighted some bizarre incentive programs intended to "bribe" students to take Common Core tests. The programs have cropped up from all over the country, and have included gift cards, iPads, "bonus points" for the next marking period, skipping English and math final exams, elective credits, extra recess and "free dress" days for schools with uniforms.
An ill conceived Maryland Department of Education PR campaign directed at parents may however win the award for most distasteful. It claimed to be letters from 4th graders to "Mom and Dad" telling them not "worry" or "be stressed out" about the "big test" because it's "just a little reading and math" and the teacher knows the kids will "do fine."
Hayden wants his parents to know he "might have a little headache from working hard on the computer" but Kara says that if her parents will just "feed her a good breakfast" and let her "wear the same clothes all week" it will help her do her best on the PARCC. (I'm not going to touch how odd it is for a state agency to suggest it's OK to let a kid wear the same clothes five days in a row, or to make light of a kid coming home from school with a headache from too much screen time, let alone to ignore that not all kids have a "Mom and Dad")
Not only did the Maryland State DOE display the bad judgement to create and post these supposed letters from 9 and 10 year olds, the DOE's Chief of Staff, John White, shared it on Facebook with the statement "Truth from the mouths of babes..."
What I find particularly offensive is that the DOE is arrogant enough to presume they can hijack the voices of children, and use them to sell their own agenda. If a random sampling of 9-10 year olds were asked what they truly think of taking a 10 hour math and english test, it's hard to imagine there wouldn't be a very wide range of responses. How completely disingenuous and arrogant to cherry pick only the rosy cheeked "everything's going to be just fine!" responses.
Here is just a few of the comments on the post, but it is a pretty representative sample of the reaction the post elicited from people that don't work for the Maryland DOE.
It didn't take a degree in PR to know that this train wreck of a post was going to be removed, and fast. Sure enough, by this morning - *POOF* - it was gone, with nary a word about the ruckus it had caused the day before. This tactical error on the part of the Maryland DOE will no doubt become a powerful recruitment tool for Maryland opt-out organizers.
But what does it say when a state department resorts to this kind of emotional manipulation to try to sell the PARCC?
Here's what I think. If educationally sound, rational arguments about the need for high-stakes annual standardized tests resonated with parents and students, DOE's wouldn't need to rely on this kind of coercion and propaganda. It seems the opt out movement's message is resonating so strongly that it is drowning out the talking points, incentives and PR tricks of those desperately trying to stay in charge and in control of the narrative.
What do you think? Let me know in the comments below.


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Many Ducks fans got their wish when the team re-signed stars Ryan Getzlaf and Corey Perry to eight-year contract extensions for a total of $135 million, but they'll have to shell out a few more dollars to cheer them on.
The Ducks announced season ticket prices for the 2013-14 season will rise an average of 4.1 percent, representing the first increase across the board in three years. The lowest price for a ticket will be $13.
"As we evaluate our pricing each season, we will continue to do everything possible to maintain reasonable pricing for our fans," Ducks chief operating officer Tim Ryan said in a statement.
Teemu Selanne played in his 1,373 NHL game, passing Teppo Numminen in appearing in the most contests by a Finnish-born player. ... Left wing Matt Beleskey was a healthy scratch for the first time this season.
Contact the writer: firstname.lastname@example.com


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But it doesn't have to be.
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Recent study found "acute" AAKG supplementation made no difference in endurance or blood pressure during the course of exercise. In fact, participants that took AAKG prior to exercise had compromised endurance and strength. "Because AAKG supplementation may hinder muscular endurance, the use of these supplements before resistance training should be questioned." [


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Former FC Barcelona skipper Carles Puyol believes that the addition of Luis Suarez to the Blaugrana makes the Catalan outfit even stronger in spite of the controversy that the ex-Liverpool has recently caused during the World Cup.
The 27-year-old Uruguay international, who bit Italy's Giorgio Chiellini, is currently serving a four-month ban meted out by FIFA, but has already issued an apology for his unsportsmanlike conduct.
"There is no justification for what Suarez did, but things like that occur when you lose your head - it can happen.," Puyol told FIFA.
"At any rate, he has apologised for it. He's a great footballer, extremely competitive and scores a great deal. I think he can bring a lot to an attack that's already brimming with quality."
"With Luis, we can be even stronger."
Should the ban be sustained, as Barca are reportedly seeking to have the decision overturned on appeal, Suarez will miss, among others, three Champions League group stage matches and nine La Liga fixtures.
For more football news, follow IBTimes Sport on Twitter.


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Senior Member
no problem, keep practicing! try to understand/admit the mistakes you make, it will help you become a better player
im sure im gonna get ridiculed for my shaco build, but! its pretty effective if you get his mechanics down. what i do is i play him like a banker. you start out with an amplyfying tome and a health pot. with summoner abilities like teleport and ignite (or exhaust) teleport to the tower your going to lane in. buff up the bushes fast. get an easy fb hit level 2 get two shiv hit level 3 up boxes once more hit 4 get decieve. its about this time that you usually have to go b. with around 1100 and teleports cd usuable again. i then upgrade the tome to a kage and then buy a philosophers stone for survivability + revenue. i then try to wait til i can buy 4 more kages. after buying the kages keep harassing with two shiv boxes and decieve. once you hit around 3k or whatever from your massive gold rush you get. sell a kages for a rabadons (this makes you an extremely powerful early gamer) then when you have a little bit of money you upgrade the philosophers into the revive item. you use this for the ms boost to get away. after doing this the next item on the list is either morellos or lich bane. its a personal preference that i go for lich bane. with lich bane your likely around 410 ap. thats a good bit of damage considering your probly about 20 minutes in. and you can spam lich banes passive ability quite alot with shacos abilities. = a lot of damage. after you get the one you started with get the other. then after that get a hextechs gunblade and then get a void staff, rabadons, or zhonyas. they all work pretty effectively. i know these are all very high end items. but because of the gold gain its not actually that late game. besides after you have rabadons and lich bane your pretty much one of the heaviest hitters and can take down turrets at your leisure. now, this build uses no boots. but.. if you know how to use your item abilities and decieve. you wont really need them anyways, or you can just eat whoevers trying to kill you with 1k shiv damage 700 dmg auto with lich wait a second, decieve and pull an 800 dmg auto. and if need be clone. on a scale of 1-10 of difficulty and how good the player needs to be i'd put it like a 7. you dont have to be great. but you need to understand how to escape, time things, etc.
anyways. thats how i play him. and i do really good.. besides. its more fun trolling with no boots ^^
^ Lol I don't even know what to say to that, sounds like a troll =\ .
but uhm... Ap shaco is not a viable strategy/build. You can only do well when you are exceptionally more skilled than your opponents, and even then the late game uselessness of AP shaco can often lead to losses. I've played normals with AP shaco and have gotten 20 stacks and still lost, have gone 8-0 and become useless end game. Once people build MR and tanks start checking bushes for jitb's then all you can do is cast a shiv every 7 seconds. Even if it does do 800 dmg.
Junior Member
^ IMO, AP shaco is not useful at all end game, no matter what you build/do. Ap shaco basically has one nuke, two-shiv, and if you get lichbane+decent AP you can use deceive as a "nuke". The problem with that is using deceive puts you in immediate danger, and with a bunch of AP items, after the initial deceive hit you arent going to be a threat. jitb's become useless end game, and can't really be used during team fights. the AOE damage on the ultimate is decent, but the range of the explosion is pitiful. Any real AP champ is better than AP shaco, hence.... troll build
also... I won the guide contest!!! thanks for the support/views !
so like..... Shaco is pretty weak in the current meta game imo.
And singed is the new ****ing OP toon . ridiculous change to his ult
He was good before the change. I'd wish theyd change it back so no one would use him again and I can continue to own. As for this shaco build it is awesome I got into jungle shaco with this and I wreck. Only confusing thing for me still is what to get after wriggles. I've been getting a pick axe or the recurve bow for the attack speed for the red buff activation then building into madreds. If not that I rush IE but I know you aren't a fan of that vision. But I was wondering would that one item work? The 35ad 30mrand when you're below some hp you get the shield? I forget the name. Ah yes! Hexdrinker. Also I saw a jungle shaco get madreds razors then build a wits end, for the Mr so fail.
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Be careful before you order this ring. The back side is extremely thin and feels fragile when worn. From the top the appearance is beautiful, but I would not recommend and am returning the ring. The size is also a half size too large. I was measured at a local jeweler, ordered what should have fit perfectly yet the ring was too large.
I bought this as a Christmas gift for my favorite guy. I was a little nervous buying jewelry without physically seeing the ring, especially where he is so fussy about his jewelry. I shouldn't have worried- it is beautiful and he loves it! A note- it does not come in a fancy box, so it may be worth it to pick one up if you are going to give this as a gift.
The ring looks awesome. The bottom of the ring is cut slightly thin and it's overall weight is lighter than expected but other than that I love it.
Beautifull Ring!!! ++++++++ I will buy 1 more for Mother
I will continue to buy on line with Overstock since this first experience was so great!
i returned the product coz it did not meet my expectation. the back was too thin and it was very light.
Everything about this ring is amazing. The stones, the diamonds and the overall look is exquisite. My father loved it.
This ring is just how it is displayed on the overstock website. When i received it, i could not have been more pleased. I bought this ring for my husband for christmas and he jusdt loveid it. It looks absolutely georgeousd om him. Its a great buy!!!i
I returned the product. The gold was very thin and the back of the ring was so flimsy that it wear down in no time.
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Skim coating textured drywall
We are refinishing a room that currently has a painted "sand-like" texture treatment on the drywall. The actual granules are fairly shallow (
We are looking for advice on how to give the walls a smooth (normal drywall) finish. Would it be best to sand the walls down or skim coat the whole thing?
If we skim coat, what is the recommended procedure?
Firstly, go over the area with a sharp taping knife to remove any high spots. By "high" I mean anything obtrusively so or out of the ordinary. Then with a wide taping knife apply at least three thin coats of drywall compound. THATS the hard part! It takes a lot of practice to get a smooth finish. No sanding between coats unless your applications have high spots or ridges. There should be very little sanding required on the last coat
You may actually find it easier and faster to remove the old drywall with the texture and just install new.
You only have to mud seams and joists then, not the entire surface.
A plasterer's trowel will make much faster work of skimming large areas than using drywall knives.
Maker sure you get one with a large enough diameter handle to control the tilt of the trowel.
The one with the tiny (under one inch diameter) handles are too small to be useful.
As I said before, skim coating is the way to go. If you can not skim coat you will not be able to mud new drywall. If you are not skilled enough to put 3 even coats on, then the only issue will be how much sanding you do. A pro will have virtually no sanding and a diyer will have more sanding. Just more sanding but doable. The taping knife will be much easier to use than a trowel.
If you choose to skim coat. you might want to consider "meshing" the surface with reinforcing mesh similar to the mesh tape used on seams only it comes in 3' width rolls and is a tad more heavy gauged. You can get it self adhering or you can tack it up using spray adhesive. It installs similar to wall papering and you can get it at most masonry suppliers. The mesh will give something for the first coats to grab a hold of as mudding over a painted surface doesn't always give you the best adhesion.
"The taping knife will be much easier to use than a trowel."
A trowel excels at covering large areas quickly and smoothly.
Avoid the trowels with a small diameter handle though.
They are very difficult to rotate to raise the leading edge.
Google skim coating and check out the UTube videos that come up.
I've done both at my house and based on that embedded sand texture you have, I'd have to vote for tearing out the old and putting up new drywall, but it's a close call. I'd worry about the knife skipping around wildly on the "sand grains" but maybe it wouldn't be a big deal. My skim coat worked out well but I put a lot of time into it and I sanded a LOT, something a pro wouldn't have to do as he'd get it smoother with the knives/trowels. I used a 24" wide taping knife and eventually learned to not worry too much about leaving ridges as I could knock then when they dried.
I think we are going to try skim coating and if it doesn't seem like it is going well, we are going to overlay with 1/4 or 3/8" drywall.
We're only dealing with two walls (8 sheets total), so it won't be a big deal if we have to go that route.
Thanks for the advice.
No one has mentioned material, but I think I would use Durabond 90 for the first coat, since it drys so hard and will better fill up the "valleys" between the bumps. I think that will give you a better surface for subsequent coats of mud. Be carefull not to create any high spots with it however, as it cannot really be sanded down like the regular (softer) mud.
I lead toward the trowel, as well, simply because you can get more material on the wall faster with a trowel. If you're more comfortable with a knife, maybe use it for the final coats.
Just an update.
The skim coating went really well. We needed two coats and then a little touchup here and there (the texture was really shallow).
Since I am really cheap and did not have a plastering trowel, I used a 3/8" v-notch trowel that I had from a previous project (the flat side, of course). It went on really well. I can see why a trowel would be the recommended tool for the job over a knife for this application.
We used SHEETROCK Easy Sand Lightweight Setting-Type Compound 90 for the two coats and then 20 for new joints, corners, and touch-up.
The walls are primed and I am going to hopefully paint them later today.


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Lady Gaga Fans at US Airways Center
By Melissa Fossum
The Evolution of the Metal Stage Show and the End of...
By Lauren Wise
By New Times
The Story of Kalliope, Phoenix's Extraordinary Party Car
By Amanda Savage
By Jason P. Woodbury
How a Single Tweet Launched A Cloud for Climbing
By Troy Farah
By New Times
The Valley duo's album (the GFB stands for Goin' For Broke), Undestroyable, was in an unremarkable white paper wrapper, and the sticker with the track listings was slightly off-center. The plain packaging clearly did not prepare me for track one's first few riffs. Was that . . . Lynyrd Skynyrd? Sho nuff! Chino D and Rise (a.k.a. John Tha Baptist), the young men behind GFB, have sampled "Sweet Home Alabama" and transformed it into "Sweet Home Arizona" with a little bit of hip-hop thrown into the mix. The lyrics are a little on the elementary side, but are nonetheless entertaining: "We ain't never going to stop/Till the fat lady sings/And she ain't even warmin' up/So go ask the bartender for more rum in your cup."
The marriage between hip-hop and classic rock on Undestroyable doesn't stop there. The next track, "Get Up Stand Up," is a tribute to Bob Marley (of course), and "Dead Song" samples the Grateful Dead's "Sugar Magnolia." Finally, we have hip-hop artists paying direct tribute to old-school hippies: "I wanna hear some grateful dead/nuff said/eyes read/trippin out/flippin out like the grateful dead heads."
The tracks that steer clear of the 1970s also stand out above other hip-hop productions I've been handed around here in past months, and there seems to be a theme of social justice inspired by the Hair era. "Sundown" is backed by subtle Latin beats and details the struggle of the working class, and, as its name implies, "Beautiful Pollution" is all about the state of the environment.
Chino D and Rise have put together an album that, while it does sound like your standard bedroom-made demo, has an element of creativity that's evident in forebears to this kind of thing like The Roots. See, it's official -- sometimes demos really can be your friend.
For more information on where to purchase Undestroyable, visit www.arizonahiphop.com
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I Was Equipped to Deal With the Pain
As silly as I felt talking about focal points and cleansing breaths with ten other waddling women in my childbirth class, the information helped me understand what I would experience. But not all pain-management instruction is alike, warns Mae Shoemaker, president of the International Childbirth Education Association in Minneapolis. Credentials are less important, she believes, than the teacher's experience, teaching style, and general approach to labor and delivery. "Think about what kind of birth experience you want. Interview several instructors, just as you would a new doctor or a contractor," Shoemaker suggests. One red flag: teachers who soft-pedal. If they refer to labor pain as "discomfort," run.
Which method is best? That depends on the amount of control you want and your philosophy about birth. But don't be afraid to incorporate your own personal pain-management strategies. I depended mightily on music -- 12 hours of the Grateful Dead for my son and 10 1/2 hours of Neil Young for my daughter.


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Kevin Magee, who has been the overseer of day-to-day operations at Fox Business Network since its days as a start-up enterprise, is departing, the network confirmed Thursday, leaving the management structure of the 21st Century Fox-owned outlet under review.
"I'm writing you today to tell you that I am leaving Fox Business and Fox News Radio. I've been thinking this over for a while now and it was a difficult decision to reach," Magee, an executive Vice President, said in a note to staffers. Magee also supervised the operations of Fox News Radio.
He has played a central role at FBN since before its 2007 launch and helped monitor its current lineup featuring Maria Bartiromo in the morning.
FBN has vied with NBCUniversal's CNBC in trying to capture the business-news aficionado, and while its audience is typically smaller, it has in recent months pursued a strategy of offering anchors who are deeply versed in the markets. Aside from Bartiromo, the FBN lineup also includes Neil Cavuto and Stuart Varney.
"What we have is a very good audience in that it is a very wealthy audience, and that's very attractive to advertisers," Magee told Variety in February. "It's not a pure numbers game. It's the quality of the audience, not the overall size."
In recent months, FBN has reworked a good portion of its programming, adding an hour featuring Deirdre Bolton and another anchored by Charles Payne. In December, it launched "The Independents." a primetime show focused on the protection of economic and civil liberties, featuring former MTV personality Kennedy.
While the network is led by Roger Ailes, the force behind the successful Fox News, Magee was the person who steered its daily operations and often was the one charged with articulating the network's goals and mission.
The executive's departure was reported previously by TV Newser.
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Original Article
The needs of terminally ill cancer patients versus those of caregivers for information regarding prognosis and end-of-life issues†
Article first published online: 23 MAR 2005
DOI: 10.1002/cncr.21010
Copyright © 2005 American Cancer Society
Volume 103, Issue 9, pages 1957–1964, 1 May 2005
Additional Information
How to Cite
Clayton, J. M., Butow, P. N. and Tattersall, M. H. N. (2005), The needs of terminally ill cancer patients versus those of caregivers for information regarding prognosis and end-of-life issues. Cancer, 103: 1957–1964. doi: 10.1002/cncr.21010
- †
See also pages 1965–75, this issue.
Publication History
- Issue published online: 18 APR 2005
- Article first published online: 23 MAR 2005
- Manuscript Accepted: 6 JAN 2005
- Manuscript Revised: 21 DEC 2004
- Manuscript Received: 1 SEP 2004
Funded by
- National Health and Medical Research Council on a Medical Postgraduate Research Scholarship
- Abstract
- Article
- References
- Cited By
- neoplasms;
- terminally ill;
- palliative care;
- communication;
- caregivers;
- prognosis;
- end-of-life issues
The difficulty of negotiating the concerns of family members while also respecting the needs of the patient adds complexity to the task of discussing prognosis and end-of-life (EOL) issues with terminally ill cancer patients. The informational needs of caregivers may be different from those of the patients themselves with regard to these topics. However, to the authors' knowledge, this issue has received relatively little research attention.
The authors conducted focus groups and individual interviews with 19 patients with far advanced cancer and 24 caregivers from 3 palliative care (PC) services in Sydney and 22 PC health professionals (HPs) from around Australia. The focus groups and individual interviews were audiotaped and fully transcribed. Additional focus groups or individual interviews were conducted until no additional topics were raised. The participants' narratives were analyzed using qualitative methodology.
The participants had varying views regarding whether patients and caregivers should be told different information concerning prognosis and EOL issues. Three themes were identified from the transcripts regarding meeting the informational needs of both the patients and caregivers: 1) the importance of consistency and openness, 2) the specific information needed to care for the patient, and 3) the value of having separate discussions with the patient and caregiver. A desire to restrict the patient's access to information by the caregiver or vice versa was reported by the HPs to be one of the most challenging issues when discussing prognosis and EOL issues. Three themes were identified with regard to this issue: 1) autonomy versus protection, 2) negotiating family dynamics, and 3) difficulty using interpreters.
The results of the current study emphasized the importance of considering the distinct informational needs of caregivers, as well as those of the patient, when discussing prognosis and EOL issues. Cancer 2005. © 2005 American Cancer Society.
Discussing prognosis and end-of-life (EOL) issues with terminally ill cancer patients and their families is challenging for health professionals (HPs). The difficulty of negotiating the concerns of family members while also respecting the patient's rights and well-being adds complexity to this task. Clinicians frequently face the dilemma of how much to say and to whom?1 when communicating with terminally ill cancer patients and their families.
Family members play a key role in the care and support of terminally ill cancer patients. Families need information to enable them to care for their dying relative.2, 3 Conversely, many patients want less information about their illness as they become sicker.4 Thus, caregivers may want more explicit information concerning the dying process, for example, than patients. However, to our knowledge this area has received little previous attention in the literature.
The situation is complicated in multicultural societies. In Western cultures, in which autonomy reigns, the wishes of the patient receive priority over those of the family members with regard to what is told and to whom concerning prognosis.5, 6 Patients from other cultural backgrounds may prefer nondisclosure, or disclosure negotiated through the family, when life expectancy is short.7, 8
To our knowledge, little is known regarding what expert clinicians, terminally ill cancer patients, and their caregivers think about these issues. Palliative care (PC) HPs have particular interest and experience in this arena, in part due to the centrality of these issues to their clinical practice. Furthermore, they may be a self-selected group of people who have innate skills in this area. Therefore, the views of these HPs may have particular value not only in their own clinical setting, but for general oncology. The views of terminally ill cancer patients and caregivers, who are the target of such discussions, should arguably have the greatest influence on clinical practice. The objective of the current study was to explore the views of terminally ill patients, their caregivers, and those of PC HPs on questions such as: 1) do terminally ill patients and their caregivers have different informational needs with regard to the patient's prognosis?; 2) do PC HPs provide different information concerning prognosis and EOL issues to patients versus caregivers?; and 3) how do PC HPs manage the situation if the patient and/or caregiver attempt to protect each other by withholding information regarding the person's illness? Australia is an ideal setting in which to conduct such a study because of the established nature of PC practice in this country.9
Specialist PC services in Australia are comprised of teams with a range of medical, nursing, and allied HPs and volunteers. PC medicine is a distinct medical specialty in Australia, with its own specific training program. Each PC service commonly provides consultations across a variety of settings including tertiary referral and district hospitals; inpatient PC units; and the community in homes, hostels, and nursing homes. Unlike the eligibility criteria for hospice care in the U.S., patients can be referred at any time from diagnosis and many still receive antineoplastic treatment with palliative intent.10 Occasionally, patients who are receiving curative chemotherapy are seen by the PC service for symptom control. However, none of the patients participating in the current study had any chance of cure from their malignancy. Patients usually remain under the primary care of their family medical practitioner and often are concurrently receiving specialist care from both an oncologist and the PC team. The mean length of time that patients are referred prior to death varies in different services; for the services participating in the current study, this figure is approximately 8–12 weeks.
Three groups believed to have important input were sampled: 1) PC patients, 2) caregivers of PC patients, and 3) HPs working in the PC setting. Patients and caregivers were eligible to take part if they were: 1) age > 18 years, 2) English-speaking, 3) well enough to take part in a focus group or interview, 4) able to provide informed consent, and 5) referred to a specialist PC service and diagnosed with an incurable and progressive illness, or the caregiver of such a patient. Sampling was aimed at achieving a diverse group of participants from different socioeconomic and cultural backgrounds; therefore, three PC services in Sydney with different population bases were approached to participate. Patients and caregivers were recruited from these services via hospitals, PC units, and the community.
PC doctors and community nurses identified suitable patients and caregivers and sought their approval to be contacted by a researcher. Patients and caregivers were then telephoned and invited to participate in the study.
The HP participants were all currently working in PC and had at least 2 years' experience in this area. Participants were selected across a range of disciplines and from various PC centers to ensure that relevant views were represented. A snowballing technique11 was used in which the initial participants were asked to suggest other HPs who may be willing to participate in an interview. Suitable HPs were contacted by an investigator and invited to participate.
All participants received an information sheet and provided written consent.
Data Collection and Analysis
Focus groups of four to eight participants, supplemented by individual interviews with those unable to attend a focus group, were held separately with patients and caregivers and conducted by a PC physician (J.C.) and a clinical psychologist (P.B.) experienced in qualitative research methods. HPs were given a semistructured individual interview, either face to face or over the telephone, conducted by the first author (J.C.). The discussion format for the interviews and focus groups is outlined in Table 1. In this article, we are reporting the views of the participants regarding the different informational needs of patients compared with caregivers with regard to prognosis and EOL issues, whether these discussions should be held with the patient and caregiver together or separately, and the situation when families are trying to withhold information from the patient and vice versa. Results of the other discussion items outlined in Table 1 will be reported elsewhere. Sociodemographic data regarding participants were collected via a brief questionnaire at the end of the interview or focus group.
|Discussion format for health professionals
|Discussions about the future in a palliative care setting are often difficult. I am referring not only to discussions regarding life expectancy but also the likely symptoms that a patient may face in the future and the likely made of death.
|• How do you tend to approach questions about the future from palliative care patients? How do you tend to approach questions about the future from the caregivers of palliative care patients?
|• How do you think information about the future should be portrayed during a palliative care consult?
|• Do you ever initiate discussion about the future during a palliative care consult? In what circumstances do you think this is appropriate?
|• When discussing the future with a palliative care patient or their caregivers, is there any way of communicating hope?
|• If a palliative care patient (or their caregiver) asked about their life expectancy:
|- What words would you use?
|- What sort of time frames would you give (if any)?
|- Would you give any statistics?
|- Would you draw survival graphs or use any other aids?
|• What advice would you give to palliative care trainees regarding discussion of the future?
|Discussion format for patients and caregivers
|Prognosis refers to likely future developments and life expectancy.
|• What information do you think is important for your palliative care doctor to tell you (or the person you care for) about your (their) prognosis? (not necessarily during the first consult)
|• What information do you think is important for a palliative care doctor to tell caregivers about the prognosis of the person they care for?
|• How do you think information about prognosis should be portrayed during a palliative care consult?
|• Who should initiate discussion about prognosis during a palliative care consult?
|• Should palliative care doctors offer to discuss prognosis with you (for caregivers: or the person you care for or with you the caregiver) at certain times?
The focus groups and telephone interviews were audiotaped and fully transcribed. Data analysis was informed by qualitative methodology.12 The transcripts were read and individual points identified by the facilitators, using the participants' own language when possible. These were discussed by both facilitators to ensure the consistency of interpretation and were organized into mutually exclusive categories. Further focus groups and/or telephone interviews were conducted until no additional topics were raised. The final categories were reviewed by all investigators and any discrepancies were resolved.
The study was approved by the ethics committees of participating institutions.
Twenty-four caregivers took part in 3 focus groups (21 participants) and 3 individual telephone interviews. Nineteen patients took part in 3 focus groups (14 participants) and 5 individual telephone interviews. The demographic characteristics of the patients and caregivers are shown in Table 2.
|Caregivers participating in focus group/individual interviews (n = 24)
|Patients participating in focus group/individual interviews (n = 19)
|Median age (yrs) (range)
|53 (23–71)
|68 (36–83)
|School certificate or below
|Completed high school but not tertiary
|Tertiary education
|Patient's underlying diagnosis
|Advanced cancer
|Primary site of malignancy
|Median time since referral of patient to palliative care (range)
|14 weeks (2 weeks–2.5 years)
|12 weeks (3 weeks–2 years)
|Current residence of patient
|Home or home of family/friends
|Inpatient palliative care unit
|Other hospital
|Caregiver's relationship to patient
|Spouse/de facto
|Same-sex partner
Twenty-two PC HPs were interviewed including 13 physicians (7 specialist PC physicians and 6 senior PC registrars in training), 4 nurses, and 5 allied health staff (an occupational therapist, a physiotherapist, a social worker, a bereavement counselor, and a pastoral care worker). The HPs worked at 10 different PC services in 2 Australian states (New South Wales, South Australia) in a variety of settings including a teaching hospital, and community and inpatient PC units (many HP participants saw patients in a combination of these settings). There was a range of PC experience among the HPs with 7 HPs (32%) having > 10 years' experience (mean of 8.3 years, with a standard deviation of 4.9 years).
Three themes were identified from the transcripts regarding meeting the informational needs of both the patients and caregivers: 1) the importance of consistency and openness, 2) the specific information needed to care for the patient, and 3) the value of having separate discussions with the patient and caregiver. A desire to restrict the patient's access to information by the caregiver or vice versa was reported by HPs to be one of the most challenging issues when discussing prognosis and EOL issues. Three themes were identified with regard to this challenge: 1) autonomy versus protection, 2) negotiating family dynamics, and 3) difficulty using interpreters. Summaries of these themes are presented below; participant quotes are available from the corresponding author on request.
Meeting the Informational Needs of Both Patients and Caregivers
Importance of consistency and openness
When discussing prognosis and EOL issues, many HPs said they would encourage open discussion with the patient and family together, unless the patient was confused or death was imminent. HPs stated that caregivers frequently have difficulty discussing EOL issues in front of the patient because they want to protect them. Likewise, the patient may wish to protect the caregiver. In these situations, HPs said they would explore the reasons behind any shielding of information and urge that it be shared. All HPs emphasized the importance of providing consistent information to the patient and caregiver, provided the patient gives consent for this information to be disclosed to the caregiver. This helps to maintain trust and prevent barriers from forming between the patient and family.
Likewise, some patients and caregivers said that it was important for the caregiver to be told consistent information, so that both patient and caregiver had the same understanding of what to expect. They believed this made it easier for them to talk openly about the future.
Specific information needed to care for the patient
Several HPs and caregivers stated that patients and caregivers have different needs for information concerning EOL issues and prognosis. The specific informational needs of caregivers were often emphasized. For example, caregivers may want information regarding how much time to take off work, what is involved in caring for a dying person at home, how to tell when the patient has died, and what needs to be done after they die. In addition, many HPs said they may provide more information to caregivers than the patient regarding potential complications around the time of death (e.g., seizures). Similarly, many caregivers said they needed this information to be prepared, whereas they felt the patient would want more general information concerning prognosis and EOL issues. They believed it could be cruel for the patient to be told details or information regarding potential perideath complications. Some caregivers said the person they were caring for did not want to know about their prognosis but had given their permission for the caregiver to discuss it with the PC team. Some patients confirmed this, saying they did not want to know their prognosis but were happy for their family to know. Patients did not provide specific details concerning what type of information would be useful for them versus their caregivers to know.
Value of having separate discussions with the patient and caregiver
Several HPs said although it is important not to give conflicting information, it may be very helpful to have separate one–to-one discussions with patients and their caregivers regarding prognosis and EOL issues because this makes it easier to explore their unique concerns and informational needs. Having separate conversations allowed honesty without worrying about what the other party was feeling. Some nurses said it is useful to have the discussion initially with both the patient and caregiver present and then a separate discussion with only the caregiver focused on the caregiver's needs. The importance of obtaining the patient's permission first to discuss their condition with family members was emphasized unless the patient was gravely ill or incapacitated.
Some HPs said caregivers are often more capable of having frank discussions concerning prognosis than the patient. In addition, a few physicians said that it is psychologically easier for them to discuss prognosis with the family than with the patient. Conversely, some HPs said it is occasionally the family members who are less able to cope with prognostic information than the patient.
Many caregivers and some patients wanted to have a discussion with the HP alone regarding EOL issues. They wanted to raise issues that may be difficult to discuss in front of the other, such as what may occur around the time of death and how the other person is coping. In contrast, some caregivers were concerned that it was unethical to discuss the patient's prognosis without the patient present. Although many patients said they would be happy for the HP to have a separate discussion with family members regarding their condition, most said they would want to give permission first. In addition, some patients believed they could cope with prognostic information better than their family. Conversely, some patients said it was important to have the support of someone in their family with them during these discussions because of the potential distress that they may feel.
A Desire to Restrict the Patient's Access to Information by the Caregiver or Vice Versa
Autonomy versus protection
The situation in which a family asks the HP to withhold the diagnosis or prognosis from the patient, who often but not always is from a non-English-speaking background, was described by HPs as a delicate balance of the families' versus the patient's right to information, autonomy, nonmaleficence, and confidentiality. Information regarding prognosis and diagnosis was not viewed as being owned by the patient but rather as having an effect on the entire family. The HPs approached this situation in different ways. Some said they would try and encourage the family to have an open conversation and acknowledge the condition of the patient. These HPs attempt to explain to families that patients are often aware they have a terminal prognosis, and that it can be very frightening and isolating for them not to talk about it. Other HPs said they would clarify beforehand what the family wanted the patient to know, and reassure the family that they would respect this wish and not raise the issue with the patient. However, they would warn families that if the patient asked them a direct question they would answer it honestly. One physician said he reassured families that if the patient asked questions concerning their prognosis he would ensure that the family was present when he gave the answers. A few HPs said they would use a combination of approaches, encouraging the family to have an open conversation but also clarifying what they wanted the patient to know and negotiating what is actually discussed. Some physicians stated the reason why they respected the wishes of family members with regard to how much information is given to the patient is that it may be important for their bereavement. For example, so family members feel they have fulfilled their duty to protect the patient from potentially distressing information.
The situation in which a patient sought to withhold information from family members was reported less frequently by HPs and was not seen as a dilemma because of the patient's right to confidentiality. It became a challenging issue when it affected the family's ability to care for the patient (e.g., if the patient did not want their spouse or immediate family members to be informed of their terminal prognosis).
A few caregivers expressed a need to protect the patient from being given distressing news by HPs and emphasized the patient's right not to know this information. Some patients believed it would be taking away their rights if a physician discussed information about them, including bad news, with their family but not with them. One patient said he believed it was up to the family to decide what information was given to the patient.
Negotiating family dynamics
HPs raised the ethical dilemma that is encountered when different family members have different opinions regarding how much information should be given to the patient. It may be easier for the HP to listen to the most assertive family member to keep the peace, but it may not be in the best interest of the patient. Most HPs suggested family conferences in this situation and emphasized the skill needed to facilitate an equal voice for all involved. Other HPs suggested negotiating a family spokesperson who would then makes decisions and communicate information to the rest of the family; the choice of spokesperson may be based on patient preferences or involve a more complex process if the patient is confused. Patients and caregivers did not raise this issue.
Difficulty with the use of interpreters
The added complexity of using interpreters when discussing prognosis and EOL issues was frequently mentioned by HPs. Some HPs said that families are occasionally very reluctant to use an official interpreter and insist on translating themselves. HPs believed this was because the family wanted to act as an informational gatekeeper. However, some HPs commented that the families might be concerned about confidentiality if the official interpreter was a member of their local community. One caregiver whose father did not speak English highlighted the difficulties when interpreters provide a more positive message than the physician. Patients did not raise this issue. However, all the patient participants in the current study spoke English.
The current study suggests that terminally ill cancer patients and their caregivers have very different needs for information concerning prognosis and EOL issues. The caregiver requires more detailed information than the patient about the dying process. In other cases, although less frequently reported by participants in the current study, the patient may desire more details concerning their prognosis than the caregiver. Although many participants emphasized the importance of open discussion and consistent information, it may not be possible to meet the informational needs of both the patient and their family members without having additional individual discussions. This allows the HP to explore the individual concerns and informational needs without the barrier of patient/caregiver protectiveness. All participant groups emphasized the issues of confidentiality and sensitivity with regard to obtaining the patient's permission prior to talking with the caregiver.
Previous studies have emphasized the caregiver's need for information.1, 13 This need is often unmet. For example, Jones at al.14 found that, of 181 caregivers of cancer patients who had died at home in the U.K., only 112 (62%) had received the information that they needed regarding the patient's illness. Similarly, Merrouche et al.15 reported that approximately 40% of family members were dissatisfied with the information they received concerning terminally ill cancer patients.
The needs of caregivers are particularly important in PC. First, families often serve as the primary caregivers and are the major source of support to the dying person. Promoting the caregiver's needs may have a positive impact on the patient's quality of life. Second, from a community health perspective, the caregiver's experience of caring for the dying patient may have consequences for their subsequent bereavement.16 This in turn can affect the health and well-being of the caregiver.16, 17
The issue of caregiver protectiveness regarding the provision of information to the patient has been documented previously.18 Although the majority of patient participants in the current study agreed that it was important for their family to receive information about their illness, only one patient approved of their family influencing the information that the patient was given regarding prognosis. This finding is similar to that noted in the previous literature.5 In a study by Noone et al.19 comparing the attitudes of elderly patients and their relatives toward telling the truth about cancer, 83% of patients wanted to be told the truth. However, only 55% of matched relatives wanted the patient to be informed. Therefore, patient information preferences cannot be predicted accurately by talking to relatives. Unfortunately, to our knowledge, literature from culturally diverse populations is limited.7, 8
The dilemma of how to respond to a family's request to withhold information from a patient has been identified frequently in both the medical and nursing literature.20–25 To our knowledge, there have been very few empiric studies performed to date in culturally diverse populations. HP participants in the current study, many of whom worked in multicultural parts of Australia, reported this to be a frequent and challenging occurrence. Likewise, Anderlik et al.20 surveyed 122 physicians from a major cancer center in the U.S. and found that 57% had received at least 1 family request to withhold information concerning prognosis from a patient during the preceding 12-month period. HP participants in the current study had various suggestions for how to handle this scenario. All said they would explain to the families that they prefer or felt obligated to answer direct patient questions honestly, but varied with regard to how much they tried to facilitate an open discussion with the patient. Suggestions by HP participants included clarifying the concerns of the caregiver and how much they wanted the patient to know, explaining the advantages of being open with the patient and the costs of the patient not being informed, and then negotiating what is actually discussed. Some HPs said they would reassure families that they would not raise the topic with the patient. It is interesting to note that none of the HPs said they would actively explore the patients' understanding of their illness and inquire about their preferences for information in this situation unless either the family consented or there was a pressing need to do so.
The reasons why HP participants were reluctant to actively explore the preferences of the patients in this situation are not clear. Perhaps they were fearful of upsetting the family and alienating them from PC. Conversely, many of the HP participants expressed a desire to be culturally sensitive and to respect that the patient and their family may have different views with regard to truth telling and patient autonomy. Both the caregiver and HP participants highlighted difficulties with using professional interpreters, another factor that contributes to the complexity of this situation. The issue of the interpreter themselves restricting the patient's access to information, as raised by one caregiver in the current study, warrants further investigation.
Various approaches have been proposed regarding the situation of caregivers trying to restrict a patient's access to information. Anderlik et al.20 reported that 4% of cancer specialists surveyed "always" abided a family's request to withhold prognostic information from a patient, 25% did so "most of the time," and 43% did so only "occasionally." Although to our knowledge no other empiric studies exist, various authors have offered recommendations. Maguire et al.22 suggested the following steps for when a family member is trying to withhold the truth from the patient. First, speak with the relative and acknowledge their request; then explore and validate the reasons for it and establish the emotional cost of the patient not being informed. Next, enter into a contract with the relative that you will not tell the patient but will explore their understanding by speaking with them separately. Finally, establish the patient's level of awareness by asking a directive question and exploring the cues given; if the patient is obviously aware of their condition, then confirm this and seek permission to convey this to the family. More recently, Maguire and Piceathly26 suggested a joint meeting with the patient and the family to facilitate a greater understanding of the situation and to discuss the current concerns of both rather than holding a separate meeting with the patient. Maguire and Piceathly26 also recommended reassuring caregivers that if it does not appear that the patient wants to know his prognosis, it will not be thrust on him. In contrast, Freedman23 recommended finding out from the patient what they want to know and offering to tell them the truth at whatever level of detail they desire. Likewise, Taboada and Bruera21 suggested sensitively exploring and respecting the preferences of the patient.
Limitations and applicability of findings
Qualitative methodology dictates small sample sizes. The use of qualitative methods such as those used in the current study is common in exploratory studies and can generate hypotheses and provide rich descriptive information regarding a phenomenon. However, it is difficult to make assumptions concerning the generalizability of the data obtained using such methodology.
The sample in the current study is limited to English-speaking patients and caregivers (some of the caregivers were caring for patients from non-English-speaking backgrounds) from three different PC services in an urban setting in Sydney in which the patient had an underlying illness of advanced cancer. The patient and caregiver participants therefore may not be representative of Australia's culturally diverse population. The educational background of the caregiver group was higher than that of the general population. All patients and caregivers had been referred to a PC service, were willing to receive ongoing follow-up from the PC team, and had been in contact with the PC service for a relatively long time (median, 12–14 weeks; range, 2 weeks to 2.5 years). Therefore, participants may have been more accepting of a palliative approach to their illness and therefore held different views with regard to discussing prognosis and EOL issues than those patients with incurable cancer outside a PC setting. We obtained each patient's and caregiver's views on only one occasion. It is likely that the views of patients and caregivers views regarding discussing prognosis and EOL issues evolved over time.
The HP participants came from various disciplines and from several different PC centers in Australia servicing culturally diverse populations in mainly urban settings. However, the views of PC HPs may differ from those providers caring for terminal patients in other settings.
Overall, the findings of the current study highlight the importance of checking the individual needs of both the patients and caregivers for information concerning prognosis and EOL issues, because they are often different. The value of having separate as well as joint discussions with the patient and caregiver about these issues was identified.
HP participants had useful suggestions for how to handle the situation of a family request to avoid discussions concerning prognosis and EOL issues with patients, most commonly those from non–English-speaking backgrounds. Training in formal communication skills may enhance the confidence of the HPs in sensitively eliciting patient preferences for information and decisionmaking in this challenging situation, including giving the patient the option of disclosure and decision-making negotiated through the family.
The authors thank all the patient, caregiver, and health professional participants for giving their time and energy to this study, and to the staff of the involved palliative care services who assisted with patient identification. They also thank Professor Robert Arnold from the University of Pittsburgh for contributing helpful comments to an earlier version of the article.
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