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Somerset construction Services
commercial and domestic construction services. Covering all aspects of building, maintenance and landscaping services. All trades covered. Founded in 2015 with fully qualified and insured trades men.
All weather construction ltd
We cover anything that is required in the building services Including wet rooms bathrooms , kitchens ,plumbing and full decoration service. We aim to please and work with the client And work to a high spec.
Areas we cover - Bournemouth-Southampton-Portsmouth-Salisbury-Dorchester-Yeovil-Taunton-Bath-Swindon-Reading-Oxford-Surrey-Wiltshire-Somerset-Dorset-Hampshire. We cover all surrounding areas so please do not worry if your area is not mentioned. 5 BEDROOM HOUSE only £99* 4 BEDROOM HOUSE only £89* 3 BEDROOM HOUSE only £79* 2 BEDROOM HOUSE only £69* 1 BEDROOM HOUSE only £59* LOUNGE ROOM only £15 DINING ROOM only £15 BEDROOM only £15 HALL, STAIRS & LANDING only £20 Phone - 0800-773-4843 Mobile - 0330-111-4843 We are a family run business who take great care in ensuring all our customers are happy with our service. We expect nothing but perfection from our highly trained technicians - we pride ourselves on being the best! We are proud to be consistently rated as one of the top carpet cleaning companies across Dorset, Hampshire, Somerset, Berkshire, Sussex, Hertfordshire, Oxfordshire, Buckinghamshire, Wiltshire and South Wales. Our reliable carpet cleaning, hard floor and upholstery cleaning service is guaranteed to leave you extremely satisfied. At No1 Carpet Cleaning we're committed to providing a consistently high level of carpet cleaning, rug cleaning and upholstery cleaning services to all our customers, that's why we have invested in the best and most efficient cleaning equipment in the market. All our machines are from Airflex Storm, who are the leaders in carpet cleaning equipment. We use the latest fast-drying steam cleaning machines on the market, are fully insured and have over 15 years experience in the industry. Using the best carpet cleaning equipment means that your carpet will not only be spotlessly clean, but almost completely dry within an hour of the cleaning process finishing leaving you free to carry on with your day. All of the carpet cleaning solutions we use are both pet friendly and child friendly. Kind Regards Richie No 1 Sales Team
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Mike Maggs
totem timber
riviera kitchens and bathrooms
Aquagas Ltd is a heating and plumbing firm that is run by Steve Smith based in Torquay and with over 30 yrs experience in the gas heating industry we also provide Bathroom and Kitchen fitting services through our sister company T/a Riviera kitchens and Bathrooms
O C Contractors
O C Contractors is a company dedicated to transforming peoples homes from a new kitchen all the way through to loft conversions and extensions. We listen to customers ideas and turn them into reality,from initial discussions to completion. We are able to provide detailed drawings to help with submitting of plans for planing permission or work off customer supplied architectural plans. Project managing our jobs means that we control every aspect of the build from the footings in the ground to the final coat of paint. For a free consultation please send you initial query via email to firstname.lastname@example.com
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Lovedecor property maintenance
general property maintenance any job big or small
Newton Home & Garden Maintenance
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Gordon Scott (Building Contractor)Certificate of Excellence 2015
Gordon Scott (Building Contractors) building a better future. Quality built with honesty communication and experience. Builders covering Devon and Cornwall offering a complete building package in one company with more than 40 years experience providing a comprehensive range of construction and building service. We treat every project small or large with the same attention to detail. We pride ourselves in offering excellent customer service and more than happy to help and advise, how ever small. All our projects are carried out by quality City and Guilds time served tradesmen assuring you have complete peace of mind. We offer a complete design and planning package from individual garden accommodation (any size), all types of repairs/alterations and conversations to new builds, the choice is yours. We work with local architects to complement your requirements, from conception to completion we will ensure your works how ever small will be carried out to the highest standards. No job to small. Contact Gordon Scott today on mobile: 07837 126 786 for your competitively priced no-obligation quotation. References available on request.
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Ultraline Tiling Group
Ultraline Tiling Group provides best tiling services in Melbourne. We have expert team of wall and floor tilers in Melbourne. To get trusted tiling services call us on 1300 315 656 today!
The Sofa Library
Hand made Sofas, Bespoke Furniture and Interiors, Soft furnishings, Flooring, Wardrobes and Bedrooms. From our interior design services through to our bespoke furniture and sofas for both domestic and high end commercial project application, we offer our customers a high street presence for all you need to find a quality and considered interior solution at a realistic price point. From the supply of our products through to our people with the expertise to put them into your home, we are here to help you realize your interiors potential.
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A fully trained plumber who has City&Guilds and 25 years of service and experience in heating and plumbing. From bathrooms, kitchens, heating systems and all renewable energies.
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We undertake all kinds of interior and exterior work. such as Kitchens , Bathrooms, Basements, Plastering Decorating etc... We are polite and honest people and we treat our customers as part of the family. Indeed a lot of our customers remain our friends long after their project is finished. Give us a try, we know you won't be dissappointed.
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Drainage Care UK offers its services across the whole of Southampton, Bournemouth and Salisbury. We can carry out drain unblocking, cctv drain surveys, drain repairs, septic tank emptying and water pipe replacements. 24/7 Emergency call out service all year round
The Moroccan encaustic tile Company
We are at the forefront of Moroccan tiles, all our tiles are handmade by artisans in our workshop in Marrakech. Largest choice of Moroccan tiles in UK, best service and prices. Bespoke designs a speciality. No minimum order, Please visit our website for more information. Our floor/wall tiles are suitable for both private homes and commercial premises. Cafes, public areas, hotels etc.. REASONS WHY CHOOSE THE MOROCCAN ENCAUSTIC TILE COMPANY. OUR MOROCCAN ENCAUSTIC TILES ARE AN INTERIOR DESIGNER'S DREAM. WITH A KALEIDOSCOPE OF 54 + COLOURS IN MANY DIFFERENT SHADES, VARIOUS SIZE CHOICE AND AN ALMOST LIMITLESS COMBINATION OF PATCHWORK OR CARPET DESIGN AVAILABLE TO SUIT ALL TASTES AND INTERIORS. OUR MARRAKECH TILES ARE TRUE MOROCCAN ENCAUSTIC, NOT PRINTED! ENCAUSTIC TILES AREN'T FIRED, THEY'RE DRIED IN THE HEAT OF THE MOROCCAN SUN WHICH MAKES THEM ENVIRONMENTALLY FRIENDLY. BRING A PIECE OF MARRAKECH INTO YOUR HOME AND ACHIEVE THAT ELEGANT COLOUR SCHEME YOU DREAMED OF. ENCAUSTIC TILES AREN'T JUST FOR MIDDLE EASTERN KINGS ANYMORE!
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text: This table is used for column layout. Middleton Public SchoolsHowe Manning SchoolFuller Meadow SchoolTritown School Union (Office of the Superintendent)Masconomet Regional School DistrictNorth Shore Technical High School Make a Payment Weather Forecast Middleton Historical Commission Thursday, June 12, 2014 at 4:00 PMTown Clerk's Office-Memorial Hall Printer-Friendly Version Middleton Historical Commission Meeting Thursday June 12, 2014 4:00 PM in the Town Clerk's Office, Memorial Hall Agenda: 1. Train Station project update 2. House plaques discussion 3. Financial update 4. Computer status 5. Approve minutes 6. Reorganize? 7. Unanticipated business POSTED: 6/10/14 @ 12:00 PM - MIDDLETON TOWN CLERK'S OFFICE Town of Middleton 48 South Main Street, Middleton, MA 01949 Website Disclaimer Privacy Statement Virtual Town Hall Website

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text: Udemy - iPhone Photography Pro ! MP4 | Video: 960x540 | 57 kbps | 48 KHz | Duration: 3 Hours | 1.02 GB Genre: eLearning | Language: English Learn how to apply professional photography techniques when taking photos with your iPhone. It's so EASY! This course that teaches you how to apply professional photography techniques using your iPhone. You will be amazed how easy it is to take photographs like a pro! 5 Star Review from one of our students: "This is brilliant. Not only does it show what the iPhone camera can do but it's a great course on how to get the best out of your photos too. It's so easy to follow and to navigate directly to the section you want as well. Highly recommended." This is the only iPhone photography course that takes you out in the field and lets you see what the camera sees! There is no better way to learn. Read more: It is a comprehensive video training course that will show you how to take stunning photographs that you never thought possible. With over 30 video training tutorials we teach you how to use all the functions of the standard iPhone camera that most people never knew existed as well as showing you how to frame a photo with the eye of a professional photographer. == LEARN HOW TO == ● Use advanced features most people don't know about in the iPhone camera ● Apply techniques used by professionals to capture stunning shots ● Understand what makes a brilliant photo AND what doesn't ● Work with lighting to highlight your subject matter for dramatic effects ● Utilise the colour wheel to make your photos pop ● Compose photos using the rule of thirds and advanced compositional guidelines ● Edit and enhance your photos - the magic beyond the capture! ● Use specific apps for certain types of photographic effects ● Add accessories to the camera, which allow you to get more creative ●Take a better photograph every time! With practical advice taught through real life scenarios by professional photographer Matt Kemp this iPhone camera training course has been broken into easy to follow sections. Matt demonstrates different approaches to taking photos, and shows you how using some simple techniques can have a dramatic effect on your photography. Watch and learn as Matt takes you through a variety of practical scenarios including: ● Landscapes ● Children ● Portrait ● Close up ● Panoramics ● and more ... Code: http://www.nitroflare.com/view/BA90D34177FBD17/zsshg.Udemy..iPhone.Photography.Pro.part1.rar http://www.nitroflare.com/view/88296289E35E7FF/zsshg.Udemy..iPhone.Photography.Pro.part2.rar http://www.nitroflare.com/view/674A49FA92B03C1/zsshg.Udemy..iPhone.Photography.Pro.part3.rar http://www.nitroflare.com/view/87B5CA6AD9941A5/zsshg.Udemy..iPhone.Photography.Pro.part4.rar http://www.nitroflare.com/view/5A6606B80B2650E/zsshg.Udemy..iPhone.Photography.Pro.part5.rar http://www.nitroflare.com/view/D860817AD07F0E4/zsshg.Udemy..iPhone.Photography.Pro.part6.rar http://www.nitroflare.com/view/6508C49466C97C1/zsshg.Udemy..iPhone.Photography.Pro.part7.rar


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Didn't need to shimmy all it took was a tott. Now it's supper time, tftc.
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When I'm in the mood for Mexican food the first place I go to is Cozumel's in Broadview Heights. The food is hot, fresh, fast, and delicious, and the wait staff is terrific and a lot of fun. As you will see from the pictures below, Cozumel's is fun and festive on the inside to!
As soon as you are seated , a basket of warm chips is brought to the table with their homemade salsa, mild or hot.
Among my favorites are the guacamole (the best in the city, IMHO) and the chicken quesadilla verde, which is a flour tortilla stuffed with perfectly seasoned chicken, green peppers, onions,tomatoes, and cheese. It comes to the table steaming hot and is served with rice and a mini taco shell filled with guacamole, sour cream, and pico di gallo. Scrumptious. This meal goes very nicely with one of their many daiquiris or margaritas.
In the summer you can dine outside at one of their lovely umbrella covered tables.
So when you're in the mood for Mexican, stop in at Cozumel's Mexican Restaurant. You won't be sorry!
And be sure to check out their website and other locations in Brunswick, Independence, and Brook Park.
If you would like to buy or sell a home in Broadview Heights, or in the surrounding communities, please call me at 440-263-7496, or you may want to visit my website for more specific information on the communities I service: Brecksville, Broadview Heights, North Royalton, Independence, Seven Hills, Parma, Parma Hts., and Garfield Hts
If you would like to buy or sell a home in the southern communities of Cleveland Ohio, please call me at 440-263-7496, or you may want to visit my website for more specific information on the communities I service: Brecksville Ohio Real Estate, Broadview Heights Ohio Real Estate, North Royalton Ohio Real Estate Independence Ohio Real Estate, Seven Hills Ohio Real Estate, Parma Ohio Real Estate, Parma Heights Ohio Real Estate and Middleburg Heights Ohio Real Estate. Information is obtained from Neohrex (Northeast Ohio Real Estate Exchange) and is deemed reliable but not guaranteed and should be independently verified. Properties subject to prior sale, rental, or other status changes. All properties that are advertised as being listed or sold by Barb Szabo are in conjuntion with ReMax Trinity.


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2wd wj
My question to the JeepGarage brains trust, Can you disconnect the front tailshaft and essentially drive the jeep as a RWD?
The reason that i am asking is that i am fairly sure through extensive forum trawling that my front yoke bearing is buggered.
My jeep makes a nasty whine under acceleration, the noise comes from the front, increases in pitch as road speed increases, temporarily quietens when going over a rise or dip in the road.
Also, there was a small amount of diff oil leaking out of the right hand side of the front axle, before the CV boot, fairly sure it was diff oil from "the ol' stick ur finger in it and smell it" trick.
I also think it could be a wheel bearing, i jacked the front up and rocked the wheels 12-6, 9-3 oclock and one had a tiny bit of play.
However, when i think about disconnecting the tailshaft, i start to wonder if the quadra drive system will try to send power to the front under normal driving conditions and just spin up, causing wear and affecting drivability.
This thought is ONLY to attempt to reduce damage to the vehicle, get rid of the noise for the time being, while i source some parts and attempt to rectify the issue properly.
I will probably try and take the tailshaft out anyway and see what happens when i drive it up and down the street. If it acts funny in any way i would not try and drive it for any length of time.
Re: 2wd wj
You have the 247 T-case under your jeep, the same as i have on my Quadra Trac II. There is no problem in removing the front propeller shaft and drive around as a 4x2. Due to the fact that the shaft is removed, the progressive coupling inside the T-case will be activated, trying to transfer power to the front shaft, but the output will just freely rotate. The rear propeller shaft is always directly connected to the T-case, so all power will still go to the aft wheels. I drove around like this for some weeks, waiting for a new propeller shaft aft CV joint to come in.
Regarding the fluid coming out of the diff tube, thats probably the seal, which is placed from inside the diff casing. Quite some work and special tools needed to remove the diff case out of the diff. With the front joke bearing you mean the pinion bearing, which is coming out of the aft side of the diff? Also check the diff fluid level, since it seems to be leaking, it can be low on fluid and cause noises. Take care to not continue driving around with a low level, it will damage the bearings and/or pinion/ring gear.
Re: 2wd wj
Wow mate thanks a lot for your reply, very informative :)
I will happily go ahead and remove the tailshaft, however some follow up questions.
If the noise remains as normal after removal, does that discount the yoke/pinion bearing of being at fault and therefore a wheel bearing is more likely the culprit?
I have some diff oil to put in, i will also do this asap as a deterrent of further damage.
With the seals inside the diff housing, could you clarify what special tools are needed, i have a very adept mechanic offering to "tutor" me as i do the work myself at his workshop, however he does run his own business and will be preoccupied most of the time. So i have access to general workshop tools.
thx again
Re: 2wd wj
You have a good change that if the noise stays the same, that the problem is a wheel bearing or a drive shaft CV joint. Are the rubber boots from the CV joints ok? Don't know which setup you have on your WJ regarding the front propeller shaft. There are or 2 CV joints or 2 U-joints in it. When you have the propeller shaft out, check those joints for play as well, you never know.
Regarding the special tools needed for removing the diff case, there is a special spreader needed, which will spread the diff casing a bit, which is necessary to remove the case. Never done this myself, so can't tell you if you would be able to remove the case without using the spreader. There is some other special tool for the removal/install of the seals, but i think that you could use some alternate ways to do that.
Re: 2wd wj
Ok front prop shaft removed (easier than i expected, 12 bolts), Noise has completely gone, and i can now hear the mud tyres flapping around on the road at speed :D:D
Does this narrow the issue down to the diff itself or a bearing inside?
On a side note, i am gettin 30l per 100k (or 7 mpg), i have cleaned the throttle body, changed engine oil, spark plugs. What am i looking at next? O2 sensors? I am just trying to tick things off the list of possible causes.
Re: 2wd wj
If you have a scanner which shows live data, you could monitor the O2 sensor ouput voltages. They should vary a lot. When they stay fixed or only vary a little, they should be replaced. Also good to check the fuel pressure at the rail.
How is the acceleration of the jeep, firm or sluggish? A (partly) plugged silencer could also be your problem.
Also when not checked yet, have a look at the air filter.
You know now that the wheel bearings are ok, there still is a change that the drive shaft CV joint is the problem. Did you check the CV or U-joints on the propeller shaft? They should be completely without play.
You have a big change that the problem is inside the diff however. I would drain the fluid and check for metal glinsters in it.
Re: 2wd wj
Is there any other way to drain the diff fluid than to take the diff cover off?
The front prop shaft did not seem to have any play in it. To check the wheel bearings is that the method of "shaking" the front wheels when theyre off the ground and feeling for play?
For the fuel economy, my air filter is clean, the car does not feel sluggish (atleast i dont think it does, its my first jeep and first v8, i am very happy with the power atm so if its running sluggish i will be SO HAPPY to get it running better) but it does feel like its driving normally, just bad fuel economy and black smoke under acceleration.
I got these codes when i did the key dance; 1281 0171 0137 1685
Googling these points to an O2 sensor, is it possible to take them out and clean them up before deciding that they require replacement?
Scanners are really expensive arent they?, also, how would i check the fuel pressure at the rail?
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The SWTOR thread
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April 29th, 2014, 01:53
Buying the artifact authorization in the Cartel is fine, as long as you're willing to do without through most of your leveling, so you can buy it after you've got some credits banked up. But honestly, how important is it to wear purple gear while leveling? In 5 levels, you'll be finding green gear that's better. Just accept the fact that you won't wear purple gear until you're max level, which is fine because that's where it really matters anyway.
In my case, I bought an account-wide artifact unlock when I was in my mid-to-late-40s, when I finally found a decent deal at 450k credits (I had seen it for sale this low a few times during my regular checks as I leveled, so I had a decent idea of how low it could go).
The credit limit is also not that big of a deal, because your credits still accrue in an escrow balance, and you can buy escrow transfers on…wait for it…the Cartel Market! This basically translates into a slight-to-moderate penalty on credit gains for f2p players once you hit the 350k cap.
For example, I currently have 1.8 million credits in escrow, and I also have three 600k escrow transfers, which I picked up for 105k each when some guy dumped a bunch of them. This means that getting access to my 1.8 million credits will have cost me 315k, which essentially translates to a ~15% "tax" on my credit accumulation, which seems totally worth it to me to avoid paying $15/month in perpetuity. And has been mentioned numerous times, credits are easy to come by in this game. Even though that 1.8 mil doesn't show up in my inventory, I know I have access to it anytime I decide to spend it, which is fine with me.
Playing f2p like this is kind of an interesting meta game, where I actually get some enjoyment out of withholding as much money from EA as possible while I enjoy their game. And I don't feel a bit bad about it, because I've seen first-hand how some people spend money hand over fist with every update and new item pack. My guild leader is insane in this regard. I actually got a free ewok companion because he bought like 8 of 'em with real money and handed them out to all the guildmates that were online at the time. Crazy…
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post #1 of 3 Old 05-29-2008, 06:41 AM Thread Starter
Diesel Shop
Hi! Wondering if anyone knows of a good performance diesel shop around NY? I can't find a listing anywhere. I'm in Orange County NY
4" lift, Bilstein shocks, BF Goodrich
all terrains, chrome Westin bull bar,
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air, Accufab elbow, Dual a-pillar
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ARP studs, Aurora 620 turbo
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SCT-Innovative, MBRP Exhaust....
Future mods - Kelderman air ride, ARP studs
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The OC..haha..dont call it that if anyone watches arrested development they will get that....sorry I cant help you but heres a bump for you im sure someone knows....
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post #3 of 3 Old 06-19-2008, 04:35 PM
depends what you need done, I might know a few people
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Follow Harriet on Twitter
About Harriet
- The Poetry Foundation's blog for poetry and related news.
- More about Harriet
- Contributors
- Archive
Journal, Day Two
I receive hate mail. Not frequently, but enough to register it and to register the disappointment—and sometimes the anger—poets feel in response to receiving a rejection letter. But receiving hate mail is not nearly as difficult, I find, as writing the rejection letter itself. Some writers seem to hold the notion that editors take pleasure in rejecting writers. The language of the process—submission—is, of course, problematic, as it conjures the image of writers bowing down, literally submitting, surrendering their works to the publishing gods. But almost every editor I've spoken to has said the least favorite part about the job is turning down writers. (Or perhaps the second least favorite thing, right after not having enough time to read published books outside of stacks of manuscripts.)
The brutal facts: Graywolf Press receives about 2,000-2,500 poetry submissions annually and publishes ten poetry collections per year. This means we accept less than half of one percent of the submissions that come in.
We select our books, then, by a variety of criteria. Graywolf does have a stable of writers whose works and careers we continue to support, and we consider that with the quality of new works those writers send in. Those situations aside, how does a manuscript stand out enough to get serious consideration? There are three primary criteria I consider when weighing submissions:
1. Are the poet's language and style deployed in a meaningful and original way?
2. Is the manuscript about something?
3. Is the manuscript really a book?
These are all three deeply interrelated, and it's difficult to take one apart from the others. But to elaborate:
First, the language and style of the submitted poetry has to be compelling, and has to be deployed in a way or form that enhances the meaning of the overall project. This is to say there must be some reason the writer chose to write this particular work as poetry, and in this particular mode, and those reasons should be in some way discernible by the reader. An example from a different but related genre: The Da Vinci Code was written as a novel, but it's clear from even a page or two that its true form is Hollywood film; despite all its success, it fails as literature in part because it was written in the wrong form. Or to go back to poetry and to use a more artful example, I think of the way Albert Goldbarth's long, rollicking poems made of long, rollicking lines are the right poetic form—with similarities to Whitman's strategies—to take in his universe of careening subjects, histories, and allusions. Regardless of what that form or style may be, the poet needs to find the right way of writing to complement what the work is about.
Which leads me, secondly, to inquire if a manuscript of poetry is confronting something—call it subject matter, call it theme: a singular focus, or a set of issues that the poetry is describing or grappling with. The manuscript needs to be about something, even something ephemeral, abstract, or glancing. I think of Claudia Rankine's Don't Let Me Be Lonely as a terrific example of a book unflinching in its confrontation with TV non-reality and our over-medicated culture. Or the way Fanny Howe's On the Ground, even for all its gaps and associative logic, relentlessly confronts spirituality and war. It surprises me how many manuscripts are seemingly written around something rather than about it, or they self-consciously avoid subject matter altogether.
And third, does the manuscript use what it's about and its deployment of language to create a satisfying, cohesive book? It used to be more the case that poetry books were assemblies of what a poet had written in a given few years: Prufrock and Other Observations. I think readers now are accustomed to reading an individual book as a discreet project, a work that attempts to take the reader across an arc from the first poem to the last. Louise Glück's The Wild Iris is a deliberately constructed and ordered collection, for example, and each poem is in its meant place. In a more open-ended mode, Lyn Hejinian's My Life is a collection that is a project unto itself. Or, to use another example, Nick Flynn's Blind Huber becomes a sequence about both the research into bees and, simultaneously, the internal dissolution of the hive. It makes a book, and we're meant to read the work as a book.
It takes a great deal of risk on the poet's part, it seems to me, to dare sounding a unique register in language and to dare writing about something dear or important. I don't mean to offer the brutal numbers above to frighten writers, but rather to challenge them: with the numbers stacked against you anyway, why not risk everything—if not in life, then on the page? Why not risk ambition in the writing? In its perhaps backhanded way—the likelihood of rejection creates a kind of creative freedom.
Posted in Uncategorized on Tuesday, May 9th, 2006 by Jeff Shotts.


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Guideline development and use
Methods of guideline development
Literature review
Expert advisory panel
Target audience
How to use the guidelines
Grading of recommendations
Limitations of the guidelines
The guidelines
Timing of prognostic and end-of-life discussions
Preparation for the discussion
Physical and social setting
How to discuss prognosis and end-of-life issues
General strategies to facilitate hope and coping when discussing prognosis and end-of-life issues
Additional background information about specific content areas and issues
Role of self-care
Endorsing organisations
Writing committee
Dr Josephine M Clayton (Chair) — Head of Department of Palliative Care, Royal North Shore Hospital, Sydney, NSW; Senior Lecturer and Cancer Institute NSW Research Fellow, Faculty of Medicine, University of Sydney, Sydney, NSW.
Dr Karen M Hancock — Project Coordinator and Research Associate, Medical Psychology Research Unit, University of Sydney, Sydney, NSW.
Professor Phyllis N Butow — Professor of Psychology, University of Sydney, Sydney, NSW.
Professor Martin H N Tattersall — Professor of Cancer Medicine, University of Sydney, Sydney, NSW.
Professor David C Currow — Professor of Palliative and Supportive Care, Flinders University, Adelaide, SA.
Correspondence: jclaytonATmed.usyd.edu.au
Australian and New Zealand Expert Advisory Group
|Dr Jonathan Adler, Palliative Care Physician
|Professor Sanchia Aranda, Cancer Nursing
|Dr Kirsten Auret, Palliative Care Physician
|Dr Fran Boyle, Medical Oncologist
|Dr Annette Britton, Geriatrician
|Associate Professor Richard Chye, Palliative Care Physician
|Dr Katy Clark, Palliative Care Physician
|Associate Professor Patricia Davidson, Cardiac Nursing
|Dr Jan Maree Davis, Palliative Care Physician
|Professor Afaf Girgis, Behavioural Scientist
|Dr Sara Graham, Carers NSW Representative/Advocate
|Professor Janet Hardy, Palliative Care Physician
|Ms Kate Introna, Palliative Care Nursing
|Professor John Kearsley, Radiation Oncologist
|Professor Ian Kerridge, Ethicist and Haematologist
|Professor Linda Kristjanson, Palliative Care Nursing
|Dr Peter Martin, Palliative Care Physician
|Dr Amanda McBride, General Practitioner
|Ms Anne Meller, Aged Care Nursing
|Associate Professor Geoffrey Mitchell, General Practitioner
|Dr Alison Moore, Linguist
|Ms Beverley Noble, Cancer Voices Consumer Representative
|Professor Ian Olver, Medical Oncologist
|Ms Sharon Parker, Nursing, Clinical Trials Research
|Associate Professor Matthew Peters, Respiratory Physician
|Dr Peter Saul, Intensive Care Specialist
|Associate Professor Cameron Stewart, Lawyer
|Ms Lyn Swinburne, Breast Cancer Network Australia Consumer Representative
|Dr Bernadette Tobin, Ethicist
|Ms Kathryn Tuckwell, Linguist
|Professor Patsy Yates, Palliative Care Nursing
Prognostic and end-of-life communication is a vital skill for health care professionals caring for patients with progressive life-limiting illnesses, and their families. Expert opinion varies, and high-quality evidence on how best to discuss these issues with such patients and their caregivers is limited. These guidelines were developed to address these issues. The guidelines were developed through the following methods:
Systematic literature review of the best available evidence on discussion of prognosis and end-of-life issues;
Review of previous relevant guidelines and expert opinions in the literature; and
Refining of draft guidelines by an expert advisory panel.
The key recommendations of these guidelines are for health professionals to consider the recommendations conveyed by the acronym PREPARED.
Prepare for the discussion, where possible:
Confirm pathological diagnosis and investigation results before initiating discussion.
Try to ensure privacy and uninterrupted time for discussion.
Negotiate who should be present during the discussion.
Elicit patient and caregiver preferences:
Identify the reason for this consultation and elicit the patient's expectations.
Clarify the patient's or caregiver's understanding of their situation, and establish how much detail and what they want to know.
Consider cultural and contextual factors influencing information preferences.
Provide information, tailored to the individual needs of both patients and their families:
Offer to discuss what to expect, in a sensitive manner, giving the patient the option not to discuss it.
Pace information to the patient's information preferences, understanding and circumstances.
Use clear, jargon-free, understandable language.
Explain the uncertainty, limitations and unreliability of prognostic and end-of-life information.
Avoid being too exact with timeframes unless in the last few days.
Consider the caregiver's distinct information needs, which may require a separate meeting with the caregiver (provided the patient, if mentally competent, gives consent).
Try to ensure consistency of information and approach provided to different family members and the patient and from different clinical team members.
Acknowledge emotions and concerns:
Explore and acknowledge the patient's and caregiver's fears and concerns and their emotional reaction to the discussion.
Respond to the patient's or caregiver's distress regarding the discussion, where applicable.
Be honest without being blunt or giving more detailed information than desired by the patient.
Do not give misleading or false information to try to positively influence a patient's hope.
Reassure that support, treatments and resources are available to control pain and other symptoms, but avoid premature reassurance.
Explore and facilitate realistic goals and wishes, and ways of coping on a day-to-day basis, where appropriate.
Encourage questions and further discussions:
Encourage questions and information clarification; be prepared to repeat explanations.
Check understanding of what has been discussed and if the information provided meets the patient's and caregiver's needs.
Leave the door open for topics to be discussed again in the future.
Discussing prognosis and end-of-life issues has been identified as an important component of care by patients with progressive life-limiting illnesses, and their families.1,2 Being adequately informed is essential for such patients and their caregivers to participate in decisions about their treatment and care, to set goals and priorities, and to prepare for death. Clinicians need to provide information in a way that assists patients and their families to make appropriate decisions, be informed to the level that they wish, and cope with their situation. These guidelines have been prepared to assist clinicians with this difficult but important task.
The guidelines were developed using the following process:
Literature review:
Refining of guidelines with an expert advisory panel.
The systematic review3 was conducted in conjunction with personnel of the systematic review section of the National Health and Medical Research Council (NHMRC) Clinical Trials Centre, in accordance with the principles and processes recommended by the Cochrane Review.4 Eligible studies were those that sampled adult patients who had an advanced progressive life-limiting illness with less than 2 years to live, including but not restricted to cancer, end-stage pulmonary disease, end-stage cardiac failure, and motor neurone disease; and/or the caregivers (including bereaved relatives) of such patients; and qualified health care professionals. More specifically for studies where patients formed the study group, the eligibility criteria included: patients in specialist palliative care or hospice settings (inpatient or community), and patients in any care setting with a diagnosis of an advanced life-limiting illness being treated with palliative intent and with a life expectancy of less than 2 years. Where samples were mixed (ie, potentially curable and advanced disease), studies were included if more than 50% of patients had an advanced life-limiting illness or where the results for such patients were provided separately. Studies where patients formed the study group were excluded if they involved patients with chronic diseases with likely life expectancy of greater than 2 years (such as dementia and multiple sclerosis), patients being treated with curative intent, or patients being cared for in an intensive care unit, or if it was not possible to determine what percentage of the study group was being treated with palliative intent or had a life expectancy of less than 2 years.
The medical literature was searched to identify relevant studies and reviews for the period between 1966 and November 2004. Searches were conducted via MEDLINE, CINAHL, EMBASE, Psycinfo and the Cochrane Register of Controlled trials (Central). Out of 4167 abstracts retrieved by electronic searches, and a further 127 abstracts identified by hand searching, 278 full manuscripts were considered for inclusion in the review. One hundred and fifty-one did not meet the eligibility criteria and four were duplicates; hence, 123 articles were included. Individual reviewers extracted data from each study using a standard format. Data extraction was checked by a second reviewer for 10% of studies to ensure consistency.
Most studies were descriptive, examining provider practices and patient and/or caregiver views, attitudes, knowledge and behaviour (Level IVa evidence according to the NHMRC 1995 ratings5). Such studies are not considered admissible evidence in the more recent NMHRC rating scale.6 These NHMRC rating scales are designed for research questions regarding interventions, diagnosis, aetiology, screening and prognostic factors, but are not readily applicable to the topic of these guidelines.
Relevant consensus guidelines and expert opinion were incorporated into the guidelines because of the lack of evidence for some topics. Consensus guidelines in similar areas were retrieved via hand searching and the search strategy for the systematic review. They were excluded from the systematic review because they were not studies. These guidelines included areas such as breaking bad news (n = 2), psychosocial clinical practice guidelines for women with breast cancer (n = 1), clinical practice guidelines for advanced breast cancer (n = 1), therapeutic guidelines for palliative care (n = 1), advance directives (n = 1) and end-of-life care (n = 1). These guidelines used a rigorous consensus-building process, with many commissioned by the Australian or New South Wales Government and endorsed by national peak bodies. Published expert opinion — the considered opinion of clinical experts (n = 12) regarding communication of prognosis and end-of-life issues with patients, and their families, with advanced life-limiting illnesses — was reviewed and cited for areas where there was a lack of studies or consensus.
An expert panel was convened, comprising 35 Australian and New Zealand health care professionals and consumers (nine palliative care medical specialists, three medical oncologists, three palliative care nurses, three consumers [including two cancer patients and one caregiver], two general practitioners, two psychosocial experts, two ethicists, two linguists, one oncology nurse, one cardiology nurse, one aged care nurse, one research nurse, one geriatrician, one respiratory physician, one radiation oncologist, one intensive care specialist, and one lawyer). The panel members were selected to reflect the multidisciplinary nature of care for patients with advanced progressive life-limiting illnesses. Representatives were selected on the basis of either their clinical expertise or a track record of publications on this topic. Consumer bodies, such as Carers NSW and Cancer Voices NSW, were approached and provided consumer representation. The guidelines were refined with the assistance of this expert panel using consensus methods (modified nominal group technique/Delphi method7).
This group was sent the guidelines by mail and asked to evaluate them (both by rating each individual point using a nominal scale and by providing suggested word changes and comments following critical review). The group then had a face-to-face meeting and discussed discrepancies of opinion and all items rated by at least 10% of the panel to be either "not important" or "somewhat important" (a score of 1 or 2 on a five-point scale where 3 was "important" and 5 was "essential"). Following the meeting, the research team refined the guidelines based on the recommendations of the expert panel. The final draft was sent again to the expert panel for a further round of feedback and final approval.
These guidelines were developed for use by all members of the health care team involved in the care of patients with progressive life-limiting illnesses, and their families, including GPs, specialist doctors and trainees (including palliative care, medical and radiation oncology, surgical oncology, geriatrics, haematology, respiratory medicine, cardiology, and neurology), junior medical staff, nurses, social workers, psychologists, psychiatrists, physiotherapists and occupational therapists. Some health care professionals (such as junior medical staff, generalist nurses and some allied health staff) may not feel it is their role to be giving detailed prognostic or end-of-life information to patients. However, the general principles in these guidelines are relevant for all health care professionals interacting with this patient population and their families at home or in hospital.
Discussions about prognosis and end-of-life issues can be conceptualised as a process of ongoing conversation over time, rather than a single discussion.8 Hence, the material in these guidelines is best covered with patients and caregivers over multiple consultations, depending on the clinical circumstances and information needs of the patient and caregivers. The response of patients and their caregivers will dictate the pace and volume of material to be discussed. Some of the issues (eg, likely symptoms and how they are treated, what will happen close to death) will be covered in different ways, or not at all, in the initial conversation compared with when the symptoms start appearing or accelerating. In the first instance, they can be discussed in general terms, and later in specific terms. It is important to give the patient and family an opportunity to have their information needs met regarding these topics, but at the same time to prevent overloading the patient and caregiver both informationally and emotionally.
The guidelines assume a relatively high level of knowledge, generic communication skills, and judgement. Maximum benefit in applying the guidelines by trainees or junior health care professionals may be facilitated by attending a basic communications skills workshop.9
Background information regarding some recommendations in the guidelines is given in the text. The recommendations themselves are presented in Boxes 1 to 16. Boxes 1 to 5 are relevant to all discussions of prognosis and end-of-life issues, and address the following topics: timing of the discussion, preparation for the discussion, physical and social setting, how to discuss prognosis and end-of-life issues, and general strategies to facilitate hope and coping. Boxes 6 to 16 are specific to certain content areas or issues. Useful phrases are given where applicable. It is suggested that you choose a phrase that fits your style and with which you feel comfortable. Some of the phrases can be adapted for your own use.
The recommendations detailed in Boxes 1 to 16 are graded as follows:
DS = descriptive study or studies;
CG = existing consensus guidelines;
EO = published expert opinion; and
RGP = recommended good practice based on the clinical and consumer consensus opinion of the expert advisory group and chief investigators.
The systematic literature review which informed these guidelines was limited to studies of patients, and/or their caregivers, with a known progressive life-limiting illness. The recommendations or suggested phrases may not be applicable to patients with debilitating chronic illnesses with a life expectancy of more than 2 years, patients having treatment with curative intent, and those in whom intensive care treatment would still have a reasonable chance of being effective. Likewise, end-of-life discussions with well elderly people, those in aged care facilities with uncertain disease trajectories, and patients in the early stages of dementia are beyond the scope of these guidelines.
All the articles included in the systematic review were written in English, and most of the patient and caregiver participants were from Anglo-Saxon backgrounds. Hence, some caution is required when interpreting these guidelines for patients from non-Anglo-Saxon backgrounds.
Discussing prognosis and end-of-life issues is difficult. Research has identified deficiencies in communication between health care professionals and patients regarding prognosis and end-of-life issues.10 Many health care professionals are uncomfortable discussing these topics.11,12 Reasons include perceived lack of training, stress, no time to attend to the patient's emotional needs, fear of upsetting the patient, and a feeling of inadequacy or hopelessness regarding the unavailability of further curative treatment.13-17 Such avoidance can lead to poorer patient satisfaction and psychological morbidity.18,19 If information provision is not honest and detailed, patients may perceive that health care professionals are withholding potentially frightening information.20,21 When cancer patients are not adequately informed of their prognosis, they are more likely to choose aggressive anticancer treatments22 and make decisions that they later regret.23 Therefore, it is in the patient's best interests to offer such information rather than withhold it in an attempt to protect the patient from losing hope or being upset. Although many health care professionals believe introducing the topic will unnecessarily upset the patient and dispel any hope, evidence suggests that patients can engage in such discussions with minimal stress24 and maintain a sense of hope even when the prognosis is poor.8 In addition, awareness of prognosis is associated with greater satisfaction with care and lower depression levels in patients.18,19
Most patients from Western countries prefer some information regarding prognosis when first diagnosed with a life-limiting illness.25,30,31 However, this information can be difficult to comprehend at this time,32 and one study indicated that patients found the information distressing if they had not asked for it.25 In one study, most palliative care patient and caregiver participants felt that it was appropriate and important for the doctor or nurse to make this an accessible topic, because they may find it difficult to raise it themselves.15 Box 1 gives recommendations for when the health care professional should consider raising the topic, apart from when the patient initiates the discussion (eg, by asking a question).
If the consultation is planned, it is important to provide consistent, accurate information by reading clinical records, speaking with health care professionals, and researching the literature to obtain up-to-date knowledge.17,28,33-35 It is helpful for health care professionals to be aware of their own feelings of grief, anxiety or guilt (including fears about holding the discussion), particularly if they have known the patient for some time. These are normal responses, and self-acknowledgement may avoid projecting feelings or biases onto the patient or caregiver.36
Good interaction between the patient and health care professional is fundamental to effective communication,43 and patients facing a progressive life-limiting illness place great emphasis on the relationship with their health care professional.2 Most patients prefer the information to come from a confident expert (ie, not delegated to the most junior person on the team).1,25,37-40,44 While having a long-term relationship is important for many patients in discussing prognostic and end-of-life issues, even the first consultation may be a time when some issues can be comfortably explored.15,35,38,45
Although it may be beneficial to provide support and ensure continuity of care by having another health care professional present,37,44,46 some patients are not in favour of this approach.31 Some research suggests that some patients wish to receive information from a different health care professional or another person (eg, priest),15 indicating that the health care professional needs to negotiate who delivers the information. Most but not all patients want to have a family member or friend with them.25,34,35 This should be ascertained.
Trust can be built by using an empathic, patient-centred style.41 Good generic communication skills involve using eye contact (if culturally appropriate); using appropriate body language such as an open posture; sitting close to the patient; active listening such as nodding or making noises of agreement or encouragement to indicate understanding; reflecting empathically; and showing compassion by using a warm, caring, and respectful manner.1,2,25,37,39,44,47,49 An empathic, patient-centred style also involves using open-ended questions with an emotional content. This approach has been shown to elicit greater expression of feelings compared with the use of closed questions.71 These open-ended questions can be asked before discussing prognosis, palliative care or end-of-life issues so that the patient's concerns, goals and values can be determined.72 It can also help create an atmosphere where the patient is treated as a "whole person" (as well as the family) and feels that the health care professional is interested in and sensitive to their problems and feelings.73
Establishing the patient's and caregiver's understanding of the situation helps establish a common ground from which to start the discussion.74 In initial consultations, the health care professional could elicit patient understanding when obtaining the patient's illness history (eg, by allowing them to tell their story and asking focussed or open-directive questions to clarify certain points).73 When the patient is well known to the health care professional, it may be more appropriate to consider summarising what has happened with their illness so far, before moving on to the current situation and clarifying the patient's understanding.
There is evidence that doctors are not good at predicting patients' information preferences, and tend to underestimate patients' need for information.75-77 Doctors frequently perceive that the patient has a greater awareness or understanding than the patient reports.22,77-81 Patients with cancer and other life-limiting illnesses frequently have misunderstandings about their illness, prognosis and goals of treatment.22,77,79,80 Some of the reasons may be to do with patients' tendencies to forget 40%–50% of the information given to them by doctors;82 they may find it difficult to absorb information if they are distressed; they may not understand the language or jargon used, particularly if the information is not communicated clearly;83,84 and they may deny or subconsciously block-out information that they find unacceptable80,85 as a way of coping with their illness.86 Additionally, doctors may withhold information, particularly if there are family requests for information to be imparted through the family rather than doctor to patient, as is the case in some cultures.55,57
Many studies suggest that most patients (at least from Western countries) have high information needs concerning prognosis and life expectancy;2,15,25,31,39,60,87-90 however, a sizable minority do not want full disclosure.31 Many patients and caregivers want information about the likely illness trajectory, treatment options and what they may accomplish, life expectancy, likely future symptoms, and what to expect around the time of death.8,25,60,61,88,90-93 However, patients may experience conflict between wanting to know and fearing bad news.61
Although most patients have high information needs, the different types of prognostic and end-of-life information may be preferred over a series of consultations or at different times, depending on the context and the patient's stage of illness.26 Evidence suggests that patients may want less prognostic detail about their illness as they become sicker, while caregivers may want more information, especially as death approaches.25,52 Younger and more educated patients may want more detailed information.28,31,49,87,94 Some patients may never want some types of information. For example, while most patients in Western cultures want to be informed that their lifespan will be limited by their illness, some patients do not want to be given the likely timeframe.1,26,42,61,95 Patients from some cultural backgrounds may prefer non-disclosure, or disclosure negotiated through the family, when life expectancy is short.55,57
It is not possible to make assumptions about individuals' information needs based on their demographic characteristics or cultural background. It is important to tailor information to individual needs, as preferences for the amount, type and timing of information vary.
Many health care professionals have difficulty in disclosing a limited life expectancy while maintaining the patient's hope, yet patients, caregivers and health care professionals have identified hope as an integral component of prognostic and end-of-life discussions.2,25,42,60,61,63,97,98 These studies also emphasise the importance of balancing honesty with hope and empathy. There are different views of what constitutes an honest approach. Some studies of patients with advanced illness have found that accurate information is equated with honesty, but it was important that this was not combined with bluntness or too much hard factual or detailed information.42,98 Others have defined honesty as a straightforward or direct approach.2,25
Several studies have addressed the construct of hope within the end-of-life context. Hope can take a variety of forms, ranging from the hope of a miracle cure to the hope of a peaceful death, and patients may simultaneously hope for a cure as well as acknowledge the terminal nature of the illness. Some patients may avoid enquiring about progress or symptoms in order to maintain hope for the future.42,91 Patients have reported obtaining a sense of hope from relationships, beliefs and faith, maintaining dignity, finding inner peace, thinking about meaningful events in their lives, having symptom control and reassurance that pain will be controlled, and enjoying a sense of humour, including occasional humour from the health care professional.31,60 In addition, studies have found that hope can be maintained by having a health care professional who is knowledgeable and offers to answer all of the patient's questions, offers hope for new developments in treatment, treats the patient as a "whole person", acknowledges difficulties in giving prognostic estimates, presents information about palliative care at a rate that the patient can assimilate, and respects alternative treatments.25,31,99,100
In the setting of an advanced progressive life-limiting illness, the main goals of disease-specific treatments are to improve the length and quality of life. It is important that the patient understands that cure is not a treatment goal, but that there may be treatments that can slow the progression of the disease or provide symptom relief. Discussion should be informed and focus on the balance between the potential effectiveness of treatments on prolonging life versus the side effects. It is important that the patient has the opportunity to be involved in the decision-making process, according to their desired level of involvement.46
When patients hear news of lack of treatment response, clinicians should be prepared for a wide range of emotions such as sadness, anger or despair.109 It is important that such news be given in an empathic way, and the continued availability of supportive and symptomatic care is emphasised.
The World Health Organization defines palliative care as:
an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.112
A "palliative approach" is an approach to care used by primary health care services and providers in accordance with the definition of palliative care outlined above.113 "Specialist palliative care services" refers to multidisciplinary health care services whose "substantive work is with patients who have a life limiting progressive illness".110 Specialist palliative care services are not available in all parts of Australia, especially in rural areas. In addition, not all patients with advanced progressive life-limiting illnesses require specialist palliative care services — some may be cared for most appropriately by their primary care providers.113 For patients with more complex palliative care needs (eg, those requiring specialist assessment or ongoing input for management of physical, psychological, spiritual or social issues), referral to specialist palliative care services, where available, is appropriate at any time from the first diagnosis of a progressive life-limiting illness. Patients may only need to see a specialist palliative care service initially for a limited time to assist in the management of a particular problem, such as uncontrolled pain. As the patient's illness progresses, he or she may need referral to community palliative care services or to an inpatient palliative care unit for terminal care.
In comparison to conventional care, specialist palliative care services improve patient and caregiver satisfaction, provide better pain and symptom control, reduce caregiver anxiety, and increase the likelihood of the patient being cared for during the terminal phase in their place of choice.114 However, referral to specialist palliative care services may evoke fears of impending death, helplessness and abandonment in the patient if this is not communicated sensitively and effectively by the health care team.
Various approaches to phrasing life expectancy have been reported in the context of an advanced progressive life-limiting illness: days versus weeks versus months, likelihood of being alive for certain events, rough range, and probabilistic (eg, 10% and 50% survival). However, whether one approach is superior to others has not been examined. Consistent findings in the literature are that it is important to avoid being exact with timeframes unless in the final days of life, and to explain the unreliability of making survival predictions. However, research has found that patients may prefer being asked if they would like a rough idea of their life expectancy.15,42 Two studies have found that patients may prefer words or numbers to explain the prognosis instead of descriptive tools such as pie charts and graphs.26,35
The possibility of uncontrolled pain in the future concerns many people, so it is important to offer reassurance that pain can be controlled in the vast majority.8,25,49,61
It is not clear whether it is appropriate for the health care professional to discuss uncommon but potentially problematic symptoms (eg, seizures and suffocation, or bleeding) and what to do should these occur.8,20,26,53,88,101 The benefits (of forewarning a patient or caregiver and having procedures in place) versus the potential harm (of worrying the patient or caregiver to a point of unnecessary distress about the possibility of the situation, albeit unlikely, occurring) need to be considered. Caregivers may need more specific information than the patient about how to care for the patient as the illness progresses25,53,119 and how to get help when complications arise at home.
Advance care planning refers to discussion of treatment decisions and choices and goals of care at the end of life, and the patient's wishes for medical care in the future if they are no longer able to be involved in the discussion. The possible benefits of advance care planning are that it may help patients ensure that, when they are no longer able to make decisions for themselves, they receive the kind of treatment and care they would prefer. In addition, advance care planning may relieve the burden of decision making for caregivers, and facilitate open communication between patients and caregivers.120,125,129
An advance directive is a statement (either made orally or in writing) by a person that outlines their wishes for future health and personal care. The directive generally becomes effective when the person is unable to make his or her own decisions. Advance directives130 are legally binding in Australia, either at common law or under statutes. The Australian Capital Territory, Northern Territory, Queensland, South Australia and Victoria have statutory schemes for advance directives. In the other states, the law of advance directives is governed by common law. Although the evidence suggests that people are willing to write such documents,131 they may have little effect on treatment decisions, including decisions to resuscitate.132-134
In some jurisdictions, a person can make an enduring medical power of attorney, or appoint someone as an enduring guardian, whereby a family member or other trusted person is appointed to make health decisions on the person's behalf should the person lose the mental capacity to make his or her own decisions. Even in the absence of such an appointment, all Australian jurisdictions have guardianship arrangements that recognise the authority of people close to the patient to make medical treatment decisions on that person's behalf in the event of lack of decision-making capacity. Including these substitute decisionmakers in discussions has been shown to improve the effectiveness of advance care planning.135,136
In-depth discussion of advance directives and enduring medical powers of attorney are beyond the scope of these guidelines. The status of advance directives and the status and responsibilities of representatives of incompetent patients is complex and varies from jurisdiction to jurisdiction. Legal advice may need to be sought.
It is important for health care providers to ensure that cardiopulmonary resuscitation (CPR) is not attempted inappropriately in someone who is dying an expected death, by documenting "do not attempt CPR" in the medical records.122,128,137,138 If ambulance transfers are being arranged, paramedics will also need to be informed in the manner required by the local ambulance service (check local policies and procedures).
There is considerable debate about the appropriateness of discussing CPR orders with dying patients. Some guidelines recommend that CPR should always be discussed with the patient (or family if the patient is incompetent).146 Other guidelines state that there is no ethical obligation either to perform or to discuss CPR when it is judged to be clinically futile.144,147 There is no common law requirement in Australia to attempt treatment, even life-prolonging treatment, which is judged to be of insufficient therapeutic benefit ("clinically futile") or is overly burdensome.44,127,148,149 However, the use of the terms "clinical futility" and "medical futility" is also controversial, as it has been argued that such terms are not capable of objective definition and may give rise to disputes between the treatment team and the patient's family.150 There is little research evidence to guide policies about whether it is desirable to discuss "no CPR" orders with dying patients before documentation. One Australian study of patients with cancer provides support from the patient's viewpoint that CPR is not preferable when death is imminent and inevitable.151 Another study found that some patients prefer to defer the timing of the decision to the doctor and do not wish to discuss the topic.152
Decisions about whether to offer or provide CPR should be made on an individual basis on the grounds of likely benefit versus likely burden. Nevertheless, in situations where it is clear that the patient is dying from a far-advanced progressive life-limiting illness and the clinician has decided that CPR is not to be performed on the basis of clinical futility (ie, negligible chance of survival with or without CPR and burdens of CPR far outweigh the benefits), then it should not be presented to patients or their caregivers as if it were an appropriate treatment option.153 This does not mean that it should not be discussed (such discussions may still be an important part of terminal care), but mostly in these circumstances patients and families should not be asked to make a decision regarding CPR.
Specific discussions about CPR are recommended before documenting "no CPR" orders in the following circumstances:
when the illness trajectory is uncertain (ie, CPR may not be clinically futile, for example a patient at an earlier stage of their illness or if a potentially reversible complication of treatment occurs);
in response to a patient or caregiver request or question about CPR; and
when the patient has made it clear that he or she wishes to be informed of all decisions made about their medical care.
There are other circumstances where the responsible clinician may decide that it is not appropriate to have a specific discussion about CPR with a dying patient or the family, before documenting a "no CPR' order in the medical record, including:
the patient is aware that he or she is dying and has already expressed a wish for care that is aimed at comfort rather than prolonging life;
the patient prefers not to discuss end-of-life care and requests that the doctor or caregiver make any decisions relating to his or her health care; and
the patient is clearly in the terminal phase of a progressive life-limiting illness and the doctor thinks that the harm of the discussion may outweigh the benefits.154,155
However, not discussing "no CPR" orders with patients or caregivers in this latter circumstance may be open to contest and requires very careful consideration. Specific recommendations about whether to discuss CPR before documenting "no CPR" orders in such circumstances are beyond the scope of these guidelines. Health care professionals should refer to relevant professional and institutional codes of ethics and policies, and to relevant judgments and statutory law, for advice on this matter.
Box 12 gives recommendations for communication about CPR should the clinician decide that such a discussion is appropriate. If discussing CPR, it is important to check that patients are aware of the poor success rate of CPR in patients with their condition. When patients and families are made aware of the facts, they are less likely to request CPR.156
When it is judged inappropriate to discuss "no CPR" orders with a particular patient or the family, the reason it has not been specifically discussed should be documented in the patient's medical records.153
Once the patient is approaching the terminal phase of the illness, or earlier depending on the patient's or caregiver's information need, it is important to explore specific issues related to the process of death and dying, as many patients and caregivers hold misconceptions about what is likely to happen, and may hold unnecessary fears.1,8 Some studies show that patients and caregivers may have differing information needs as the patient's illness progresses.8,25,53 Caregivers may prefer more detailed information about the dying process, potential complications and immediate post-death arrangements than patients.8,25,53
The information preferences and autonomy of the patient are paramount, yet it is vital to include family members in discussions surrounding the transition from curative to palliative care.163 The difficulty of negotiating the concerns of family members while also respecting the patient's wellbeing and autonomy adds complexity to the task of discussing prognosis and end-of-life issues in a palliative care setting. There is also the potential complicating factor of requests by family members (often a culturally related issue, as discussed above) to withhold information from the patient. Various approaches have been reported in studies of mainly health care professionals' views and in the empirical literature regarding these issues. No studies have been conducted to evaluate benefits of one approach over another. As for all issues, it is important to make repeated efforts to help family members understand the patient's condition.145 These guidelines present various ways of addressing these issues based on research, expert opinion and other guidelines. A combination of approaches, or different approaches depending on the circumstances, may be appropriate.
It is important to address conflict rather than avoid it, so that patients and families have the opportunity to share in decision making and be satisfied with care. As for all sections in these guidelines, the use of empathy is important in helping patients and family members feel respected and understood. Research shows that patients who feel understood and listened to are more prepared to accept their doctor's recommendation.164
In the context of palliative care, denial may be defined as "an unconscious mechanism aimed at negating a disease-oriented threat to the integrity of personhood and daily life".165 It may involve avoidance of reality. The use of denial by patients is not always counterproductive to their wellbeing. It can reduce psychological distress and help them absorb the consequences of life-threatening information in a manageable and self-determined timeframe.165 It is not problematic if it does not affect the patient's ability and desire to seek and accept help.165 However, patients or family members may request medically futile treatments because of refusal to accept the diagnosis or prognosis of a life-limiting illness. Such treatments may have side effects that interfere with quality of life and the completion of unfinished business when time is limited. In this case, denial is a problem that the health care professional should address.
Patient requests for medically futile treatments may represent denial or a lack of prognostic understanding. It is important to determine the reason for the request before giving new information.
At the end of the discussion, it is important to reflect on how the discussion went and how it could be improved next time, as well as recognising the emotional impact of the discussion on oneself and the need for self-care. Discussing prognosis and end-of-life issues in patients with advanced life-limiting illnesses is not easy. Eliciting patients' and caregivers' emotional concerns and responding empathically involves giving of oneself emotionally, and can take its toll. Not only do health care professionals have to deal with the patient's emotions and concerns, but potentially their own feelings of failure, helplessness and frustration arising from advancing illness, which may be compounded by stresses in their private lives.166,167 If health care professionals are to be encouraged to discuss prognosis and end-of-life issues with people who have advanced life-limiting illnesses, it is important to acknowledge the need for support and self-care of the health care professionals. Such support includes debriefing with colleagues, encouraging the development of strong collaborative team relationships, and providing communication skills training.74
1 Timing of discussion
2 Preparation for the discussion
3 Physical and social setting
"Some people like to bring someone who is close to them to the appointment."
"Is there anyone else you would like to be here with you while we talk?"
"If there are things that you might prefer to discuss with me alone I'd be happy to organise that."
If planning a discussion: "Are you comfortable having another member of my team present when we discuss your results?"
"I would be very happy to discuss . . . with you. We won't have enough time today to address that properly. Is it all right if I come back [state when]?"
4 How to discuss prognosis and end-of-life issues
"This has been a tough time for you and your family, and you have faced the challenges of this illness with great courage."
"Do you have any questions or other concerns?"
"Some people are worried about things that may or may not happen in the future. It can help to talk about this."
"I am very happy to talk to you about any concerns or questions you have about this now or later. Is there anything you would like to ask me today about this?"
"Often people with conditions like yours have got a lot of questions that are sometimes scary, or sometimes they're not certain if they want to know the answer. Often the thing they fear or believe is worse than how it really is. So if there's anything you want to know, feel free to ask me and I'll answer as best as I can."
"What is your understanding of your health situation and what is likely to happen?"
"Do you have thoughts about where things are going with your illness?"
"Can you summarise to me what the doctors have explained to you about your illness? Do you think, or did they mention, the illness may affect your health in the future?"
"I am very happy to answer that, but do you mind telling me what made you ask that question?"
"What worries you most about . . . [eg, what may happen]?"
"What frightens you about all of this?"
"What do you hope for the future?"
"How much would you like to know?"
"Some people like to know everything that is going on with them and what may happen in the future, others prefer not to know too many details. What do you prefer?"
"I am happy to give you as much information as I can based on what you want to know."
"It is also important for [name of caregiver] to have the opportunity to find out the things [he/she] needs to know to be able to take care of you. Are you happy for me to speak with [him/her] about your medical condition?"
"Is it OK with you if I tell your [relative/caregiver] what I've discussed with you?"
"Often [daughters/sons] like to ask detailed questions. Is it okay if I answer your [son's/daughter's] questions? Is there anything I should not discuss?"
"How do you think [patient] is going?"
"What concerns do you have at the moment?"
"What do you understand is likely to happen to [name of patient]?"
"What information will best help you to cope with your caregiving role?"
"Can you please help me to understand what I need to know about your beliefs and practices to take the best care of you?"54
"Is there someone else you would like me to involve or speak to?"
"Every person is different. I can only tell you what usually happens to people in your situation, not exactly what will happen to you."
"I know that often people expect doctors to know what is going to happen, but in truth we can often only take educated guesses and can often be quite wrong about what the future holds, and especially how long it is. What we can be sure about is . . . and what we don't know for sure is . . ."
"A lot of people find it hard not knowing what will happen next or when. Is this something you find difficult?"
"I want to talk about three things today: the test results; what this will mean for you; and the treatment that is possible. And you might have some things to discuss too. Now, the test results . . . Do you have any questions so far?"
"Doctors sometimes forget and use words that may not be understood. Please stop me if I am doing this."
"It sounds like this information is different from what you expected, and I think it would be upsetting for anyone."58
"How are you feeling about what we have discussed?"
"These are important issues. Would you like to speak to a member of the hospital support staff such as a pastoral caregiver?"
". . . is clearly really important to you. Would it be [useful/helpful] to explore these issues further? Who might be the right person you can do this with?"
"Would you like to talk to someone about spiritual matters?"
"What are the things in life that give you strength and sustain you?"
"Are your beliefs being challenged by your current experiences?"
"Have I given you the information you need [at this point/so far]?"
"To make sure we are on the same wavelength, I want to check your understanding of what we have discussed."
"Is there anything I've said that you'd like me to go over?"
"We've spoken about an awful lot just now. It might be useful to summarise what we've said . . . Is there anything from that that you don't understand or want me to go over again?"
"Do you feel you've understood everything that you've been told? Is there anything you would like me to go over again? After all, some of this is pretty technical."
"Is there anything else you would like to discuss?"
"Is there anything from our previous discussions that you would like to revisit?"
"Don't hesitate to ask me again about any of the issues we have discussed today."
"So, we've talked about . . . at length and also talked quickly about . . . Is that your recollection as well?"
5 General strategies to facilitate hope and coping during prognostic and end-of-life discussions
"Our team [or whoever applicable] will do our best to support you throughout this illness."
"I [or our team or whoever applicable] will do whatever [I/we] can to assist you in whatever lies ahead for you."
If the patient is no longer able to come for outpatient follow-up:
"I will be available to discuss your care with your [GP/community nurse/palliative care team] even if you are not able to come and see me in the clinic."
"We've been talking about some treatments that are really not going to be effective now and that we don't recommend you use. But there are a lot of other things we can still do to help and support you and make sure you are as comfortable as possible."41
"Although this type of chemotherapy has not been useful, there are other treatments we can use to make you more comfortable."
"The aim of treatment is changing more towards maximising your function and comfort."
"I cannot give you any specific treatment to make this illness go away, but there is a lot we can offer to help you cope with it."
"We have a lot of ways to relieve [pain/nausea/dyspnoea] and other symptoms."
"We will do everything we can to ensure you are as comfortable as possible."
"We cannot promise that you will have no pain. However, we can control almost all of the pain almost all of the time."
"What are your most important [hopes/expectations] about the future?"
"As you think about the future and that you may not have a very long time to live, what is most important to you? Are there any aspects of your life that you want to attend to?"51
"Have you any unfinished business?"
"What are the things you most want to invest your time and energy in?"
"What are the things you want to do in the time you have?"
"Is there any particular event that you are looking forward to?"
"Some of my patients tell me it helps to try to take one day at a time, and live for the moment as much as possible."
"You will have good days and bad days."
"Many people find that it helps them to cope by trying to maintain some [sense of normality/normal life] or having a routine."
"Be kind to yourself and do the fun things — it doesn't have to be all about your illness."
"I have no problem with you exploring alternative treatments. They are not my area of expertise. However, if the treatments were a magic bullet, we would be aware and we would also use them. I know they are usually expensive."
"Everything has benefits and burdens. What are you hoping this therapy will achieve?"
"You must do whatever you feel is important, but remember that none of these things have been proven to work (or we would be using them) and many are very expensive."
6 Commencing or changing disease-specific treatments
7 Cessation of disease-specific treatments
8 Introducing specialist palliative care services
9 Discussing life expectancy
10 Discussing future symptoms and symptom management
11 Advance care planning
12 "No CPR" orders
13 Discussing the process of death and dying
14 Requests by family members to withhold prognostic or end-of-life information from the patient
15 Dealing with conflicts (eg, differing family opinions, conflicts between doctor and patient or doctor, patient and caregiver)
16 Dealing with denial or expectations that are not consistent with clinical evidence (eg, requests for medically futile treatments)
"What is your understanding of what is likely to happen with your illness and future treatment options?"
"While we are hoping that things will go well with treatment . . . or be possible for . . . to occur, if by some chance you didn't get better, what would be the most important things that you would want or need to do while you are still able to?"
"I wish too that this disease would get better. If we cannot make that happen, what other shorter-term things would you like to achieve?"
"Have you thought about what might happen if things don't go as you wish? Sometimes having a plan that prepares you for the worst makes it easier to focus on what you hope for most."41
"I know you are hoping that the treatment will work well, but I feel it is important to talk about 'what if'."
"I can see that you really want to get better and I would like that too. Are there ever times when you have darker moments and don't feel that things are going so well? Can you tell me what is on your mind during those times?"
"That would be wonderful if . . . were to occur, wouldn't it? Are there times when it doesn't seem so sure? Would you like to talk about that?"
"Sometimes it helps to talk these difficult things through with another experienced doctor. Would you like me or your GP to ask for a second opinion?"
These recommendations can also be applied to those in Box 6.
Endorsing organisations
Australasian Society of HIV Medicine
Australian and New Zealand Society of Palliative Medicine
Australasian Chapter of Palliative Medicine, Royal Australasian College of Physicians
Australian College of Rural and Remote Medicine
Australian General Practice Network
Australian Society of Geriatric Medicine
Cancer Voices Australia
Cardiac Society of Australia and New Zealand
Clinical Oncological Society of Australia
Motor Neurone Disease Association of Australia
Palliative Care Australia
Palliative Care Nurses Australia
Royal Australian College of General Practitioners
Royal College of Nursing, Australia
Thoracic Society of Australia and New Zealand


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Warrior (Final Fantasy)
this wiki
Specializing in combat, the Warrior has high attack and defense and can wield any weapon.
The Warrior (せんし, Senshi?), also known as the Fighter, is the most versatile member of the Warriors of Light in the original Final Fantasy. He has access to the best weapons and armor available. He also has impressive Strength and Stamina and the most HP out of any character class. His main drawback is his dependence on powerful equipment, making him a rather expensive class to maintain.
The Fighter's sprite was originally depicted with red hair in the NES version, partially due to the palette limitations of the hardware. He was depicted with dishwater blond hair in the WonderSwan Color version and has remained as such in all subsequent releases. His artwork, as the Warrior of Light (ウォリアー・オブ・ライト, Wōria Obu Raito?), depicts him of having dark blue armor and horns on his helmet.
In the Final Fantasy: Memory of Heroes official novelization, the Fighter's name is given as Zest (ゼスト, Zesuto?). He leads the Warriors of Light and bears the Fire Crystal. He has short red hair and is righteous and courageous in nature. Honest, straightforward and prone to tunnel vision, unlike the other three, he has no memories of his past.
|Available equipment
|Battle Axe - Great Axe - Light Axe - Mythril Axe - Hammer - Mythril Hammer - Staff - Power Staff - Crosier - Knife - Dagger - Mythril Knife - Rapier - Scimitar - Saber - Falchion - Broadsword - Rune Blade - Werebane - Coral Sword - Wyrmkiller - Long Sword - Claymore - Mythril Sword - Flame Sword - Ice Brand - Sunblade - Masamune
|Clothes - Leather Armor - Chain Mail - Iron Armor - Knight's Armor - Mythril Mail - Flame Mail - Ice Armor - Copper Armlet - Silver Armlet - Ruby Armlet - Diamond Armlet
|Leather Shield - Iron Shield - Buckler - Mythril Shield - Flame Shield - Ice Shield - Aegis Shield - Protect Cloak
|Leather Cap - Helm - Great Helm - Mythril Helm - Ribbon
|Leather Gloves - Bronze Gloves - Steel Gloves - Mythril Gloves - Giant's Gloves - Protect Ring
After completing the Citadel of Trials, Bahamut, the Dragon King, upgrades him to the rank of Knight (ナイト, Naito?). As a Knight, he is able to equip nearly every weapon and armor and is able to cast low-level White Magic spells. In all versions, it is recommended to promote the Fighter sooner than later, as being upgraded too late runs the risk of decreased spell charges (MP in later editions). The costume looks exactly the same except inverted colors and a head ornament and a cape.
|Available equipment and magic
|All Warrior weapons, Thor's Hammer, Cat Claws, Venom Blade, Vorpal Sword, Defender, Excalibur
|All Warrior armor, Diamond Armor, Dragon Mail
|All Warrior shields, Diamond Shield
|All Warrior helms, Healing Helm, Diamond Helm
|All Warrior gloves, Diamond Gloves - Gauntlets - Giant's Gloves
|White Magic
|Cure - Protect - Blink - NulShock - Invis - Blindna - Silence - NulBlaze - Cura
Name originsEdit
In the Dawn of Souls and subsequent remakes, there are ten optional auto-names for the different character classes. Each name is a reference to another character or location name in the Final Fantasy series.
The ten names for the Warrior class are:
- Argus - Location in Final Fantasy III.
- Alus - Character in Final Fantasy III.
- Banon - Character in Final Fantasy VI.
- Baron - Location in Final Fantasy IV.
- Desh - Character in Final Fantasy III.
- Doma - Location in Final Fantasy VI.
- Giott - Character in Final Fantasy IV.
- Leo - Character in Final Fantasy VI.
- Sasune - Location in Final Fantasy III.
- Zeza - Character in Final Fantasy V.
In addition, the name Cloud from Final Fantasy VII was used in screenshots for the Final Fantasy Origins manual.
Other appearancesEdit
Triple TriadEdit
The Warrior has a Triple Triad card in the version playable via Final Fantasy Portal App.
Non-Final Fantasy guest appearancesEdit
Monster Hunter 4 UltimateEdit
As part of a collaboration between Capcom and Square Enix, Tetsuya Nomura was asked to design various new armor types for the playable characters, and their feline companions.
For Palico Support Nomura created the Purrity Palico Armor set, which is based on the Warrior of Light.
- The sprites of the Knight form of this job from the WonderSwan Color version onwards look similar to Cecil Harvey's sprites as a Paladin in Final Fantasy IV except with a different head ornament.
- In the original NES version, at the party selection screen, the Fighter appears along with the Thief, the Black Belt and the Red Mage as the default party, making them the first characters to be seen in the Final Fantasy series.


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The performance of the forwards against Tonga in the opening match of the Rugby World Cup has left me a little worried.
The concern came in the second half - the moment we lost Tony Woodcock and Brad Thorn our scrum packed up. I always say good players have a "bonus". It means you've got a job to do, and you do your jobs, and what comes above that is a bonus.
I think we had too many forwards who weren't doing their job - they were looking for "plums" or "bonuses" before they did their job.
I thought the backs all played well, except perhaps for Toeava. Yet there weren't too many forwards who you could mark better than five (out of 10).
The biggest worry for me is Thorn. Why did they take him off against Tonga? He's the one player who needs a lot of rugby, he's probably not playing as well as he did last year, when he was the super giant, and he's struggling to get back to that form.
I said last week that if the whole team plays well, we'll win the World Cup. Well against Tonga the backs played well and the forwards struggled. On that performance, we've got to improve upfront.
Sonny Bill Williams was one of the standouts and you have to give him a lot of praise. He was under the cosh and he really showed us what he can do. I bet that made the selectors pleased, because they've now got a quality backup if someone gets injured.
The greatest excitement of the last week is around Richie McCaw. That great, great player is going to be the first New Zealander to get 100 tests and I think that's tremendous.
It's a remarkable achievement and I'm pleased he'll be the first to reach 100 because he deserves it and it's history - we'll always remember that he was the first to play 100 tests.
I'm pleased with the team the selectors have picked to play Japan tomorrow night, and it's unfortunate that Dan Carter can't play, but Colin Slade will do terribly well.
Others are talking about rotation with the eight changes, but I'm not worried about that.
In a week's time Graham Henry and the selectors will pick their first-choice team to play France, and I expect Israel Dagg to be at fullback.
Israel is the form player and he is the guy who has to play the big games. You've got to pick him.
This week I just hope they play Brad Thorn for 80 minutes. And that Richie has a night to remember.


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Robo Smasher Gameplay – First Look HD
To Learn More About the Game, Check out our Robo Smasher Page.
Robo Smasher is a 3D arena style MMO shooter with a third person camera published by KRU Interactive – the same company behind Nexus: The Kingdom of the Winds, Dark Ages and Shattered Galaxy. Shoot down enemy robots and use nearby deadly blocks to destroy your enemies. The gameplay in Robo Smasher is most similar to that of BotS from Acclaim Games, which was shut down. One big issue with the game is that it has a low playerbase – so finding a game could be difficult. To learn more about Robo Smasher check out the official MMOHuts Robo Smasher page which includes a detailed review, tons of screenshots, and additional videos.
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Archaeologists believe they have found the long-lost remnants of HMS Beagle, the ship that took Charles Darwin on the voyage during which he formulated the theory of evolution.
The fate of the Beagle, which carried Darwin for five years from 1831, has remained a mystery for more than a century.
However, according to The Observer newspaper, archaeologists using ground-penetrating radar think they have found it buried under mud in an estuary in Essex, south-east England.
"I am quietly confident we have found the Beagle," marine archaeologist Robert Prescott, of Scotland's St Andrews University, said.
The radar image shows a ship similar in size to the Beagle - a 27-metre, 10-gun brig that was used as a customs boat after Darwin's voyage - lying under three metres of mud near a long-abandoned dock, Dr Prescott said.
"Most of the upper part of the ship may have gone, but we have the lower part and hull, and who knows what remnants of Darwin's trip may still lie down there," he said. "That is why this ship is so intriguing."
Detective work by Dr Prescott revealed that the Beagle was moored on the River Roach, where it intercepted smugglers bringing contraband through the Essex marshes. In 1870, the Beagle was auctioned to two scrap merchants.
Darwin's voyage took him on a lengthy surveying trip of South America and the Galapagos Islands.
From notes he took about differences in bird and animal life, Darwin concluded that species change gradually through a process of natural selection, which benefits those best adapted to their environment.
His ideas were published in 1859 in On the Origin of Species, attracting vehement criticism from Christians before eventually becoming accepted as one of the most important scientific theories in history.
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