This paper summarises the results of 327 Australian health care chaplains with regard to their involvement in issues concerning Not For Resuscitation (NFR)/Do Not Attempt Resuscitate (DNAR) decisions within the health care context. The findings indicate that 24% of the chaplains surveyed had provided some form of pastoral intervention directly to patients and/or their families dealing with issues concerning NFR/DNAR and that approximately 18% of chaplains had assisted clinical staff with issues concerning NFR/DNAR decisions. Differences of involvement between volunteer and staff chaplains are noted, as are the perspectives of chaplaincy informants regarding their role in relation to NFR/DNAR decisions. Some implications of this study with respect to chaplaincy training and practice are noted.

OBJECTIVE: To explore the role of health care chaplains in providing pastoral care to patients, their families and clinical staff considering decisions to withdraw life support. METHODS: Quantitative data were obtained retrospectively from a survey of 327 Australian health care chaplains (both staff and volunteer chaplains) to initially identify chaplaincy participation in withdrawal-of-life-support issues. Qualitative data were subsequently obtained by in-depth interview of 100 of the surveyed chaplains and thematically coded using the World Health Organization Pastoral Intervention (WHO-PI) codings to explore chaplains' roles. RESULTS: Over half the staff chaplains surveyed (57%) and over a quarter of the volunteer chaplains (28%) indicated that they had been involved with patients or their families in withdrawal-of-life-support decisions. Over a third of staff chaplains (37%) and 16% of volunteer chaplains had assisted clinical staff concerning withdrawal-of-life-support issues. The qualitative data revealed that chaplains were involved with patients, their families and clinical staff at all levels of pastoral intervention, including "pastoral assessment","pastoral ministry","pastoral counselling and education" and "pastoral ritual and worship". The specific nature of chaplaincy involvement varied considerably depending on the idiosyncratic issues faced by patients, families and clinical staff. These activities indicated that pastoral care could be provided for the support and benefit of patients, their families and clinical staff facing a complex bioethical issue. CONCLUSIONS: Through a variety of pastoral interventions, some chaplains (mostly staff chaplains) were involved in assisting patients, their families and clinical staff concerning withdrawal-of-life-support issues and thus helped ensure an holistic approach within the health care context. Given this involvement and the future potential benefit for patients, families and clinical staff, there is a need to develop continuing education and research on pastoral care and chaplaincy services.

This paper summarizes the experiences of 327 Australian health care chaplains with regard to their involvement in issues concerning pain control within the health care context. The findings indicate that approximately 60% of surveyed chaplains had provided some form of pastoral intervention directly to patients and/or their families dealing with issues concerning pain, and that approximately 36% of chaplains had assisted clinical staff with issues concerning patient pain. Differences of involvement between volunteer and staff chaplains are noted, as are the perspectives of chaplaincy informants regarding their role in relation to pain control. Some implications of this study with respect to chaplaincy utility and training are noted.

Organic mulch is a complex organic material that is typically populated with its own consortium of microorganisms. The organisms in mulch breakdown complex organics to soluble carbon, which can then be used by these and other microorganisms as an electron donor for treating RDX and HMX via reductive pathways. A bench-scale treatability study with organic mulch was conducted for the treatment of RDX- and HMX-contaminated groundwater obtained from a plume at the Pueblo Chemical Depot (PCD) in Pueblo, Colorado. The site-specific cleanup criteria of 0.55 ppb RDX and 602 ppb HMX were used as the logical goals of the study. Column flow-through tests were run to steady-state at the average site seepage velocity, using a 70%:30%(vol.:vol.) mulch:pea gravel packing to approach the formation's permeability. Significant results included:(1) Complete removal of 90 ppb influent RDX and 8 ppb influent HMX in steady-state mulch column effluent;(2) pseudo-first-order steady-state kinetic rate constant, k, of 0.20 to 0.27 h(-1) based on RDX data, using triplicate parallel column runs;(3) accumulation of reduced RDX intermediates in the steady-state column effluent at less than 2% of the influent RDX mass;(4) no binding of RDX to the column fill material; and (5) no leaching of RDX, HMX or reduction intermediates from the column fill material. The results of the bench-scale study will be used to design and implement a pilot-scale organic mulch/pea gravel permeable reactive barrier (PRB) at the site.

The sustainability of biodegradation reactions is of interest at Type 1 chlorinated solvent sites where monitored natural attenuation is being considered as a remedial alternative. Type 1 chlorinated solvent sites are sites undergoing reductive dechlorination where anthropogenic substrates (such as landfill leachate or fermentable organics in the waste materials) ferment to produce hydrogen, a key electron donor. A framework is provided that classifies Type 1 chlorinated solvent sites based on the relative amounts and the depletion rates of the electron donors and the electron acceptors (i.e., chlorinated solvents). Expressions are presented for estimating the total electron donor demand due to the presence of solvents and competing electron acceptors such as dissolved oxygen, nitrate, and sulfate. Finally, a database of 13 chlorinated solvent sites was analyzed to estimate the median and maximum mass discharge rate for dissolved oxygen, nitrate, and sulfate flowing into chlorinated solvent plumes. These values were then used to calculate the amount of hydrogen equivalents and potential for lost perchloroethylene (PCE) biodegradation represented by the inflow of these competing electron acceptors. The median and maximum mass of PCE biodegradation lost due to competing electron acceptors, assuming 100% efficiency, was 226 and 4621 kg year(-1), respectively.

The Monitoring and Remediation Optimization System (MAROS), a decision-support software, was developed to assist in formulating cost-effective ground water long-term monitoring plans. MAROS optimizes an existing ground water monitoring program using both temporal and spatial data analyses to determine the general monitoring system category and the locations and frequency of sampling for future compliance monitoring at the site. The objective of the MAROS optimization is to minimize monitoring locations in the sampling network and reduce sampling frequency without significant loss of information, ensuring adequate future characterization of the contaminant plume. The interpretive trend analysis approach recommends the general monitoring system category for a site based on plume stability and site-specific hydrogeologic information. Plume stability is characterized using primary lines of evidence (i.e., Mann-Kendall analysis and linear regression analysis) based on concentration trends, and secondary lines of evidence based on modeling results and empirical data. The sampling optimization approach, consisting of a two-dimensional spatial sampling reduction method (Delaunay method) and a temporal sampling analysis method (Modified CES method), provides detailed sampling location and frequency results. The Delaunay method is designed to identify and eliminate redundant sampling locations without causing significant information loss in characterizing the plume. The Modified CES method determines the optimal sampling frequency for a sampling location based on the direction, magnitude, and uncertainty in its concentration trend. MAROS addresses a variety of ground water contaminants (fuels, solvents, and metals), allows import of various data formats, and is designed for continual modification of long-term monitoring plans as the plume or site conditions change over time.

An innovative methodology for improving existing groundwater monitoring plans at small-scale sites is presented. The methodology consists of three stand-alone methods: a spatial redundancy reduction method, a well-siting method for adding new sampling locations, and a sampling frequency determination method. The spatial redundancy reduction method eliminates redundant wells through an optimization process that minimizes the errors in plume delineation and the average plume concentration estimation. The well-siting method locates possible new sampling points for an inadequately delineated plume via regression analysis of plume centerline concentrations and estimation of plume dispersivity values. The sampling frequency determination method recommends the future frequency of sampling for each sampling location based on the direction, magnitude, and uncertainty of the concentration trend derived from representative historical concentration data. Although the methodology is designed for small-scale sites, it can be easily adopted for large-scale site applications. The proposed methodology is applied to a small petroleum hydrocarbon-contaminated site with a network of 12 monitoring wells to demonstrate its effectiveness and validity.

Ethics is a hot topic these days. Home health care providers need not be ethicists, however they do need to be able to identify problems quickly, and know how to address them. This paper explores the ethical issues arising from a narrative analysis involving an advanced cancer patient receiving Total Parenteral Nutrition (TPN) at home. It shows how complicated it is today to make nutrition support decisions that would have been customary less than 30 years ago. For and against arguments of TPN for advanced cancer patients are reviewed. Ethical positions adopted by the medical and nursing professions are explored and contrasted. The importance of patient autonomy, within a holistic notion of care, including decisions incorporating quality of life, are affirmed, providing a challenge to monitoring the status quo in approaches to decision making.

OBJECTIVE: To identify key issues affecting women general practitioners in their professional and non-professional lives. DESIGN: A qualitative study using the Delphi technique, with three rounds of data provision circulated to each participant. Coding was used to ensure anonymity. SETTING AND PARTICIPANTS: The participants were a purposive sample of 40 women GPs drawn from all Australian States and Territories. The study was conducted between October 1996 and January 1997. OUTCOME MEASURES: Key issues affecting the professional and non-professional lives of women GPs. RESULTS: Some of the key professional issues for women GPs were job satisfaction, balancing work and personal life, autonomy, availability of flexible and part-time work and training, affordability of professional expenses, fair remuneration, and having a voice in decision-making. Key non-professional issues included self-care; time for relationships with a partner, children, family and friends; and time management to allow pursuit of non-medical interests. CONCLUSIONS: The conflicting demands made on women GPs diminish their job satisfaction and lead to stress and imbalance in their lives. Recommendations to ameliorate the problems for women GPs include appropriate training, policy formation, financial and other support, and a change in cultural expectations of women GPs by the community, the profession and governments.