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Recommended Citation: WWQA Ecosystems, 2023. White Paper – Embedding Lakes into the Global Sustainability Agenda. Published by UK Centre for Ecology & Hydrology on behalf of the United Nations Environment Programme coordinated World Water Quality Alliance Ecosystems Workstream. 22nd March 2023. ISBN: 978-1-906698-82-9. doi: 10.5281/zenodo.7752982. This White Paperhas been prepared by the World Water Quality Alliance (WWQA) Ecosystems Workstream as a contribution to the work of the United Nations Environment Programme (UNEP) in their implementation of United Nations Environment Assembly (UNEA) Resolution 3/10 on "Addressing water pollution to protect and restore water-related ecosystems" (UNEP/EA.3/Res.10). The White Paper has been prepared following a peer review process and represents the views of the authors. The White Paperdoes not necessarily reflect the opinions or policies of contributing organisations.&nbsp

Direct land-to-atmosphere carbon exchange has been the primary focus in previous studies of peatland disturbance and subsequent restoration. However, loss of carbon via the fluvial pathway is a significant term in peatland carbon budgets and requires consideration to assess the overall impact of restoration measures. This study aimed to determine the effect of peatland land management regime on aquatic carbon concentrations and fluxes in an area within the UK's largest tract of blanket bog, the Flow Country of northern Scotland. Three sub-catchments were selected to represent peatland land management types: non-drained, drained, and restoration (achieved through drain blocking and tree removal). Water samples were collected on a fortnightly basis from September 2008 to August 2010 at six sampling sites, one located upstream and one downstream within each sub-catchment. Concentrations of dissolved organic carbon (DOC) were significantly lower for the upstream non-drained sub-catchment compared to the drained sub-catchments, and there was considerable variation in the speciation of aquatic carbon (DOC, particulate organic carbon (POC), CO2, and CH4) across the monitoring sites, with dissolved gas concentrations inversely correlated with catchment area and thereby contributing considerably more to total aquatic carbon in the smaller headwater catchments. Significantly higher POC concentrations were observed in the restored sub-catchment most affected by tree removal. Aquatic carbon fluxes were highest from the drained catchments and lowest from the non-drained catchments at 23.5 and 7.9 g C m−2 yr−1, respectively, with variability between the upstream and downstream sites within each catchment being very low. It is clear from both the aquatic carbon concentration and flux data that drainage has had a profound impact on the hydrological and biogeochemical functioning of the peatland. In the restoration catchment, carbon export varied considerably, from 21.1 g C m−2 yr−1 at the upper site to 10.0 g C m−2 yr−1 at the lower site, largely due to differences in runoff generation. As a result of this hydrological variability, it is difficult to make definitive conclusions about the impact of restoration on carbon fluxes, and further monitoring is needed to corroborate the longer-term effects.

Estuaries receive and process a large amount of particulate organic carbon (POC) prior to its export into coastal waters. Studying the origin of this POC is key to understanding the fate of POC and the role of estuaries in the global carbon cycle. Here, we evaluated the concentrations of POC, as well as particulate organic nitrogen (PON), and used stable carbon and nitrogen isotopes to assess their sources across 13 contrasting British estuaries during five different sampling campaigns over 1 year. We found a high variability in POC and PON concentrations across the salinity gradient, reflecting inputs, and losses of organic material within the estuaries. Catchment land cover appeared to influence the contribution of POC to the total organic carbon flux from the estuary to coastal waters, with POC contributions >36% in estuaries draining catchments with a high percentage of urban/suburban land, and

In the UK most large reservoirs constructed for public water supply are in upland areas and situated in catchments that contain at least some organic-rich soils. Dissolved organic matter (DOM) leaching from these soils imparts a brownish colour to water and raises treatment challenges for the water industry since excessive post-treatment concentrations result in the generation of potentially harmful disinfection by-products in drinking water. The primary method for maintaining sufficiently low pre-disinfection DOM concentrations is chemical coagulation, but in the past 15 years water companies have increasingly considered the capacity for catchment interventions to improve raw water quality at source, reducing the need for costly and complex engineering solutions in treatment works. There remains considerable uncertainty around the effectiveness of these catchment engineering-based measures and a comprehensive overview of the research in this area remains lacking. Here we review the peer-reviewed evidence for the effectiveness of four management options for upland organic soil-dominated catchments that are being considered by the water industry as options for controlling DOM releases. These are ditch blocking, revegetation, reducing forest cover, and cessation of managed burning. Results of plot scale investigations into effects of ditch blocking on ditch-blocking are available but largely equivocal, while there is a paucity of information regarding impacts at spatial scales of more direct relevance to water managers. The presence of plantation forestry on peat soils is generally associated with increasing DOM concentrations, although canopy removal has little short-term benefit and can even further increase concentrations. Although not widely studied, the available evidence suggests that Sphagnum mosses produce DOM that is more easily removed via conventional treatment processes compared to vascular plants such as heather and grass species. We found surprisingly little published research around the extent to which manipulation of in-reservoir processes might be used to mitigate or exacerbate changes in inflowing DOM as part of a catchment management approach. This review concluded that catchment management measures have rarely been monitored with downstream water quality as the focus, and that restoration impacts vary across sites. To mitigate the uncertainty surrounding restoration effects on DOM, measures should be undertaken on a site-specific basis, where the scale, effect size and duration of the intervention are considered in relation to subsequent biogeochemical processing that occurs in the reservoir, the treatment capacity of the water treatment works and future projected DOM trends.

Dissolved inorganic carbon (DIC) fluxes from the land to ocean have been quantified for many rivers globally. However, CO2 fluxes to the atmosphere from inland waters are quantitatively significant components of the global carbon cycle that are currently poorly constrained. Understanding, the relative contributions of natural and human-impacted processes on the DIC cycle within catchments may provide a basis for developing improved management strategies to mitigate free CO2 concentrations in rivers and subsequent evasion to the atmosphere. Here, a large, internally consistent dataset collected from 41 catchments across Great Britain (GB), accounting for ∼36% of land area (∼83,997 km2) and representative of national land cover, was used to investigate catchment controls on riverine dissolved inorganic carbon (DIC), bicarbonate (HCO3−) and free CO2 concentrations, fluxes to the coastal sea and annual yields per unit area of catchment. Estimated DIC flux to sea for the survey catchments was 647 kt DIC yr−1 which represented 69% of the total dissolved carbon flux from these catchments. Generally, those catchments with large proportions of carbonate and sedimentary sandstone were found to deliver greater DIC and HCO3− to the ocean. The calculated mean free CO2 yield for survey catchments (i.e. potential CO2 emission to the atmosphere) was 0.56 t C km−2 yr−1. Regression models demonstrated that whilst river DIC (R2 = 0.77) and HCO3− (R2 = 0.77) concentrations are largely explained by the geology of the landmass, along with a negative correlation to annual precipitation, free CO2 concentrations were strongly linked to catchment macronutrient status. Overall, DIC dominates dissolved C inputs to coastal waters, meaning that estuarine carbon dynamics are sensitive to underlying geology and therefore are likely to be reasonably constant. In contrast, potential losses of carbon to the atmosphere via dissolved CO2, which likely constitute a significant fraction of net terrestrial ecosystem production and hence the national carbon budget, may be amenable to greater direct management via altering patterns of land use.

Wind farms can help to mitigate increasing atmospheric carbon (C) emissions. However, disturbance caused by wind farm development must not have lasting deleterious impacts on landscape C sequestration. To understand the effects of wind farms on peatlands, we monitored streamwater in five catchments (5.7–31 km2area) draining Europe’s second largest onshore wind farm at Whitelee, Scotland, UK for 10 years after wind farm development that occurred in phases. Dissolved organic carbon (DOC) concentrations were measured every 2–4 weeks and DOC fluxes estimated using flow from either direct measurements in the catchments or scaled via catchment area from a nearby river flow gauge. Similar measurements were made at a nearby peatland catchment unimpacted by wind farm development that acted as the best possible reference site. Generalised additive mixed models (GAMM) were fitted to all catchments to assess differences in trends and seasonality in DOC and flow between catchments. Interactions terms allowed for the possibility of changing seasonal patterns, and temporal correlations were included in the models and formal testing using an AR(1) structure. Change points in DOC trends were identified using first derivatives of the estimated trends and compared with the timings of wind farm construction. DOC exports from the wind farm-impacted catchments are high at 17–34 g C m-2 year-1. The models showed increasing trends in streamwater DOC concentrations and fluxes in the wind farm-impacted catchments, with timing apparently synchronous with the development phases. In contrast, streamflows were more stable. Trends and seasonality of DOC concentrations and fluxes were different in the reference catchment during the study period. Hydrological and biogeochemical processes driving the DOC response of peatland catchments to wind farm development will be discussed, and their consequences for landscape C sequestration assessed.

Inland waters play an active role in the global carbon cycle and emit large volumes of the greenhouse gases (GHGs), methane (CH4) and carbon dioxide (CO2). A considerable body of research has improved emissions estimates from lakes, reservoirs and rivers but recent attention has been drawn to the importance of small, artificial waterbodies as poorly quantified but potentially important emission hotspots. Of particular interest are emissions from drainage ditches and constructed ponds. These waterbody types are prevalent in many landscapes and their cumulative surface areas can be substantial. Furthermore, GHG emissions from constructed waterbodies are anthropogenic in origin and form part of national emissions reporting, whereas emissions from natural waterbodies do not (according to Intergovernmental Panel on Climate Change guidelines). Here, we present GHG data from two complementary studies covering a range of land uses. In the first, we measured emissions from nine ponds and seven ditches over a full year. Annual emissions varied considerably: 0.1-44.3 g CH4 m(-2) year(-1) and -36-4421 g CO2 m(-2) year(-1). In the second, we measured GHG concentrations in 96 ponds and 64 ditches across seven countries, covering subtropical, temperate and sub-arctic biomes. When CH4 emissions were converted to CO2 equivalents, 93% of waterbodies were GHG sources. In both studies, GHGs were positively related to nutrient status (C, N, P), and pond GHG concentrations were highest in smallest waterbodies. Ditch and pond emissions were larger per unit area when compared to equivalent natural systems (streams, natural ponds). We show that GHG emissions from natural systems should not be used as proxies for those from artificial waterbodies, and that artificial waterbodies have the potential to make a substantial but largely unquantified contribution to emissions from the Agriculture, Forestry and Other Land Use sector, and the global carbon cycle. Funding Agencies|European Research CouncilEuropean Research Council (ERC)European Commission [725546]; FORMASSwedish Research Council Formas [2018-01794, 2020-00950]; NERCUK Research & Innovation (UKRI)Natural Environment Research Council (NERC) [NE/N018087/1]

Federal accountability policies requiring rapid, measurable outcomes have increasingly shaped the nature and type of public literacy services available to adults. However, little empirical research has explored the impact of accountability policies on program practice in adult basic education, and almost no research has focused on the effect on services for adults who have difficulty reading. This ethnographically grounded research article explores one publicly funded adult basic education program’s efforts to comply with federal accountability policy and the impact these efforts had on services for adults with difficulty reading. Findings suggest that efforts to comply with accountability policies resulted in instructional practices that limited students’ opportunities for substantive engagement with reading and in program policies that excluded students who did not produce outcomes from participation. The findings also suggest that in the context of accountability pressures, student marginalization became normalized as an ordinary part of practice.

The flux of terrigenous organic carbon through estuaries is an important and changing, yet poorly understood, component of the global carbon cycle. Using dissolved organic carbon (DOC) and fluorescence data from 13 British estuaries draining catchments with highly variable land uses, we show that land use strongly influences the fate of DOC across the land ocean transition via its influence on the composition and lability of the constituent dissolved organic matter (DOM). In estuaries draining peatland-dominated catchments, DOC was highly correlated with biologically refractory “humic-like” terrigenous material which tended to be conservatively transported along the salinity gradient. In contrast, there was a weaker correlation between DOC and DOM components within estuaries draining catchments with a high degree of human impact, that is, relatively larger percentage of arable and (sub)urban land uses. These arable and (sub)urban estuaries contain a high fraction of bioavailable “protein-like” material that behaved nonconservatively, with both DOC removals and additions occurring. In general, estuaries draining catchments with a high percentage of peatland (≥18%) have higher area-specific estuarine exports of DOC (>13 g C m−2 yr−1) compared to those estuaries draining catchments with a high percentage (≥46%) of arable and (sub)urban land uses (

This qualitative research article explores barriers experienced by a group of African American and Latinx adults who sought to enroll and stay enrolled in a publicly funded literacy class and how these barriers were related to policy. Barriers included (a) an inadequate number and type of available classes, (b) a lack of community awareness of classes, and (c) institutional procedures that determined class eligibility. Barriers were created as practitioners attempted to comply with government accountability policy and funding requirements. These findings provoke questions about whether accountability policies promote inequitable access to public adult literacy services for racially minoritized adults.

Maintenance and enhancement of peatland carbon storage is a major policy objective towards meeting greenhouse gas (GHG) targets. Management interventions can influence both the storage capacity and the vulnerability of the stock to climate-change induced increases in drought frequency and severity, and incidence of wildfires. Quantification of these interactions is vital in informing best management practice, but is also challenging, given the ephemeral nature of climatic extremes and the usual paucity of high-quality ground-based observations within an area of interest capable of providing the necessary pre-impact and control data.Following a dry and warm spell in spring 2019, a large wildfire burnt approximately >60 km2 of blanket bog and wet heath within the Flow Country peatlands of Caithness and Sutherland, North Scotland. While the Flow Country is a site of global significance currently under consideration for UNESCO World Heritage Site Status, it has also been substantially modified in places by drainage and notably forestry (670 km2) and is now undergoing rapid and large-scale restoration. Serendipitously, the fire scar impacted the whole range of land-uses and occurred in an area actively used for research, and therefore where some baseline datasets were available.The NERC funded FireBlanket project used this opportunity to investigate how land-uses interacted with wildfire in terms of 1) InSAR-derived “bog breathing” patterns exhibited during the 2018 drought 2) immediate and longer-term effects on vegetation communities 3) export and fate of organic carbon from land to ocean. By understanding how different management strategies of forestry and forest-to-bog restoration influence fire risk and damage, we hope to inform decision-making in the future.Our preliminary results show that in near-natural and restored (drain-blocked) blanket bogs, the drought of 2018 led to a rapid surface compression that maintained near-surface moisture until 2019, in turn reducing the severity of the wildfire. In drained and degraded blanket bogs, this mechanical feedback is absent, due to higher bulk density and differences in vegetation assemblages, notably reduced cover of Sphagnum mosses. In those areas, the 2018 drought led to a rapid and sustained loss of moisture in the upper peat layers, associated with higher burn severity and more pronounced fire damage on vegetation. Furthermore, while DOM concentrations increased post-fire in streams receiving water from all burnt areas compared to unburnt ones, the changes were more pronounced in catchments with man-made drains.Whilst further data processing and analysis is still underway, our study currently suggests that restoration is likely to increase wildfire resilience and reduce wildfire severity. When taking management decisions at the landscape scale, strategic re-wetting around vulnerable areas (e.g. highly degraded or undergoing forest-to-bog management leading to large volumes of brash on the ground) may help reduce the risks of occurrence of large catastrophic wildfires, and help minimise the carbon losses associated with these events.

Peatlands are a globally important carbon (C) store, although it is well understood that anthropogenic pressures including drainage can reduce potential for C sequestration, in part due to increased losses of C via the aquatic pathway. Superimposed onto land-use pressures on peatlands are those caused by extreme climate events. Following a drought in 2018 and a subsequent dry period in spring 2019, a large wildfire burnt approximately >60 km2 of blanket bog and wet heath within the Flow Country peatlands, North Scotland in May 2019. The fire burned various peatland land types, including near-natural peatland and drained peatland areas. This event created an urgent opportunity to quantify the interacting effects of peat condition and wildfire on water quality, with a focus on dissolved organic matter (DOM) losses. An extensive water monitoring programme was established, covering 40 individual headwater stream sampling locations across the Flow Country, and monthly sampling ran from September 2019 to October 2020, with samples analysed for dissolved organic carbon (DOC), nutrients and UV-vis-based measurements to inform DOM composition. Initial data shows that samples from burned, drained areas are associated with higher DOC concentrations relative to both burned, near natural peatland areas, and unburned control sites. Furthermore the DOM from burned, drained sites is of a more aromatic nature, as indicated by elevated specific UV absorbance (SUVA), compared to unburned control sites. Such findings imply that wildfires may adversely affect water quality through changes DOM quantity and quality in areas of damaged (drained) peatland. However, more detailed compositional analyses are required to accurately predict changes in the ecological functioning of this peatland derived DOM as it enters the aquatic environment and, therefore, its likely end-fate.

Inland waters are important sources of greenhouse gases and emissions from polluted subtropical systems may be contributing to the observed global increase in atmospheric methane concentrations. Here we detail a scoping study where dissolved concentrations of greenhouse gases methane (CH4), carbon dioxide (CO2) and nitrous oxide (N2O) were measured in two contrasting urban lakes in Bangalore (Bengaluru), Karnataka, India, from June 2018 to February 2020. Bellandur Lake is a severely polluted system whilst Jakkur Lake has been subject to partial restoration via treatment of organic matter inputs. Methane concentrations in Bellandur Lake were three orders of magnitude higher than in Jakkur Lake, with a mean concentration of 3.02 ± 1.57 mg CH4-C L−1 compared to 1.72 ± 1.22 μg CH4-C L−1. At Bellandur Lake, dissolved CO2 concentrations were of the same order of magnitude as for CH4, whereas at Jakkur Lake dissolved CO2 concentrations were two orders of magnitude greater than for CH4. Concentrations of N2O were negligible in both lakes. Extrapolating our data to estimate greenhouse gas fluxes, mean daily methane fluxes from Bellandur Lake were consistently in excess of 1000 mg CH4 m2 d−1, rendering the lake a source of GHGs to the order of 148,350 ± 21,790 ton yr−1 CO2-e yr−1, compared to 100 ± 37 ton CO2-e yr−1 from Jakkur Lake, with CH4 contributing primarily to this difference. We propose that the contribution of severely polluted urban lakes to global CH4 production warrants further investigation, particularly as our evidence suggests that standard secondary wastewater treatment to support restoration of these systems has the potential to significantly reduce CH4 emissions.

Rising dissolved organic matter (DOM) concentrations, and associated increases in water colour, have posed a potential problem for the UK water industry since the phenomenon was first reported in the early 1990s. Elevated DOM concentrations in raw water are of particular concern in upland catchments dominated by organic soils where DOM production tends to be highest. In recent years, water companies have considered the capacity for catchment interventions to improve raw water quality at source, relieving the need for costly and complex engineering solutions in treatment works, but there is considerable uncertainty around the effectiveness of these measures. One of the primary evidence gaps is the extent to which catchment management is capable of influencing DOM concentrations at the point of abstraction, field studies rarely extending beyond sub-catchment or stream scale. Our review of the published evidence suggests that catchment management could make a contribution to mitigating recent DOM increases in some circumstances, particularly where plantation forestry has been grown on peat, and where control of nutrients in runoff could reduce in-reservoir DOM production. Evidence for the efficacy of most other measures that target reductions in DOM loading for catchment to reservoir remains insufficient to support wider scale application. Collectively, these measures have the potential to reduce DOM concentrations in drinking water reservoirs but they must be selected on a site-specific basis, where the scale, effect size and duration of the catchment intervention are considered in relation to both the treatment capacity of the works and future projected DOM trends.

The transport of dissolved organic matter (DOM) across the land-ocean-aquatic-continuum (LOAC), from freshwater to the ocean, is an important yet poorly understood component of the global carbon budget. Exploring and quantifying this flux is a significant challenge given the complexities of DOM cycling across these contrasting environments. We developed a new model, UniDOM, that unifies concepts, state variables and parameterisations of DOM turnover across the LOAC. Terrigenous DOM is divided into two pools, T1 (strongly-UV-absorbing) and T2 (non- or weakly-UV-absorbing), that exhibit contrasting responses to microbial consumption, photooxidation and flocculation. Data are presented to show that these pools are amenable to routine measurement based on specific UV absorbance (SUVA). In addition, an autochtonous DOM pool is defined to account for aquatic DOM production. A novel aspect of UniDOM is that rates of photooxidation and microbial turnover are parameterised as an inverse function of DOM age. Model results, which indicate that ~ 5% of the DOM originating in streams may penetrate into the open ocean, are sensitive to this parameterisation, as well as rates assigned to turnover of freshly-produced DOM. The predicted contribution of flocculation to DOM turnover is remarkably low, although a mechanistic representation of this process in UniDOM was considered unachievable because of the complexities involved. Our work highlights the need for ongoing research into the mechanistic understanding and rates of photooxidation, microbial consumption and flocculation of DOM across the different environments of the LOAC, along with the development of models based on unified concepts and parameterisations.

The role of plant phenology as regulator for gross ecosystem productivity (GEP) in peatlands is empirically not well constrained. This is because proxies to track vegetation development with daily coverage at the ecosystem scale have only recently become available and the lack of such data has hampered the disentangling of biotic and abiotic effects. This study aimed at unraveling the mechanisms that regulate the seasonal variation in GEP across a network of eight European peatlands. Therefore, we described phenology with canopy greenness derived from digital repeat photography and disentangled the effects of radiation, temperature and phenology on GEP with commonality analysis and structural equation modeling. The resulting relational network could not only delineate direct effects but also accounted for possible effect combinations such as interdependencies (mediation) and interactions (moderation). We found that peatland GEP was controlled by the same mechanisms across all sites: phenology constituted a key predictor for the seasonal variation in GEP and further acted as distinct mediator for temperature and radiation effects on GEP. In particular, the effect of air temperature on GEP was fully mediated through phenology, implying that direct temperature effects representing the thermoregulation of photosynthesis were negligible. The tight coupling between temperature, phenology and GEP applied especially to high latitude and high altitude peatlands and during phenological transition phases. Our study highlights the importance of phenological effects when evaluating the future response of peatland GEP to climate change. Climate change will affect peatland GEP especially through changing temperature patterns during plant-phenologically sensitive phases in high latitude and high altitude regions.

Three different nitrogen fertilizer types, ammonium nitrate, urea and urea coated with a urease inhibitor (Agrotain®), were applied at standard rates (70 kg N ha−1) to experimental plots in a typical and intensively managed grassland area at Easter Bush Farm Estate (Scotland). The nitrogen use efficiency of the fertilisers was investigated as well as nitrogen losses in the form of nitrous oxide fluxes (N2O) and ammonia (NH3) and during fertilisation events in the 2016 and 2017 growing seasons. Nitrous oxide was measured by the standard static chamber technique and analysed using Bayesian statistics. Ammonia was measured using passive samplers combined with the FIDES inverse dispersion model. On average, fertilisation with ammonium nitrate supported largest yields and had the highest nitrogen use efficiency, but as large spatial and seasonal variation persisted across the plots, yield differences between the three fertilizer types and zero N control were not consistent. Overall, ammonium nitrate treatment was found to increase yields significantly (p-value

This research synthesis analyzed qualitative depictions of adult literacy learners and identified five ways in which they are typically characterized: the Heroic Victim, the Needy (Problem) Child, the Broken (but Repairable) Cog, the Pawn of Destiny, and the Capable Comrade. These types do not capture the diversity or complexity of all adult literacy learners, and we do not argue that they are comprehensive. Rather they are representative of the ways in which adult literacy learners are portrayed in the research literature. We argue that each type, like characters in a narrative, drive the “action” in research, policy, and practice arena. The ways in which they populate research may have very real consequences for how adult literacy learning opportunities are provided and the outcomes that can be expected.

It is not known how often physicians use metaphors and analogies, or whether they improve patients' perceptions of their physicians' ability to communicate effectively. Therefore, the objective of this study was to determine whether the use of metaphors and analogies in difficult conversations is associated with better patient ratings of their physicians' communication skills.Cross-sectional observational study of audio-recorded conversations between patients and physicians.Three outpatient oncology practices.Ninety-four patients with advanced cancer and 52 physicians.None.Conversations were reviewed and coded for the presence of metaphors and analogies. Patients also completed a 6-item rating of their physician's ability to communicate.In a sample of 101 conversations, coders identified 193 metaphors and 75 analogies. Metaphors appeared in approximately twice as many conversations as analogies did (65/101, 64% versus 31/101, 31%; sign test p0.001). Conversations also contained more metaphors than analogies (mean 1.6, range 0-11 versus mean 0.6, range 0-5; sign rank test p0.001). Physicians who used more metaphors elicited better patient ratings of communication (rho = 0.27; p = 0.006), as did physicians who used more analogies (Spearman rho = 0.34; p0.001).The use of metaphors and analogies may enhance physicians' ability to communicate.

OBJECTIVES: To determine whether inpatient palliative consultation services improve outcomes of care. DESIGN: Retrospective telephone surveys conducted with family members of veterans who received inpatient or outpatient care from a Department of Veterans Affairs (VA) medical facility in the last month of life. SETTING: Five VA Medical Centers or their affiliated nursing homes and outpatient clinics. PARTICIPANTS: Veterans had received inpatient or outpatient care from a participating VA in the last month of life. One family member completed each survey. MEASUREMENTS: The telephone survey assessed nine aspects of the care the patient received in his or her last month of life: the patient's well-being and dignity (4 items), adequacy of communication (5 items), respect for treatment preferences (2 items), emotional and spiritual support (3 items), management of symptoms (4 items), access to the inpatient facility of choice (1 item), care around the time of death (6 items), access to home care services (4 items), and access to benefits and services after the patient's death (3 items). RESULTS: Interviews were completed with 524 respondents. In a multivariable linear regression model, after adjusting for the likelihood of receiving a palliative consultation (propensity score), palliative care patients had higher overall scores: 65 (95% confidence interval (CI)=62–66) versus 54 (95% CI=51–56; P

To identify aspects of end-of-life care in the U.S. Department of Veterans Affairs (VA) health care system that are not assessed by existing survey instruments and to identify issues that may be unique to veterans, telephone interviews using open-ended questions were conducted with family members of veterans who had received care from a VA facility in the last month of life. Responses were compared to validated end-of-life care assessment instruments in common use. The study took place in four VA medical centers and one family member per patient was invited to participate, selected from medical records using predefined eligibility criteria. These family members were asked to describe positive and negative aspects of the care the veteran received in the last month of life. Interview questions elicited perceptions of care both at VA sites and at non-VA sites. Family reports were coded and compared with items in five existing prospective and retrospective instruments that assess the quality of care that patients receive near the end of life. Interviews were completed with 66 family members and revealed 384 codes describing both positive and negative aspects of care during the last month of life. Almost half of these codes were not represented in any of the five reference instruments (n = 174; 45%). These codes, some of which are unique to the veteran population, were grouped into eight categories: information about VA benefits (n = 36; 55%), inpatient care (n = 36; 55%), access to care (n = 33; 50%), transitions in care (n = 32; 48%), care that the veteran received at the time of death (n = 31; 47%), home care (n = 26; 40%), health care facilities (n = 12; 18%), and mistakes and complications (n = 18; 27%). Although most of the reference instruments assessed some aspect of these categories, they did not fully capture the experiences described by our respondents. These data suggest that many aspects of veterans' end-of-life care that are important to their families are not assessed by existing survey instruments. VA efforts to evaluate end-of-life care for veterans should not only measure common aspects of care (e.g., pain management), but also examine performance in areas that are more specific to the veteran population.

To evaluate the FATE (Family Assessment of Treatment at End of Life) Survey for use as a nationwide quality measure in the VA health care system.Nationwide telephone survey.Five VA medical centers.Eligible patients received inpatient or outpatient care from a participating VA facility in the last month of life. One respondent/patient was selected using predefined eligibility criteria and invited to participate.The FATE survey consists of 32 items in 9 domains: Well-being and dignity (4 items), Information and communication (5 items), Respect for treatment preferences (2 items), Emotional and spiritual support (3 items), Management of symptoms (4 items), Choice of inpatient facility (1 item), Care around the time of death (6 items), Access to VA services (4 items), and Access to VA benefits after the patient's death (3 items).Interviews were completed with 309 respondents. The FATE showed excellent psychometric characteristics, with good homogeneity (e.g., Cronbach (alpha = 0.91) and no evidence of significant ceiling effects. The FATE also demonstrated good discriminant validity. For instance, FATE scores varied across facilities (range 44-72; Kruskal Wallis test p0.001). Patients who were seen by a palliative care service had better scores (mean 66 versus 52; rank sum test p0.001), as did patients who were referred to hospice (67 versus 49; rank sum test p0.001).The FATE survey offers an important source of quality data that can be used to improve the end-of-life care of all veterans, regardless of the type of care they receive or their site of death.

Most adults have been infected with EBV. Many studies have indicated that antibodies against specific EBV antigens, particularly IgA antibodies, can be predictive or prognostic of EBV-associated malignancies, such as NPC. We hypothesized that healthy individuals from families with a history of multiple members affected with NPC (who therefore might be genetically susceptible to NPC themselves) might have an EBV antibody profile that is distinct from that seen in healthy individuals from the community at large. To explore this possibility and examine determinants of anti-EBV antibody levels in healthy, high-risk individuals, we evaluated data from 2 parallel studies of NPC in Taiwan, which included 1,229 healthy members of families in which 2 or more individuals were affected with NPC and 320 controls from the community at large. Blood collected from participants was tested for IgA antibodies against EBV VCA and EBNA-1 and for neutralizing antibodies against EBV DNase using standard assays. We observed evidence of familial aggregation of EBV seroreactivity among individuals from high-risk, multiplex NPC families. Anti-VCA IgA and anti-EBNA-1 IgA antibody seroprevalence in unaffected family members of NPC cases was 5-6 times higher than in members of the community (p < 0.01). This elevated seroprevalence among unaffected individuals from high-risk families was observed regardless of the relationship of the unaffected individual to the closest affected relative (siblings, parents, children or spouses). No sociodemographic or environmental factors examined were found to strongly and consistently correlate with elevated seroprevalence, but patterns emerged of increasing seroprevalence among older individuals and among females. Unaffected individuals from high-risk NPC families have elevated anti-EBV IgA antibody titers. The etiologic and clinical implications of this finding remain to be established.

To determine whether inpatient palliative consultation services improve outcomes of care.Retrospective telephone surveys conducted with family members of veterans who received inpatient or outpatient care from a Department of Veterans Affairs (VA) medical facility in the last month of life.Five VA Medical Centers or their affiliated nursing homes and outpatient clinics.Veterans had received inpatient or outpatient care from a participating VA in the last month of life. One family member completed each survey.The telephone survey assessed nine aspects of the care the patient received in his or her last month of life: the patient's well-being and dignity (4 items), adequacy of communication (5 items), respect for treatment preferences (2 items), emotional and spiritual support (3 items), management of symptoms (4 items), access to the inpatient facility of choice (1 item), care around the time of death (6 items), access to home care services (4 items), and access to benefits and services after the patient's death (3 items).Interviews were completed with 524 respondents. In a multivariable linear regression model, after adjusting for the likelihood of receiving a palliative consultation (propensity score), palliative care patients had higher overall scores: 65 (95% confidence interval (CI)=62-66) versus 54 (95% CI=51-56; P.001) and higher scores for almost all domains. Earlier consultations were independently associated with better overall scores (beta=0.003; P=.006), a difference that was attributable primarily to improvements in communication and emotional support.Palliative consultations improve outcomes of care, and earlier consultations may confer additional benefit.

Objective To determine how soap operas portray, and possibly misrepresent, the likelihood of recovery for patients in coma. Design Retrospective cohort study. Setting Nine soap operas in the United States reviewed between 1 January 1995 and 15 May 2005. Subjects 64 characters who experienced a period of unconsciousness lasting at least 24 hours. Their final status at the end of the follow-up period was compared with pooled data from a meta-analysis. Results Comas lasted a median of 13 days (interquartile range 7-25 days). Fifty seven (89%) patients recovered fully, five (8%) died, and two (3%) remained in a vegetative state. Mortality for non-traumatic and traumatic coma was significantly lower than would be predicted from the meta-analysis data (non-traumatic 4% v 53%; traumatic 6% v 67%; Fisher's exact test both P < 0.001). On the day that patients regained consciousness, most (49/57; 86%) had no evidence of limited function, cognitive deficit, or residual disability needing rehabilitation. Compared with meta-analysis data, patients in this sample had a much better than expected chance of returning to normal function (non-traumatic 91% v 1%; traumatic 89% v 7%; both P < 0.001). Conclusions The portrayal of coma in soap operas is overly optimistic. Although these programmes are presented as fiction, they may contribute to unrealistic expectations of recovery.