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Next Sunday, 19 January, begins the Week of Prayer for Christian Unity. The Reverend Darnell Coleman will be our guest preacher at the 10 am service. Darnell is an ordained Baptist minister and Assistant Minister at the Greater Missionary Baptist Church in Pacoima.
[ January 14, 2014; 7:00 pm to 9:00 pm. ] The Budget Committee will meet Tuesday at 7 pm at the Martin residence.
[ January 25, 2014; 10:00 am to 12:00 pm. ] The Pro-Life Chapter of St. Mary's will meet on Saturday, beginning with Mass at 10 am, followed by light refreshments and a presentation.
[ January 15, 2014; 10:00 am to 11:00 am. ] Midweek Mass will be celebrated this week on Wednesday at 10 am (commemoration of St. Paul of Thebes, the first Hermit).
You are currently browsing the St. Mary the Virgin Anglican-Rite Catholic Church weblog archives for January, 2014.


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text:
Many people in Scotland now benefit from anticipatory care before they die: an after death analysis and interviews with general practitioners
Julia Tapsfield1,
Charlie Hall2,
Carey Lunan3,
Hazel McCutcheon3,
Peter McLoughlin4,
Joel Rhee5,
Alfonso Leiva6,7,
Juliet Spiller2,
Anne Finucane2 and
Scott A Murray1
1 Primary Palliative Care Research Group, Centre for Population Health Sciences, The Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
2 Marie Curie Hospice Edinburgh, Edinburgh, UK
3 NHS Lothian, Edinburgh, UK
4 Department in Strategic Planning and Modernisation, Lothian NHS Board, Edinburgh, UK
5 School of Public Health & Community Medicine, The University of New South Wales, Sydney, New South Wales, Australia
6 Primary Care Research Unit of Mallorca, Baleares Health Services-IbSalut, Palma, Spain
7 Instituto de Investigación Sanitaria de Palma, Palma, Spain
Correspondence to Professor Scott A Murray, Primary Palliative Care Research Group, Centre for Population Health Sciences, The Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, EH8 9AG, UK; Scott.Murray{at}ed.ac.uk
Background Key Information Summaries (KIS) were introduced throughout Scotland in 2013 so that anticipatory care plans written by general practitioners (GPs) could be routinely shared electronically and updated in real time, between GPs and providers of unscheduled and secondary care.
Aims We aimed to describe the current reach of anticipatory and palliative care, and to explore GPs' views on using KIS.
Methods We studied the primary care records of all patients who died in 2014 in 9 diverse Lothian practices. We identified if anticipatory or palliative care had been started, and if so how many weeks before death and which aspects of care had been documented. We interviewed 10 GPs to understand barriers and facilitating factors.
Results Overall, 60% of patients were identified for a KIS, a median of 18 weeks before death. The numbers identified were highest for patients with cancer, with 75% identified compared with 66% of those dying with dementia/frailty and only 41% dying from organ failure. Patients were more likely to die outside hospital if they had a KIS. GPs identified professional, patient and societal challenges in identifying patients for palliative care, especially those with non-cancer diagnoses.
Conclusions GPs are identifying patients for anticipatory and palliative care more equitably across the different disease trajectories and earlier in the disease process than they were previously identifying patients specifically for palliative care. However, many patients still lack care planning, particularly those dying with organ failure.
Service evaluation
This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Anticipatory and advance care planning is about 'thinking ahead'. It encourages practitioners to work with patients, carers and relatives to plan for the right person to do the right thing, at the right time, to achieve patient goals, facilitating shared decision-making and person-centred care in the appropriate setting. Planning ahead is recognised as being central to the provision of palliative care.1
With ageing populations and rising multimorbidity, general practitioners (GPs) are caring for increasing numbers of patients with complex conditions approaching the end of life. Even in countries where palliative care is relatively well developed, most people still do not benefit from palliative care before they die. We previously reported that only around 20% of people with non-malignant illnesses were identified for generalist palliative care in 2011 in Scotland, and that this varied greatly from 75% in cancer to 20% in dementia/frailty and 19% in organ failure.2 Such patients were identified just weeks before death. This is illustrated in figure 1. Considerably fewer than this received specialist palliative care. These findings illustrated the need for the WHO resolution published in 2014, that palliative care should be integrated into the care of people with all advanced conditions from an early stage.3
Percentage of patients on the general practice palliative care register at death, according to illness trajectory and if so when they were placed on the register.
Since 2012, the Scottish Government has funded two new initiatives which together aim to extend generalist palliative care to all people who might benefit and to improve care for people with advanced illness earlier rather than later and in all settings. These are the Scottish Palliative Care Directly Enhanced Service (DES) and the Key Information Summaries (KIS) for anticipatory care (see box 1 for a summary). The specific inclusion of anticipatory care planning in the latest Scottish payment contract for GPs provides a framework for identifying high-risk patients. This planning uses tools such as the Scottish Patients At Risk of Readmission and Admission score (SPARRA)4 and the Supportive and Palliative Care Indicators Tool (SPICT), which has been validated.5 ,6
Details of the two initiatives to promote anticipatory and palliative care in Scotland
The Scottish Palliative Care Directly Enhanced Service has encouraged general practitioners (GPs) to identify more patients with non-malignant disease for palliative care by supporting them to use the Supportive and Palliative Care Indicators Tool (SPICT)5 to trigger them adopting a palliative care approach and to report specifically on numbers of non-malignant patients placed on their GP palliative care register.
The Scottish Key Information Summary (KIS) is a new IT development in NHS Scotland pioneering a shared medical record between healthcare professionals. It was introduced into all GP practices across Scotland in 2013 and allows selected parts of the GP electronic patient record to be shared with the wider NHS using a template within the GP clinical system. Patients with the most complex health and social care needs are selected to have a KIS written to capture key points of their anticipatory care plans. These include details of medical diagnoses, medications, carers, social care and next of kin details, baseline function and cognition, understanding of illness, wishes about resuscitation and place of care and any drugs or equipment at home. It has a small extra section for palliative care which details any anticipatory prescribing and is designed to be added to over time as the patient's clinical condition progresses. The KIS is now available when the patient consents to be viewed by secondary care, community teams, NHS24, the GP out-of-hours service, the Scottish Ambulance Service, hospital pharmacies and some hospices.
We aimed to better understand how the KIS was facilitating anticipatory and palliative care among patients approaching end of life, the current reach of anticipatory and palliative care, and to explore views of GPs on using KIS in practice.
We recruited nine GP practices across NHS Lothian to incorporate a mix of sociodemographic status and practice sizes.
Quantitative data collection and analysis
Participating practices provided the researcher with a list of all patients who had died in 2014. The principal researcher, JT, a GP with research training, accessed GP clinical records to review the notes of all deceased patients to see if a KIS had been completed. She also recorded which components were completed, and when, in relation to death. Case notes were reviewed to identify which of the three main disease trajectories—cancer, dementia/frailty or organ failure—the patient was on at time of death. JT also examined whether the patient had multimorbidity (two or more chronic conditions) and their place of death. Patients with sudden unexpected deaths were excluded from the analysis.
Logistic regression was performed by AL. The binary outcome of the logistic regression model was hospital death or death outside of hospital (elsewhere). The estimated ORs of patients dying in hospital were adjusted for a cluster of practices by means of a logit link in a binomial distribution of a robust generalised estimating equation and an exchangeable correlation structure.7 All analyses were performed using STATA software (V.11.1; StataCorp LP).
Qualitative data collection and analysis
JT, revealing that she was a GP interested in palliative care, also sought via the practice manager to interview a GP from each practice who was experienced in using a KIS (see box 2 for the interview schedule). Interviews were conducted face to face, lasting from 10 to 30 min, digitally recorded and transcribed verbatim together with field notes. Transcripts were analysed by JT for key topics and a priori and emerging themes.8 To increase reflexivity, JR, an experienced qualitative researcher, also analysed one-third of the transcripts and discussed the coding and analysis strategies with JT. Throughout the data analysis process, emerging themes and the coding tree were discussed with the multidisciplinary research steering group through regular meetings.
Semistructured interview schedule
How long have you worked in this practice as a general practitioner (GP)? How long have you been working as a GP?
Can you tell me how your practice uses the Key Information Summary (KIS) for anticipatory care planning?
How do you decide when to start a KIS? Do you use the Scottish Patients At Risk of Readmission and Admission (SPARRA) data/Supportive and Palliative Care Indicators Tool (SPICT)/suggestion from hospital?
Do the GPs complete the KIS themselves or are other team/admin members involved with them?
How do you deal with issues of consent and does this pose any challenges when completing a KIS?
What would trigger you to complete a Palliative Care Summary?
What about patients with non-malignant conditions? Do you find them more difficult to identify than those with cancer?
Have you received any formal training (including communication skills training) in discussing anticipatory care with your patients?
Do you think such training would be helpful, and if so are you aware of any?
What might influence your decision to attend such training?
What are your thoughts on the KIS and how do you find it to use in practice?
How time-consuming is it and does this factor into your decisions to complete/which parts to complete?
How does your practice run your KIS and Palliative Care meetings
How do you decide which patient to discuss?
Are they useful?
How do you find communication between primary and secondary care around KIS?
Does this help your decision to use the KIS?
Is it different for patients with and without cancer ?
Do you get much feedback from secondary care/out-of-hours about your KIS?
What would you do to improve the current service if you were given the chance?
The Caldicott guardian approved the process of accessing notes of deceased patients which helped consenting practices to feel able to participate. Permission from the South East Scotland Research Ethics Service to proceed with this study as a service evaluation, and ethical approval from the University of Edinburgh Ethics Review Group were granted.
Quantitative results
Sample characteristics
A total of 605 deceased patients from the nine practices were identified, after excluding sudden unexpected or unexplained deaths. The median age was 81 years (IQR 72–92 years). Of these, 35% were identified as dying with cancer, 31% with dementia and/or frailty and 34% with organ failure. In total, 85% were suffering from multimorbidity (table 1). GP practices ranged in size from 5691 to 11 473 patients (table 2).
Patient sample characteristics
General practice characteristics
Identification for anticipatory care
Practices varied greatly, identifying between 92% and 36% of patients for anticipatory care (ie, having a KIS). Overall, 60% of patients had a KIS completed prior to death (table 3). The proportion of patients with a KIS was highest for those with cancer (74%), and lowest for those with organ failure (41%). KIS were started a median of 18 weeks before death.
Percentage of patients with different components of the KIS completed at death, and if so when discussed, according to illness trajectory
Over half of all patients who died had an anticipatory care plan (58%). Again, patients with cancer were most likely to have an Anticipatory Care Planning (ACP), whereas those with organ failure were least likely. ACPs were started a median of 15 weeks before death, approximately 3 weeks after the KIS was started.
Overall, 40% of deceased patients had the Palliative Care Summary (PCS) part of the KIS completed, and this occurred a median of 11 weeks prior to death. Those with cancer were most likely to have a PCS (62%), whereas those with organ failure were least likely to have this (22%). Figure 2 displays the differences in levels of anticipatory and palliative care by illness trajectory.
Percentage of patients with a Key Information Summary (KIS) and with a Palliative Care Summary (PCS) at death, according to illness trajectory and if so when the KIS and PCS were started.
Around half of all patients who died with cancer or frailty/dementia had a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) form completed prior to death in contrast to only 25% of those with organ failure. Only 29% of patients had their preferred place of death recorded, and 23% had their preferred place of final care recorded. Patients with cancer were most likely to have had a record of both these preferences, whereas patients with organ failure were least likely (table 3).
Overall, 50% of patients died in hospital (table 3). Logistic regression was performed to assess the impact of illness trajectory on the likelihood of dying in hospital versus dying in another location, adjusting for practice cluster. The odds of dying in hospital for patients with organ failure was higher than the odds of dying in hospital for patients with cancer (OR=2.30, 95% CI 1.26 to 4.18), or those with dementia/frailty (OR=2.25, 95% CI 1.13 to 4.51).
Anticipatory care and place of death
Across all trajectories, a higher proportion of patients with anticipatory care (ie, with a KIS) died outside of hospital compared to those with no KIS. Overall, 65% of patients with a KIS died in a location other than hospital, compared to only 27% of patients who had no KIS (figure 3).
Deaths in the community: percentage of patients with a Key Information Summary (KIS) or no KIS on each trajectory who died in a location other than hospital.
Logistic regression was performed to assess the impact of having a KIS, a preferred place of care recorded or a preferred place of final care recorded on the likelihood of dying in hospital versus dying in another location, adjusting for practice cluster (table 4). The odds of dying in hospital were over 5.5 times higher for patients without a KIS compared to those with a KIS (OR=5.59, 95% CI 3.31 to 9.42). The odds of dying in hospital were nearly seven times higher for those without a preferred place of care record, compared to patients with a recorded place of care preference (OR=6.61, 95% CI 3.41 to 12.83). The odds of dying in hospital was 7.6 times higher for patients without a record of preferred place of final care compared to patients with a recorded preference (OR=7.6, 95% CI 4.27 to 13.55).
Univariate analysis of potential predictors of dying in hospital, adjusted for practice cluster
Qualitative results
JT conducted interviews with four male and six female GPs who had been qualified as GPs for an average 18 years (range 2–30) and had worked in their current practice for 12 years (range 1–23).
Opinions about KIS
In general, GPs thought the KIS was useful, although not always intuitive to complete; "I think it's one of the bits of paperwork that is useful as opposed to being a pain in the neck" (GP6).
Various methods were used to identify patients for KIS with most practices using the SPARRA data4 as part of this process. Other patients were identified opportunistically or through regular multidisciplinary team (MDT) meetings.
In general, they found that patients were happy to consent and positive around the idea of data sharing in this way. "Generally it's very positively received in my experience" (GP4).
Anticipatory and palliative care issues
GPs discussed difficulties with ensuring that the KIS was well completed and kept up to date, acknowledging that a good ACP can be hard to do. One GP commented that what was written in a KIS tended to focus more on what clinicians, as opposed to patients, might see as important. "I think in general if you look through some of them we're good at putting in the medical background. It's the anticipatory kind we're not always particularly great at that—unfortunately probably the most important bits" (GP 3).
There was a feeling that a well-written free text summary within the KIS was the key to facilitating good anticipatory care, and was probably more important than 'ticking all the boxes' or identifying patients specifically for palliative care. Several participants stressed the importance of continuity of care. "I think the bottom line is, I would say, it needs to be the clinician that really knows the patient, sees them on a regular basis that needs to be doing the ACP" (GP8).
GPs recognised challenges in identifying patients for palliative care, particularly those with non-malignant diagnoses. "You maybe just manage them [non-cancer patients] and you don't really think about them as perhaps benefitting from palliative care" (GP9), although confidence varied and several mentioned feeling that they were improving with this. A few commented that it was often recognised retrospectively that palliative care should have been started or could have been started earlier. "Fairly frequently when we do SEA [significant event analysis] of palliative care cases, almost always you say in retrospect we could have started the whole palliative process a bit sooner, but it involves difficult conversations and facing up to truths that people find difficult to face up to sometimes" (GP 4).
Access of KIS by out of hours and secondary care services
In general, GPs felt KIS were particularly useful for GPs working out of hours (OOH). "Certainly OOH are good, they very frequently will feedback they've had a good ACP so that's useful" (GP 3). GPs who also worked OOH commented on finding them useful when working in this setting.
GPs were less confident about access to KIS in hospitals "I often feel secondary care don't know it's there or are not using it. We've come across that a couple times where we've had patients who were admitted and it was clear they hadn't known to access that or hadn't used it" (GP 3). They reported receiving little or no feedback from hospital services. "The communication is one way, it's from us to secondary care at the moment" (GP 5).
Areas for improvement: IT, training and communication
While most felt that KIS were an improvement on previous methods for data sharing of anticipatory care, there were still issues with integration into GP clinical systems and improving ease of use. "Issues around the layout (in the computer systems are) difficult, can't blend very well" (GP 2). None of the GPs interviewed had had any formal training around discussing and delivering anticipatory care.
There was a desire to see increased use of KIS by secondary care. GPs would welcome increasing dialogue between themselves and other MDT members being able to contribute more actively to anticipatory care planning and KIS and what makes a good care plan. "It would be good to get feedback on if this is a good ACP or this isn't great or we need a bit more information. And better communication from secondary care, on patients they have discharged who are at risk of going back in, to have an ACP" (GP 10).
When comparing the 2014 findings in this present study with 2011 data from a similar group of 10 Scottish practices, we found that patients had a much greater chance of being formally identified for an anticipatory or palliative care approach prior to death than before the KIS was introduced. Moreover, we previously reported that only 20% of patients with frailty/dementia were identified for palliative care, and this was at a very late stage—median of 2 weeks before death. However, this study shows that 35% of patients with frailty/dementia had been identified for palliative care, a median of 10 weeks prior to death.2 A comparison of figures 1 and 2 illustrates these and other differences.
However, despite improvements, many patients, especially with organ failure, were still not documented as identified for an anticipatory approach. Earlier identification helps a series of conversations to take place over time, as we noted in the progressive completion of the KIS in this study, at a pace that suits individual patients, rather than rushed discussions during the last days or weeks of life. As more parts of the KIS were progressively completed, the OR of dying in a location other than hospital for patients with a KIS, compared to those with no KIS, increased.
Surprisingly, slightly fewer patients with a cancer diagnosis were identified as 'palliative' than previously.2 GPs commented that it was the identification for anticipatory care, and the creation of a meaningful ACP, that was of prime importance in managing these patients, rather than being identified specifically for palliative care. Given the ageing population and increasing number of people9 with multimorbidity, there is a shift from disease-focused interventions, which have tended to favour patients dying from cancer for palliative care, towards a more generic goals of care approach. This may be the way forward when thinking about how to deliver equitable care for all in their last phase of life.10 It is not always necessary to talk about dying.
Previous literature has shown that care planning for patients at home, in care homes or at hospital discharge can reduce hospital admissions and increase the chance of dying outside of hospital.11 ,12 Advance Care Planning is sometimes deferred by professionals for fear that the patient may lose hope. However, this is not the case.13 Patients with a KIS, in particular those who had had a discussion about where they wanted to die, were less likely to die in hospital. This is important as most people prefer to die outside of hospital,14 and so any interventions which may facilitate this should be incorporated early into routine care.
GPs recognised the challenges in ensuring high-quality anticipatory care, as previously described.15 Our study, however, noted high levels of conversations around DNACPR/Preferred Place of Care (PPC)/Preferred Place of Final Care (PPFC) documented over a number of weeks, evidencing that GPs are taking time to discuss these issues. GPs face significant challenges in dealing with the increasing numbers of patients who would potentially benefit from anticipatory care and having these conversations sensitively and meaningfully takes time.16 Financial incentives only partly address this. National figures show that GPs are writing more KIS than they are resourced for.17 In order to ensure that patients can continue to be appropriately identified for and offered high-quality anticipatory care planning, these resource issues need to be considered. GPs were positive about KIS in the interface between themselves and GPs working OOH, as reported in a previous KIS evaluation.18
Limitations and generalisability
Enthusiastic KIS adopting practices might have been more likely to participate in this evaluation, but individual practices ranged from having 96% to 36% of patients on a KIS at death, displaying a much wider range of implementation than expected from practice demographic populations. GPs interviewed tended to be experienced and sometimes the practice lead in this clinical area. This was an in-depth evaluation from one Scottish Health Board. However, the KIS and the Palliative Care DES were implemented Scotland-wide and we consider that findings would be similar across the country as there was a wide nationwide uptake of both initiatives. Provisions for electronic shared care records, although 100% in Scotland, vary widely across the rest of the UK, but large projects are going ahead in England.19 We highlight the importance of having electronic, real-time, easily shareable records and the potential benefits they can have. The SPARRA tool has been developed over a number of years, and has widespread use in Scotland, but has not been formally validated.
Implications for service development, teaching, training and research
Conversations about anticipatory and palliative care are sensitive and take time to do well, as also previously described.20 ,21 Time and resources required to address this should be invested, especially given the increasing evidence that planning ahead with patients and carers can reduce hospital admissions and deaths in hospital. Hospital admissions are costly to the NHS, can precipitate a decline in older patients22 and many patients would prefer to avoid admission and die at home. Training in when and how to have anticipatory conversations is needed to improve utilisation, especially when there is so much variation in the number of patients started on KIS by different practices. Research focused on training interventions to improve patient identification and anticipatory care planning is recommended.23
Patients with multimorbidities, in this study noted to be 85% at death, particularly need coordinated care, such as anticipatory care. The KIS has a large part to play in the care of this patient group. Anticipatory care planning is 'everyone's role' and better mechanisms could exist to allow 'real-time' sharing of anticipatory care planning conversations by developments such as the KIS. Routine access of KIS, for patients who have one, should be seen as a compulsory part of care in all settings to help ensure that patient preferences are taken into account and to prevent repeated difficult conversations in multiple settings.
This initiative in Scotland to introduce anticipatory care early in the course of all progressive illnesses has proved to be successful. We evaluated a move away from waiting to identify patients specifically for 'palliative care' towards earlier identification of patients for 'anticipatory care' across all trajectories of physical decline. GPs found that planning with patients to anticipate likely events, which patients wanted to avoid, and seeking consent to share this information with other services involved with patient care were easier to do than having conversations about dying and possible needs for palliative care. Many people with non-malignant illnesses are sometimes more worried about getting dementia or a hospital or care home admission than actually dying, so dealing with their most pressing concerns enables a more person-centred approach than talking about dying.10 More work into how to integrate this type of approach early for a complex multimorbid population internationally is indicated. Further studies comparing 'anticipatory care' or 'future care planning' with 'palliative care' using the KIS and similar initiatives would be useful to guide how people and their carers can best be helped to get early appropriate care to optimise their last phase of life.
GPs have made considerable progress in identifying patients for an anticipatory care approach, earlier in the disease process, and more equitably across the different disease trajectories, than they were previously in identifying patients for palliative care. However, many still miss out from any care planning, particularly those dying with organ failure. Being identified for an anticipatory approach, in particular having a discussion around the preferred place of death, and communicating this with other medical providers is associated with allowing patients to die outside of hospital should they wish to do so, especially in the residential care setting.
Shared electronic records in the form of KIS are appreciated by GPs and are working well, greatly improving communication between GP and OOH care. Providing good anticipatory care should be seen as everyone's business. Secondary care must increase access and awareness of this development for patient benefit. More work is needed to support clinicians in secondary care and the wider MDT to become more actively involved with anticipatory care to ensure that this approach is maintained at all stages, in all settings, when caring for patients over the course of their illness.
The Gold Standards Framework (16 July 2015). http://www.goldstandardsframework.org.uk/advance-care-planning
Zheng L ,
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. How good is primary care at identifying patients who need palliative care? A mixed methods study. Eur J Palliat Care 2013;20:216–22.
World Health Organisation. Strengthening of palliative care as a component of integrated treatment within the continuum of care. Eighth meeting, 23 January 2014, EB134.R7. http://apps.who.int/gb/ebwha/pdf_files/EB134/B134_R7-en.pdf
ISD Scotland. Scottish Patients at Risk of Readmission and Admission (SPARRA) (16 July 2015). http://www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/SPARRA/
Boyd K
. SPICT™ 2014 (16 July 2015). http://www.spict.org.uk
Highet G ,
Crawford D ,
Murray SA , et al
. Development and evaluation of the Supportive and Palliative Care Indicators Tool (SPICT): a mixed-methods study. BMJ Support Palliat Care 2014;4:285–90. doi:10.1136/bmjspcare-2013-000488
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. Analysing qualitative data. BMJ 2000;320:114–16. doi:10.1136/bmj.320.7227.114
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. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012;380:37–43. doi:10.1016/S0140-6736(12)60240-2
Kendall M ,
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. Different experiences and goals in different advanced diseases: comparing serial interviews with patients with cancer, organ failure or frailty and their family and professional carers. J Pain Symptom Manage 2015;50:216–24. doi:10.1016/j.jpainsymman.2015.02.017
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. Anticipatory care planning and integration: a primary care pilot study aimed at reducing unplanned hospitalisation. Br J Gen Pract 2012;62:e113–20. doi:10.3399/bjgp12X625175
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. Advance care planning does not adversely affect hope or anxiety among patients with advanced cancer. J Pain Symptom Manage 2015;49:1088–96. doi:10.1016/j.jpainsymman.2014.11.293
Public Health England. What we know now 2013: New information collated by the National End of Life Care Intelligence Network (15 July 2015). http://www.endoflifecare-intelligence.org.uk/resources/publications/what_we_know_now_2013
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. Advance care planning in the community. Oxford University Press, 2011.
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. Coordination of care for individuals with advanced progressive conditions: a multi-site ethnographic and serial interview study. Br J Gen Pract 2013;63:e580–8. doi:10.3399/bjgp13X670714
Quality and Outcomes Framework: guidance for NHS Boards and GP practices 2014–2015. P157 (16 July 2015). http://www.psd.scot.nhs.uk/professionals/medical/documents/qof-2014-15-guidance-for-nhs-boards-and-gp-practices.pdf
Craig J ,
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. An evaluation of the impact of the key information summary on GPs and out-of-hours clinicians in NHS Scotland. Scott Med J 2015;60:126–31. doi:10.1177/0036933015577540
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. Coordinate My Care: Royal Marsden Hospital. 2012 (cited 1 April 2012). http://www.royalmarsden.nhs.uk/consultants-teams-wards/clinical-services/pages/coordinate-my-care.aspx
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. Are UK primary care teams formally identifying patients for palliative care before they die? Br J Gen Pract 2012;62:e344–52. doi:10.3399/bjgp12X641465
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. Having the difficult conversations about the end of life. BMJ 2010;341:c4862.. doi:10.1136/bmj.c4862
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. The role of intervening hospital admissions on trajectories of disability in the last year of life: prospective cohort study of older persons. BMJ 2015;350:h2361.. doi:10.1136/bmj.h2361
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. Training general practitioners in early identification and anticipatory palliative care planning: a randomized controlled trial. BMC Fam Pract 2015;16:126. doi:10.1186/s12875-015-0342-6
Twitter Follow Charlie Hall at @chazhallNI
Contributors SAM and JT designed the study and recruited the practices. JT collected the data and did the initial analysis supported by JR (qualitative) and AL and AF (quantitative). All authors met as a steering group to bring multidisciplinary perspectives. All authors contributed to the initial draft of the paper and also in checking the final manuscript.
Funding A grant of £4,000 from NHS Lothian funded this study. The posts of CH, JS and AF were funded by Marie Curie. The researcher was in receipt of an academic fellowship from the Scottish School of Primary Care through the University of Edinburgh.
Ethics approval South East Scotland Ethics Service.
Data sharing statement Further data may be available by contacting the corresponding author.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/ This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

redpajama_set_name: RedPajamaCommonCrawl


A play about oil, donuts and road rage, about colonialism, reconciliation and what it means to be a man. And dancing. It's also about dancing.
ASL interpreted. Wheelchair accessible. No stairs or ramps to get into the building or the theatre. Doors into ATB Financial Arts Barns are a 34" width. Entrance to Westbury Theatre is a 32" width. Accessible seating is available on either side of the front row. Gendered washrooms are available. Washrooms are accessible and have clearance for a 32"w x 32"h chair. Air conditioned. More accessibility information is available on the Edmonton Fringe Festival website.


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RENMORE PANTOMIME will celebrate its 40th anniversary with Sleeping Beauty, specially scripted by Panto Dame Peter Kennedy, and directed by AIMS award-winning twins, Brian and Seán Power.
With Ireland trying to get back to its winning ways in the Eurovision Song Contest, Irish Eurovision royalty, King Johnny (Nathan Mannion ) and Queen Linda (Katie Creaven ), marry with the sole intention of creating a genetically perfect Eurovision star of the future. Princess Beauty (Katie Feeney ) is born and the Eurovision hopes of the kingdom rest on her.
Uncle Louie (Michael Cooney ), Sir Philip (David Booth ) and Prince Nicky (Declan J Gardiner ) judge the competing hopefuls, which include Jill (Siofra Ní Chonluain ) and Egbert (Michael Healy ) and Beauty. However, the wicked Queen Diana (Marsha Maly ) believes the Eurovision crown belongs to her and puts a curse on Beauty to prevent her from representing Ireland.
With Nanny Annie (Peter Kennedy ), and Penny (Eilish O'Malley ) and Dopey Dave (Richard Brown ) by Beauty's side, can they break the wicked Queen's curse? The Renmore Smurfs will be there as well.


Insulated lunch bag with velcro closure. Easy-to-carry handle; Folds flat for storage. Front pocket perfect for snacks. One Color Imprint Only.
Insulated Cooler Bag (CPP-3324) with handle and front pocket . Includes two containers with lids that match bag accents.
Foil lined insulated lunch bag. Easy-to-carry handle; Folds flat for storage. Front pocket perfect for snacks.


Stillwater Area High School and police are looking into a threatening message left on the wall of a bathroom stall.
The message discovered Tuesday night referenced Thursday's date, but classes will be held as usual.
Officials have found "nothing to substantiate this as a credible threat," according to a letter sent to parents signed by Principal Rob Bach.


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Home/EUROPE/Turkey faced with the French "genocide law"
EUROPEHOMEPOLITICS
Turkey faced with the French "genocide law"
Foreign Policy News December 25, 2011
French National Assembly
On Thursday, December 23, the French National Assembly (lower house of French Parliament) passed a draft bill to penalize for denial of the Armenian genocide. The proposed document foresees the punishment of one year in state prison coupled with 45,000 euros for any person who denies the massacres of 1915 in eastern Anatolia and beyond constituted genocide.
The draft legislation angered France's NATO ally Turkey which rejects the labeling and considers the claims for usage of word "genocide" are unfounded. Turks claim many Armenians and Muslims died in the Ottoman Empire during the WWII as it fought on many fronts and insists that Armenians killed as many Turks, in most cases, in retaliation to Armenian massacres of Kurds and Turks. The adopted bill will now go to the Senate (upper house of French Parliament) and if passed, will become a law.
The legislation was sponsored by MP Valerie Boyer who is a member of the ruling Union for Popular Movement (UMP) party of the incumbent President Nicolas Sarkozy. She spoke up in defense of the bill, reiterating that the draft law is based on European law on sanctioning parties denying genocides and that it has nothing to do against Turks, specifically. However, regardless of the objectives, the Turkish government sees the step as an insult to Turkish people and asserts the motion was spearheaded by the French President Nicolas Sarkozy, who implicitly favors the legislation. Sarkozy's popularity has been in decline and voter base is shrinking before the 2012 Presidential elections due to rising unemployment and diminishing social benefits. The "genocide law" is thus considered as a bold move to gain popularity among the 500,000 strong Armenian-French community which could play a significant role in the presidential race.
Turkey has already recalled its Ambassador to France, Tahsin Burcuoglu on Friday and announced withdrawal of all joint Franco-Turkish military exercises. Condemnation of the French law has spun all sectors of economic activity as many Turkish consumers of French products have joined boycott campaigns announced in social groups. The passage of the bill was also criticized by the key Turkish ally, Azerbaijan which has its own problems with neighboring Armenia over the Nagorno-Karabakh, a territory within the Republic of Azerbaijan, but under Armenian control since 1994 as a result of bitter war between Armenia and Azerbaijan in 1992-1994.
Turkey has additionally dispatched its own legislators and businessmen to Paris in an effort to quell the draft bill and urge their French counterparts to reject it in the Senate. Senate will be voting on it in two months.
Armenian genocide French law on criminalizing denial of Armenian genocide
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An inevitable "Meds Yeghern" in Franco-Turkish relations
French Senate passes the controversial Armenian genocide bill
French Senate committee's take on "Armenian genocide law" negative
Foreign Policy News
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BA is set to acquire BMI
The dust is settling with #Iran. Now, Washington must pivot to #Syria https://t.co/Gk0TLAGfcE via @foreignpolicyns


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New BC party offers something for pro-lifers
Home/Politics, Pro-Life/New BC party offers something for pro-lifers
Paul Tuns2017-04-03T08:21:14-04:00March 31, 2017|Politics, Pro-Life|
Robin Richardson's Vancouver Island Party has pro-life and pro-family policies.
A new Vancouver Island separatist party has released its guiding principles which includes policies that some pro-life and pro-family supporters could welcome.
In a 44-page document, Robin Richardson, a former Member of Parliament, outlines the mission and guiding principles of the Vancouver Island Party. The VIP wants independence for Vancouver Island, voicing their motto "Island First and Proud of It!" They want the opportunity to maintain and enhance the way of life enjoyed by the inhabitants of Vancouver Island, free from the restraints of what it considers an insecure, left-leaning mainland government, but remaining a part of Canada as an eleventh province. The VIP states that its policy platform is "economically responsible, socially progressive, environmentally green, and culturally respectful."
VIP believes in a fiscally responsible government, hence its insistence on balanced provincial budgets, elimination of the provincial government debt, making corporate/business taxes competitive with other Canadian jurisdictions, and exploring a flat income tax system. Fair labour laws and practices, green energy, development of rail and port facilities would be helpful to creating a buoyant green economy and lots of jobs for Vancouver Islanders, Richardson argues.
Richardson says that a new province could more easily carry out a democratic reform of government: adoption of some form of proportional representation; recall legislation; direct initiative/referendum; public funding of provincial parties; and a servant-leadership approach for all levels of government.
In health care policy, the party promises investments in palliative care and mental health, and to find savings in bulk purchasing of pharmaceutical drugs.
Jeff Gunnarson, vice president of Campaign Life Coalition, says "there are many policies that would be very welcome to pro-family and pro-life people, especially in the areas of health and education."
VIP says it takes a centrist approach to public issues and their resolution, so while it is not prepared to outlaw abortion, its policies would reduce that practice over time. Richardson says VIP supports the sanctity of life and the dignity of the human person. The party is prepared to make adoption easier, support parenting and pregnancy centres, and provide funding for post-abortion grief. It would protect unborn children's health by reducing the perceived need for abortion through educational initiatives such as requiring comprehensive information on the full range of post-abortion effects on women having an abortion, and ensuring that evidence-based medicine must apply to all kinds and practices of medicine, including abortion, in order to obtain government funding under the Canada Health Act. The onus then would be on the doctor to prove that an abortion was necessary. Effectively, such an approach would result in fewer abortions because no abortion would be permitted unless the life of the mother was truly and demonstrably threatened by the pregnancy.
Moreover, freedom of conscience and religion would be respected and protected as per the Charter of Rights and Freedoms so that health care professionals and institutions would be free to act according to their conscience in participating in or referring for euthanasia, assisted suicide or abortion.
The VIP platform would support the family structure by its declaration that it is the right and duty of parents to raise their own children responsibly, according to their own conscience and beliefs. It recognizes the principle that parents are the child's first and most important teachers. This attitude in practice would help eliminate the type of state-imposed sexual health curriculum introduced in Ontario and so-called equity policies in Alberta. Families would be also given tax relief for homecare of their children (income splitting for couples with children) and government grants would be given on a per pupil basis to approved/qualified home schools equal to the grants given to school boards per student.
Yet according to Gunnarson, there are internal contradictions in some elements of the platform, or at least aspects that appear difficult to reconcile. He pointed to the fact that principle of environmentalism to conserve the natural environment of Vancouver Island, Gunnarson warns that language such as "sustainable development" come with baggage including population control measures that worry pro-life advocates.
VIP stands for devolution, explained as the concept of subsidiarity, the belief that social bodies like government exist for the sake of individuals and that whatever individuals can do for themselves, society or the state should not take over and do for them. Individuals should be held accountable for their actions and take responsibility for their own welfare as much as possible.
Gunnarson said "all in all, the Vancouver Island Party is a breath of fresh air on the political scene," because "many of its policies make sense." Without commenting on their goal of separating from British Columbia, Gunnarson said it is "refreshing" to see "an truly centrist party promote policies that are pro-life and pro-family."
Public inquiry reveals no justification for declaring national emergency
Resolve to do more
Justice Minister indicates willingness to delay euthanasia for mental illness


This spring, return with us to a time before texting and e-mail, to a time of simpler pleasures: friends and family and music as warm and comforting as a visit home. Los Angele's own Balalaika Orchestra presents its 23rd annual concert featuring melodies guaranteed to set you on a journey through your past. Your journey will be conducted with the help of some remarkable guest soloists including soprano, Anna Belaya and baritone Vladimir Chernov. They will be joined onstage by high-flying dancers and instrumental masters of the domra and balalaika. With our world famous folk instrument orchestra providing a shimmering musical landscape behind these artists, during the concert you may hear another sound, that of your heartstrings.


Students demanding safer roads have given the government 48 hours to concede their demands. They ignored Dhaka North City Corporation (DNCC) Mayor Atiqul Islam and city police chief Asaduzzaman Mia's request to end the protest and vowed to continue demonstration until their demands are met, local media reported.
Abrar Ahmed Chowdhury, a Bangladesh University of Professional student, died in front of Bashundhara residential area on Tuesday (Mar 19) morning after being run over by a bus. Private university students have since been demonstrating at Pragati Sarani.
Witnesses said hundreds of students from BUP, North South University and Siddheshwari College occupied the street just after 9.15 a.m., halting traffic on the busy road.


When purchasing a ranch property, the buyer should have a clear vision for what the ranch is going to be used for. The buyer will need to consider if the ranch will be a for-profit business, purely for recreational purposes or will there be some overlap of the two. A cattle or bison ranch will be used as a for profit business. While hunting, fishing and horse ranches can be bought for the purpose of recreation or a business component could be added to accommodate guest lodges.
This is the image that comes to mind when people commonly think of a ranch. This type of ranch requires large and extensive acreage and feedlots. Knowledge of the business is essential, as well as hiring people who can help work on the ranch.
This type of property has the appropriate habitat for hunting deer, elk or antelope. A hunting ranch will require a source of water and appropriate shade for the animals. It is important to continually maintain the perfect conditions for wildlife in order to preserve the quality of hunting.
A fishing ranch, of course, will have a water source on the property. This might mean natural streams or rivers for fly-fishing. Or a man-made lake that has been well-stocked.
This property has been designed for the horse lover. A horse property usually consists of a barn, riding trails, arenas, pastures, hay storage and horse stalls.
These properties, with their extensive acreage and privacy, allow high-end buyers to purchase a ranch that is usually located in a highly sought after resort spot. Buyers of this type of property might enjoy a bit of hobby ranching, while enjoying the relaxing tranquility of luxurious amenities.


The first step is to go to Amazon and apply for Amazon Associate Program. By applying to this program, you will have the ability to earn commission by promoting any Amazon product. Since Amazon is a widely-known online merchant, you don't have to worry about their reputation and credibility.
It is better for you to choose a product which has $100-$200 price tag in order to earn good amount of commission in each sale. Also, you should choose product that is bestseller on Amazon and has good amount of positive feedbacks. The product can be in any category according to your interest.
You need to write a review article about the product that you decide to promote. If you're not personally use the product, you can find some information from the feedbacks on the product page. Make sure to write a professional review about the product. Tell the benefits and drawbacks of the product in your review.
The simplest way to publish your review is to create a free blog on Blogger. If you have no cash at the time, you don't need to set up a website for your review. You just need a Blogger blog. Go to blogger.com and set up a new blog there. Choose a good name for your blog. Remember that your name should be related with the product that you review. After you've set up your free blog, you can publish your review to your blog.
Your work isn't done here. You need to attract people to read your review article and finally make them to buy the product that you promote. To do this, you have to write regular articles related to the product that you review and submit those articles to article directory such as EzineArticles.com. You have to write articles that are related with the review article that you've written. So, for example, if you are writing a review article about coffee maker product, you can write articles about 'How to Make High Quality Coffee at Home' 'Benefits of Using Coffee Maker Product" and so on. The last thing is to place the link to your blog in your articles.
Those are simple steps you can do to earn serious cash by writing articles. If you follow the steps properly, you will be able to get at least $500 commission check per month from Amazon. The key is to keep writing and promoting.
Web Security Vulnerabilities – How to Fix Them?


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Lupii București, cunoscuți și ca Bucharest Wolves, sunt echipa profesionistă de rugby care reprezintă cluburile românești din SuperLiga la European Rugby Challenge Cup (Challenge-ul european al cluburilor), al doilea eșalon valoric al rugby-ului european.

Echipa a fost creată de Federația Română de Rugby pentru a familiariza cu nivelul înalt european cei mai buni jucători ai competiției interne eligibili la naționala României. Sub denumirea "Bucharest Oaks" (Stejarii București), a jucat primul său meci de European Challenge Cup împotriva clubului francez RC Toulon, scorul fiind 16–20. În anul 2011 s-a redenumit "Lupii București".

Referințe

Legături externe
 Pagina oficială de Facebook
 Știrile despre Lupii București la Federația Română de Rugby
  Prezentare  pe EPC Rugby

Rugby în România
Cluburi de rugby din România

redpajama_set_name: RedPajamaWikipedia


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What made Jude Law famous?
What made Jude Law famous? – Additional Questions
Which actor has been in the most movies?
Who is the highest paid actor?
Who is the richest actor?
Which actor has made the most money?
Who is the most famous actor of all time?
What is the #1 grossing movie of all time?
Who is the highest paid actor 2022?
Who Is Highest Paid actor 2021?
Who is the most popular actor right now?
Who is the best actor in the world?
Who is God of acting?
Which actor has most fans in world?
Who is the best girl actor in the world?
Who has the hottest body in Hollywood?
Who has the hottest female body in Hollywood?
Who is the cutest actor in the world?
Who is the most handsome man alive?
What made Jude Law famous? Jude Law made his breakthrough splash in The Talented Mr. Ripley, though anyone who had been following his early career through Gattaca, Music From Another Room, and Wilde already knew what he was capable of by the time the world saw him in the Anthony Minghella thriller.
What has Jude Law been in recently?
Known For. The Talented Mr.
Closer Dan (2004)
The Grand Budapest Hotel Young Writer (2014)
Sky Captain and the World of Tomorrow Sky Captain (2004)
Actor.
The Rhythm Section: Deleted and Extended Scenes Iain Boyd (2020)
The Hat Mystery Assailant (2020)
The Third Day Sam (2020)
Who did Jude Law play in Harry Potter? For over 20 years, Albus Dumbledore has been one of the most beloved characters in J.K. Rowling's "Harry Potter" world but actor Jude Law, who continues to play the character in Fantastic Beasts: The Secrets of Dumbledore, reveals that Dumbledore is going through "a process of regression" from the older Harry Potter
What else did Jude Law play in? British actor Jude Law has received Oscar nominations for his performances in 'The Talented Mr. Ripley' and 'Cold Mountain,' having also starred in projects like 'A.I.,' 'Sherlock Holmes' and 'Spy. '
Ernest Borgnine. Known for his trademark gap-toothed grin, Ernest Borgnine had starred in 148 films by the time of his death in 2012.
Making Jerry Seinfeld one of the world's richest actors. He makes approximately $50 million annually. Actress and investor Jamie Gertz is the richest actor in the world. The '80s star's net worth is estimated to be $3 billion.
Thanks to the "Fast and the Furious" franchise, as well as blockbusters like "Moana" and "San Andreas," Dwayne Johnson's movies have earned nearly $11.4 billion worldwide.
Actually, based on science, Samuel L. Jackson is the most popular actor of all time, ever. According to a 2018 study published in Applied Network Science, using a wide range of metrics—including number of films, times appearing as top billing, and length of career—Jackson is peerless in the field.
Tom Cruise — $100 million+ ("Top Gun: Maverick")
Leonardo DiCaprio — $30 million ("Killers of the Flower Moon")
Dwayne Johnson — $22.5 million+ ("Black Adam")
Chris Hemsworth — $20 million ("Extraction 2")
Denzel Washington — $20 million ("The Equalizer 3")
Eddie Murphy — $15 million ("Beverly Hills Cop 4")
Brit actor Daniel Craig is the world's highest-paid actor, the courtesy lucrative deal signed with streaming service platform Netflix in 2021. His runaway hit mystery comedy film "Knives Out" released in the year 2019 will premiere the next two upcoming sequels on Netflix.
1. Dwayne Johnson. Dwayne Douglas Johnson who is also known as The Rock is an American actor, as well as a wrestler, who was born on 2nd May 1972. Dwayne/Rock is a talented person who is famous in both Hollywood and the wrestling fields.
While Leonardo tops the Best Actor in the world list for Google, coming a close second to him on the list is Tom Hanks. The 66-year-old actor has had a splendid Hollywood career with films such as Forrest Gump, Cast Away and several other notable works to his name.
Mohanlal is referred as the god of acting. His talent of natural acting is amazing. He received these awards and honours as a part of this.
One of the most successful film stars in the world, SRK has been regularly referred to as the world's biggest movie star by international media. In fact according to a popularity survey, 3.2 billion people around the world know Shah Rukh Khan, more than who know Tom Cruise.
From Audrey Hepburn to Meryl Streep, these iconic women are some of the best female actors in cinematic history, according to Ranker.
The 10 Best Female Actors In Movie History, According To Ranker
1 Bette Davis.
2 Meryl Streep.
3 Dame Maggie Smith.
4 Dame Judi Dench.
5 Dame Helen Mirren.
6 Ingrid Bergman.
7 Audrey Hepburn.
David and Victoria Beckham were dubbed the Hottest Celeb Couple, capturing 34 percent of the vote. Now broken up Cameron Diaz and Alex Rodriguez came in second. Brad Pitt was named the Best Male Celebrity Body Over 40, capturing 29 percent of the vote.
Hollywood's 25 hottest fit celebrity women
1 of 25. Julianne Hough.
2 of 25. Jennifer Lawrence.
3 of 25. Kerry Washington.
4 of 25. Jessica Biel.
5 of 25. Stefanie Keenan/Getty Images for Target.
6 of 25. Elsa Pataky.
7 of 25. Rachel Bilson.
8 of 25. Jennifer Lopez.
The Top 25 Sexiest Men
No 1 – Jamie Dornan. At the top spot for us at Heart it has to be the original Mr Grey.
No 2 – Idris Elba. Idris Elba smoulders on the cover of Maxim magazine.
No 3 – Henry Cavill.
No 4 – David Beckham.
No 5 – Ryan Gosling.
No 6 – Ryan Reynolds.
No 7 – Bradley Cooper.
No 8 – Jake Gyllenhaal.
Robert Pattinson has the most perfect physical features, followed by British actor Cavill, who has a score of 91.46 percent. In 2020, Hollywood actor Robert Pattinson was announced as the most attractive man in the world according to science.
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According to the National Eating Disorders Association, an estimated 20 million women and 10 million men develop an eating disorder at some point in their life. The NFCA's Healthcare Relations Manager Kristin Voorhees is one of those 20 million women.
As a professional in the field of patient advocacy, it is a natural fit to share personal insights and experiences that extend beyond the topic of celiac disease when given the right opportunity. So, during National Eating Disorders Awareness Week (NEDAwareness) I thought that I would join the country's discussion of reducing the stigmas associated with disordered eating behaviors and body image issues.
According to the National Eating Disorders Association, an estimated 20 million women and 10 million men develop an eating disorder at some point in their life. I am one of those 20 million women.
When I read that statistic, it is hard to wrap my head around the number of people living in discomfort and unhappiness with their bodies. After all, to quote Baz Lurhmann, who sang the infamous "Everybody's Free (To Wear Sunscreen)" song adapted from Mary Schmich's Chicago Tribune column, isn't your body supposed to be "the greatest instrument you'll ever own"?
As someone with a history of an eating disorder not otherwise specified (EDNOS), I found my diagnosis of celiac disease to be more than just a relief; it was incredibly apt, almost too coincidental of a solution. I could begin to heal my body through nutrition.
For years I lived in a fog where each day revolved around the same slew of preoccupations: food, exercise and weight. Almost immediately, my celiac disease diagnosis uprooted these thoughts and I began to view food as medicine, not the devil.
Perhaps my perspective is a sappy one. But for those living with celiac disease who still wrestle with the all-consuming preoccupations that only those with an eating disorder too often can understand, I gently encourage you to focus on the content and not the frame: it is possible to heal when food is your medicine.
To read more about celiac disease and eating disorders, check out this research recap.
You can also join the NEDAwareness conversation over on their website.
Questions? Comments? Please feel free to email me: [email protected].


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There is a company called NordicTrack that makes exercise equipment. One of their products is pictured above. I am all for exercise, but today I am thinking about another "Nordic Track," the one that is now politically linked to Bernie Sanders, who is pictured below.
Anu Partanen is a journalist based in New York. She is also the author of a forthcoming book called, The Nordic Theory of Everything. Partanen wrote an article for The Atlantic, published on March 16th, titled "What Americans Don't Get About Nordic Countries." Except for Bernie Sanders, of course. He gets it. That's where I got the Bernie Sanders' photo, from that article in The Atlantic.
This is what Americans fail to understand: My taxes in Finland were used to pay for top-notch services for me.
What Partanen is saying, to cut to the chase, is that we all are better off (individually) when we pool resources and act together. What a concept!
When Hillary Clinton says, "We are not Denmark," I'm forced to agree. We don't currently live in a country that pools our national resources to make life better for everyone, both collectively and individually.
Of course, we could live in such a country (and without moving to Scandinavia, either)!
It might be time to start exercising on that Nordic Track!


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« Israel Will Not Be A 'Perfect Victim' By George Will | Main | Reception for Sculpture exhibit artist Bob Clyatt »
Ed Koch Commentary: Citizens Recall and Be Guided by The Letter of President George Washington to The Jews of Rhode Island. It Applies to The Muslims of New York. BY Edward I. Koch
New York, NY, August 16, 2010
President Obama was right to express his views on constructing a mosque near Ground Zero, the site of the 9/11 catastrophe, "As a citizen and as President, I believe that Muslims have the same right to practice their religion as everyone else in this country. And that includes the right to build a place of worship and a community center on private property in Lower Manhattan in accordance with local laws and ordinances."
The President is also right to oppose as he does the efforts by some to amend the 14th Amendment to the United States Constitution to bar babies born to illegal immigrants from becoming citizens.
Mayor Michael Bloomberg, who was first to take up the fight to protect the legitimate rights of American Muslims to build a mosque near Ground Zero, was right and courageous to lead the way and point Americans in the right direction.
President Obama, according to The New York Times of August 15th is now "faced with withering Republican criticism of his defense of the right of Muslims to build a community center and mosque near Ground Zero." Those leading the charge against the President, according to The Times, "including Newt Gingrich, the former House speaker, Representative John A. Boehner, the House minority leader and Representative Peter King of New York, forcefully rejected the President's stance."
The President's position will be remembered by later generations of Americans with the same high regard as President George Washington's letter in 1790 to the Jews of Rhode Island who built the Touro Synagogue in that state. Moses Seixas of the Hebrew Congregation in Newport, Rhode Island wrote to George Washington: "Deprived as we heretofore have been of the invaluable rights of free Citizens, we now with a deep sense of gratitude to the Almighty disposer of all events behold a Government, erected by the Majesty of the People — a Government, which to bigotry gives no sanction, to persecution no assistance — but generously affording to all Liberty of conscience, and immunities of Citizenship: — deeming every one, of whatever Nation, tongue, or language equal parts of the great governmental Machine: — This so ample and extensive Federal Union whose basis is Philanthropy, Mutual confidence and Public Virtue, we cannot but acknowledge to be the work of the Great God, who ruleth in the Armies of Heaven, and among the Inhabitants of the Earth, doing whatever seemeth him good."
President Washington responded as follows: "...The Citizens of the United States of America have a right to applaud themselves for having given to mankind examples of an enlarged and liberal policy: a policy worthy of imitation. All possess alike liberty of conscience and immunities of citizenship. It is now no more that toleration is spoken of, as if it was by the indulgence of one class of people, that another enjoyed the exercise of their inherent national gifts. For happily the Government of the United States, which gives to bigotry no sanction, to persecution no assistance requires only that they who live under its protection should demean themselves as good citizens, in giving it on all occasions their effectual support. It would be inconsistent with the frankness of my character not to avow that I am pleased with your favorable opinion of my Administration, and fervent wishes for my felicity. May the children of the Stock of Abraham, who dwell in this land, continue to merit and enjoy the good will of the other Inhabitants; while every one shall sit in safety under his own vine and figtree, and there shall be none to make him afraid. May the father of all mercies scatter light and not darkness in our paths, and make us all in our several vocations useful here, and in his own due time and way everlastingly happy. G. Washington"
Let us not do again, albeit in different form and to a different group what we did to Japanese-Americans during World War II when we rounded them up without cause. No Japanese-American was ever charged with treason, notwithstanding that they were placed in internment camps for the balance of the war.
I am a proud Jew. Proud of my religion and my culture. Columnist David Brooks, also Jewish and similarly proud, in a New York Times article of January 12, 2010, wrote of our people's accomplishments: "Jews are a famously accomplished group. They make up 0.2 percent of the world population, but 54 percent of the world chess champions, 27 percent of the Nobel physics laureates and 31 percent of the medicine laureates. Jews make up 2 percent of the U.S. population, but 21 percent of the Ivy League student bodies, 26 percent of the Kennedy Center honorees, 37 percent of the Academy Award-winning directors, 38 percent of those on a recent Business Week list of leading philanthropists, 51 percent of the Pulitzer Prize winners for nonfiction."
We Jews also have our share of thieves, predators, child molesters, Ponzi-schemers, traitors and profiteers. Muslims have their share of great world accomplishments – the concept of zero, advancements in mathematics, medicine, chemistry, botany and astronomy. They also have their share of crazies, tyrants, homophobes, those holding hostile and irrational attitudes towards women, vilification of Jews, Christians, Hindus and other so-called infidels.
Let's be calm now and not need the passage of time to bring us to our senses and years later apologize. Of course, those who suffered the loss of loved ones, and those exposed to the catastrophe of 9/11 have every right to hold opinions opposing the building of the mosque. They are grieving and rightfully enraged at anyone associated in any way with the 19 Muslim terrorists who were responsible for the deaths of nearly 3,000 Americans killed on 9/11, and all of us must sympathize with them and their feelings.
But Americans must never forget who we are and why our Founding Fathers and those who built the original 13 colonies came here. It was primarily to find and create a new country in which they could practice religious freedom, denied them in England. Jews found that freedom of religion in New Amsterdam, where the East India Company of Holland directed the first public anti-Semite in that city – its Governor, Peter Stuyvesant – to let them in, he first refusing to do so.
I believe we are locked in battle with fanatical Islam and will be for the foreseeable future. I do not believe the vast majority of Muslims, and American Muslims in particular, are fanatics or enemies of the American people.
Government should neither favor nor hinder the efforts of religious institutions, other than to protect their rights to engage in carrying them out as permitted under the First Amendment of the Constitution.
A final word on those seeking to end the concept of American citizenship by virtue of birth, led by Senator Lindsey Graham (R-SC): Don't they understand that the concept of citizenship by birth is one of the great American ideas of which we have been justly proud and which distinguishes us from many other countries and has served us well? They should not fear the Know Nothings, whose voices are loud, but whose numbers are small. They should not shame themselves by joining these violators of American values and traditions.
The Honorable Edward Irving Koch served New York City as its 105th Mayor from 1978 to 1989. His e-mail address is: eikoch@bryancave.com
Posted at 01:08 PM in Ed Koch Commentary By Edward I. Koch | Permalink
Tags: Ed Koch, Freedom of religion, George Washington, Ground Zero, House, Islam, New York City, United States, United States Constitution, Westchester newspaper


A family's desire for a piece of land and a house is as old as civilization itself. Through the centuries, the pressure of this desire has grown as the world's population has soared. The problem is more acute in some countries than others.
The founders of the governing National Liberation Party in Costa Rica recognized this pressure shortly after the 1948 revolution that brought them to power, and three decades ago they set up the National Urban Housing Institute (INVU) to arrange for low-cost housing and the Institute of Lands and Colonization (ITCO) to handle land distribution.
Because neither of these organizations could solve the growing problems of subsistence families living in slums, the Mixed Institute for Social Assistance (IMAS) was set up 20 years ago.
All three – IVU, ITCO and IMAS grew steadily in bureaucratic structure, even though their planning often fell short of meeting growing demands for low-cost housing and available parcels of land.
Costa Rica has long been plagued by problem of squatters, individuals or families who casually move on to a piece of land – sometimes public, sometimes private – and remain unless they are forcibly ejected.
The Constitution guarantees the inviolability of land ownership, and also provides that expropriated land must be paid for immediately and at a fair price. But if squatters manage to live for one year on land they have occupied, they then can remain on the property.
In recent years, the practice of squatting has grown into a tactic employed by displaced labor groups or political movements.
The violence in the southern area of Coto Brus is but one of numerous such instances that has plagued this and previous administrations.
President Luis Alberto Monge's government seems inclined to solve such crises by expropriating the occupied land so that it can be turned over to the squatters – who most certainly need some place to live. The negotiations are being carried out under direct supervision of the Council of Government.
This policy is not only complicated and expensive for a government in deep financial trouble, but also seems to bypass the three well-staffed institutions – INVU, IDA, and IMAS – which were created specifically to deal with such problems. One is tempted to ask what they are doing, and why their planning had not foreseen such emergencies.


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Pink Friday: Roman Reloaded – drugi studyjny album amerykańskiej raperki Nicki Minaj. Album wydany został 3 kwietnia 2012 przez wytwórnie Young Money Entertainment, Cash Money Records i Universal Republic Records.

Na płycie gościnnie wystąpili: Cam'ron, Rick Ross, 2 Chainz, Lil Wayne, Nas, Drake, Young Jeezy, Chris Brown, Bobby V i Beenie Man. Album był promowany singlem "Starships", którego premiera miała miejsce 14 lutego 2012. Zadebiutował na 9. miejscu notowania Billboard Hot 100. Kolejnymi singlami zostały "Beez in the Trap" z 2 Chainz i "Right by My Side" z Chrisem Brownem. Płyta jest promowana również podczas trasy koncertowej Pink Friday Tour.

Album jest podzielony na dwie części: pierwsza to utwory hip hop a druga pop i dance. Nad płytą pracowali producenci z którymi Minaj jeszcze nie pracowała, m.in. RedOne, Dr. Luke i Alex da Kid.

Na liście Billboard 200 album zadebiutował na miejscu pierwszym. Znalazł się też na szczycie list w Kanadzie i Wielkiej Brytanii.

Single
 "Starships" - pierwszy singel z albumu wydany 14 lutego 2012. Zastąpił Va Va Voom który początkowo miał być pierwszym singlem. Teledysk do utworu ukazał się 26 kwietnia 2012. Na liście Billboard Hot 100 piosenka znalazła się najwyżej na pozycji piątej.

 "Right by My Side" - 27 marca 2012 wydany jako drugi singel. W piosence gościnnie wystąpił Chris Brown. Teledysk do piosenki miał premierę 16 maja 2012. Utwór zadebiutował na liście Billboard Hot 100 na pozycji 51.

 "Beez in the Trap" - kolejny singel wydany 24 kwietnia 2012. 2 Chainz wystąpił gościnnie w utworze. 6 kwietnia 2012 pojawił się teledysk do singla. Piosenka na liści Billboard Hot 100 znalazła się na najwyższej pozycji 48.

 "Pound the Alarm" - 17 lipca 2012 został wydany jako czwarty singel z albumu i drugi międzynarodowy. Teledysk ukazał się 31 lipca 2012.

 "I Am Your Leader" - został wydany 25 sierpnia 2012 roku. W teledysku gościnnie wystąpił Rick Ross i Cam'Ron.
 "The Boys" - został wydany jako pierwszy singiel z reedycji krążka Pink Friday: Roman Reloaded zatytułowanej Pink Friday: Roman Reloaded - The Re-Up. Dnia 18 października miał swoją premierę na oficjalnym kanale Nicki Minaj. W teledysku wystąpiła wraz z Cassie.

 "Come On A Cone" - został wydany 15 października 2012 roku jako drugi teledysk z płyty Pink Friday: Roman Reloaded - The Re-Up, a siódmy z Pink Friday: Roman Reloaded .Teledysk został nagrany na koncertach ale są w nim również sceny z gal na których była Nicki Minaj.

 "Va Va Voom" - został wydany 26 października 2012 roku jako trzeci singel z płyty Pink Friday: Roman Reloaded - The Re-Up, a ósmy z Pink Friday: Roman Reloaded. Teledysk jest utrzymany w baśniowym i magicznym klimacie.

Lista utworów

Notowania i certyfikaty

Notowania

Certyfikaty

Historia wydania

Przypisy

Albumy muzyczne wydane w roku 2012
Albumy Nicki Minaj
Albumy Cash Money Records
Albumy Young Money Entertainment
Albumy wyprodukowane przez Alexa da Kida
Albumy wyprodukowane przez Cirkuta
Albumy wyprodukowane przez Dr. Luke'a
Albumy wyprodukowane przez Hit-Boya
Albumy wyprodukowane przez J.R. Rotema
Albumy wyprodukowane przez RedOne'a
Albumy wyprodukowane przez T-Minusa


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