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Development and evaluation of the feasibility and effects on staff, patients, and families of a new tool, the Psychosocial Assessment and Communication Evaluation (PACE), to improve communication and palliative care in intensive care and during clinical uncertainty

  • Irene J Higginson1Email author,
  • Jonathan Koffman1,
  • Philip Hopkins2,
  • Wendy Prentice1,
  • Rachel Burman1,
  • Sara Leonard2,
  • Caroline Rumble1,
  • Jo Noble2,
  • Odette Dampier2,
  • William Bernal2,
  • Sue Hall1,
  • Myfanwy Morgan3 and
  • Cathy Shipman1
BMC Medicine201311:213

DOI: 10.1186/1741-7015-11-213

Received: 3 August 2013

Accepted: 30 August 2013

Published: 1 October 2013

There are widespread concerns about communication and support for patients and families, especially when they face clinical uncertainty, a situation most marked in intensive care units (ICUs). Therefore, we aimed to develop and evaluate an interventional tool to improve communication and palliative care, using the ICU as an example of where this is difficult.

Our design was a phase I-II study following the Medical Research Council Guidance for the Development and Evaluation of Complex Interventions and the (Methods of Researching End-of-life Care (MORECare) statement. In two ICUs, with over 1900 admissions annually, phase I modeled a new intervention comprising implementation training and an assessment tool. We conducted a literature review, qualitative interviews, and focus groups with 40 staff and 13 family members. This resulted in the new tool, the Psychosocial Assessment and Communication Evaluation (PACE). Phase II evaluated the feasibility and effects of PACE, using observation, record audit, and surveys of staff and family members. Qualitative data were analyzed using the framework approach. The statistical tests used on quantitative data were t-tests (for normally distributed characteristics), the χ2 or Fisher’s exact test (for non-normally distributed characteristics) and the Mann–Whitney U-test (for experience assessments) to compare the characteristics and experience for cases with and without PACE recorded.

PACE provides individualized assessments of all patients entering the ICU. It is completed within 24 to 48 hours of admission, and covers five aspects (key relationships, social details and needs, patient preferences, communication and information status, and other concerns), followed by recording of an ongoing communication evaluation. Implementation is supported by a training program with specialist palliative care. A post-implementation survey of 95 ICU staff found that 89% rated PACE assessment as very or generally useful. Of 213 family members, 165 (78%) responded to their survey, and two-thirds had PACE completed. Those for whom PACE was completed reported significantly higher satisfaction with symptom control, and the honesty and consistency of information from staff (Mann–Whitney U-test ranged from 616 to 1247, P-values ranged from 0.041 to 0.010) compared with those who did not.

PACE is a feasible interventional tool that has the potential to improve communication, information consistency, and family perceptions of symptom control.

Palliative care Communication Uncertainty Critical care unit Intensive therapy unit End-of-life care Intensive care unit Psychosocial

Communication and support for patients and their families are of central concern in healthcare, and yet too often are poorly addressed, especially at times of rapid changes in health status and in clinical uncertainty. The intensive care unit (ICU) is one setting in which patients’ circumstances can change rapidly. Although the central goal in the ICU is to preserve or extend life, the nature of illness or trauma means that more than one in five people admitted to an ICU die there [1]. Many (36 to 70%, depending on type of the ICU) deaths occurring in ICUs are preceded by a decision to limit or withhold life-sustaining treatment [1, 2]. Recent initiatives, such as care pathways, have sought to improve end-of-life care, but these have focused on patients who are already known to be dying [3]. There is a need to develop a wider range of interventions before this point to improve symptom control, communication, and support in ways appropriate both for patients who may recover, and for those who deteriorate or die [4]. This is particularly important for the growing number of people who experience co-morbidities and because of the advances in medical treatments, both making prognostication ever more difficult. Palliative care is an area of healthcare focused on relieving and preventing the suffering of patients with complex needs and their families, including physical, emotional, communication, social, and spiritual aspects. Unlike much hospice care, palliative care is relevant at all stages of illness, including during curative treatment and at the end of life.

Summary of existing literature on levels of need and interventions

We searched electronic databases to identify literature on the needs of patients and families in the ICU and potential interventions. Systematic reviews and research have highlighted concerns about support for patients and families, symptom control, communication, and decision-making, especially regarding when to stop invasive treatments, and attention to individual wishes and to dignity, respect, and peace in the ICU (Table 1) [525]. To address these problems, initiatives have sought to increase specialist palliative care input and/or to to embed the principles of palliative or hospice care into everyday practice [26, 27]. Interventions include having a palliative care team presence at family meetings and on ward rounds, providing education and support for ICU staff, making recommendations for symptom management, and directly supporting patients and families in shared care and implementation of care pathways. However, evidence of best practice in this area is limited [18]. A randomized, controlled, feasibility study evaluating palliative care teams in an Australian ICU found no significant differences in satisfaction with care of families and staff or in length of stay, but the study was underpowered (10 patients randomized to each arm) [28]. A prospective, observational study of a structured palliative care intervention for trauma patients in the ICU [29] applied the intervention to all trauma patients because of the high mortality (15 to 20%). The study found that Do Not Resuscitate orders, life support withdrawal, and discussions of symptom management occurred significantly earlier, with no change in mortality rate, but the effect on families or patients was not assessed. The Liverpool Care Pathway for the care of the dying patient (LCP) is adapted for ICU, but needs comparative evaluation [30].
Table 1

Commonly identified concerns of patients and families in ICU care, in progressive illness: data from literature, phase I interviews and observation

Areas of concern identified in the background literature review

Results from the family member and patient interviews, and from observation

Results from the staff interviews and focus groups

Symptom management, with distressing symptoms sometimes not addressed [516, 31]

There was a general perception among family members that symptoms were well controlled, and that timely action was taken when the patient appeared to be distressed. There was varying documentation of assessment of symptoms and symptom assessment tools changed frequently, for example, from one nursing shift to the next

Most interviewees thought that end-of-life care was well provided by the medical and nursing workforce, which was considered very experienced

Communication issues, in particular communicating the changing circumstances to patients and families; [17, 3139]

The importance of being able to ask questions and have them answered was emphasized by family members, but there was also a sense that family members felt they were responsible for getting information by asking the right questions of the right people. Particular words stood out for some people, reinforcing the need for careful choice of the words in this context. Factors described by family members as affecting communication included: their poor memory of the details of a discussion; shock affecting their ability to take in information; and their poor knowledge of medical issues making it hard for them to understand all the information given. There was an overall sense that the information given was complete and honest, that family members found it helpful if bad news could be tempered with good news, and that the uncertainty of outcome was explained well

Improved information for families including what to do in the event of a death; better privacy/side rooms for patients and family members; private space to talk to families; a position on reception for someone to greet and support family members; more support for family members and provision of on-site accommodation

Dealing with prognostic uncertainty and decision-making, which may lead to prolonged dying [25, 40], or conversely, very rapid deterioration of the patient once a decision to withdraw treatment is made, with families sometimes feeling abandoned [31, 33, 35, 36, 4144]

The greatest factor influencing involvement in decision-making was patient capacity. Preferences of family members for involvement varied; generally most of them wanted information about the process but not greater input (some preferring less). Some types of decision were more likely to be influenced by family members (place of care, aim of care, some interventions for example, tracheotomy) whereas others were more often directed by the clinician (for example, resuscitation status)

Decision-making towards the end-of-life in ICU is complex and multifactorial. Although not everyone was aware of it, the LCP was reported to be used particularly on the medical ICU. It was thought to be useful for patients on a longer dying trajectory and for those discharged to the wards, to ensure continuity of care. There were concerns about its length, but also some support because it included components of basic nursing care. It was felt by some to be unnecessary in contexts where there was one-to-one nursing care and where many patients died too quickly to benefit

Meeting individual wishes, expectations and spiritual needs that vary between different social and cultural groups [2124]. Resource use, organ donation, and surrogate decision-making, all of which may involve conflict [21, 22, 33, 45, 46]

Family members identified factors such as financial and legal concerns; parking and transport; information needs; religious, cultural and spiritual needs assessment; and documentation and management. The importance of understanding family structures was emphasized by some family members, along with ensuring that information about the patient was given to the correct family members. When this was done well it was praised by those interviewed, but there were instances of family members feeling that their relationship was not respected by staff or that information was being given to someone other than a person designated to receive this information, and these situations caused distress

Greater support for staff and debriefing in difficult cases, although there were contrasting views about the usefulness of debriefing; a support group for nurses, particularly for those new and less experienced; better support for staff, for example the opportunity of access to an external counseling service; and more educational opportunities

Supporting dignity, respect and peace of patients and supporting the family [19]

Family members often described not knowing when discussions with staff would take place, and a few suggested that having a plan for future communications would be beneficial

Staff suggested changes to practice including: a ‘home to die’ service; more spiritual support; more hands-on nursing, massage, washing, support for family members; overt recognition of the importance of caring for the dying so that junior staff do not see it as a failure; reducing noise levels where possible; a bereavement service; and improved communication with other teams, including palliative care

Abbreviations: ICU intensive care unit, LCP Liverpool Care Pathway for the care of the dying patient.

Therefore, our study aimed to adapt or develop and evaluate a new evidence-based tool to better meet patient and family communication and holistic care needs in ICU.

Design and approval

The study had ethics approval from the South East London Research Ethics Committee (08/H0805/65 and 08/H808/103), and full hospital Research and Development approval.

Development, implementation, and preliminary evaluation of the tool followed the Medical Research Council guidance for the development and evaluation complex interventions [47]. Phase I explored concerns using interviews of staff and families, and observed the process of care for them, leading to tool development. Phase II tested the feasibility and effects of the tool on staff and families (see Figure 1). We used the Methods of Researching End-of-life Care (MORECare) statement of good practice to aid our procedures [48] (for compliance details, see Additional file 1).
Figure 1

Components of the study by phase of the Medical Research Council guidance on the development and evaluation of complex interventions, showing how the different components combine to inform the next phase in the sequence.

The study took place in two adult ICUs (general medical and surgical) in a 950-bed south London teaching hospital, serving a socially and culturally heterogeneous population. The two ICUs have 32 beds, and an annual intake of more than 1,900 admissions (1,800 excluding readmissions), associated with 250 to 300 deaths in the ICU. Most (70 the 80%) of these deaths follow life-sustaining treatment limitations. The ICU standardized mortality ratio (SMR; Knauss Acute Physiology and Chronic Health Evaluation (APACHE) II) was 0.62 during the study, and these ICUs have a lower SMR than the median SMR within the UK casemix program [49]. The ICUs service the local population and also provide support to regional trauma, neurosciences, transplantation, and cardiac services for the southeast of England. Of the admissions, 75% are white British, and 25% are non-white British (80% black Caribbean or African, and 20% from other groups). The hospital has 1,200 deaths annually (20 to 25% of deaths in the hospital occur in the ICU).

Phase I: development and implementation of the intervention

We conducted qualitative interviews with families and staff, and observed their process of care and staff activity (see Additional file 2). Semi-structured interviews were conducted face-to-face with a lead family member (for one patient, with two family members at the family’s request), and were recorded and transcribed verbatim. A topic guide was developed from a literature review, initial observations, and discussion with service users. We conducted focus groups with ICU doctors, nurses, and other professionals involved in the delivery of care to patients and their families and palliative care practitioners to explore the experience and views of an end-of-life care pathway for the intensive care setting, using a topic guide. Staff participants were purposively selected to gain perspectives from a broad range of health care professionals, taking into account differences in age, gender, length of time working on the units, and nursing grade.

Results were presented to a working group of clinicians from ICU and palliative care, who developed the new interventional tool, termed the Psychosocial Assessment and Communication Evaluation (PACE). Initial versions were tested in three 6-week pilot periods, and amended as necessary.

Training and implementation

Training to support PACE implementation (Additional file 3) was followed by two further audits of the records (Figure 1). We conducted non-participant observation during and after implementation, and collected completed and de-identified copies of PACE logs. We conducted qualitative interviews with families, broadly similar in characteristics to those interviewed before PACE was introduced. These interviews explored experiences of care, and checked for any adverse effects of PACE.

Phase II evaluation: staff views of PACE and survey of family members

We evaluated PACE using two approaches: a survey of staff about PACE, and a survey of family members’ satisfaction with care. A staff questionnaire survey was emailed to all ICU doctors and nurses, with two reminders. The survey asked about any difficulties experienced in completing the PACE, views of its use, and its effect on care.

We attempted to survey one family member for each patient cared for on the ICU during the period of PACE implementation and use. Family members were identified and given information about the study, and then on a subsequent visit were given the questionnaire. We excluded family members whom the staff deemed were too distressed to complete the questionnaire, family members of patients admitted for less than 12 hours or family members who had visited the ICU fewer than 3 times. The questionnaire had mainly closed questions with a few open questions, and was administered by the researchers, unless the family wished to self-complete. It included the 24-item Family Satisfaction in the Intensive Care Unit questionnaire (FS-ICU) [50], validated to measure family member satisfaction with a patient’s admission in ICU. We compared responses according to whether a PACE was or was not completed for the corresponding patient.

Analysis and sample sizes

All data were anonymized. All qualitative interviews (both phases) and focus groups were digitally audio-recorded, transcribed verbatim, and entered into NVivo9 (supplier via King’s College London, QSR International, Qualitative data were analyzed using the framework approach [51], which enabled the systematic identification of themes both from questions and from emergent issues. This was undertaken independently by two researchers (CS, CR), with the Project Advisory Group agreeing the thematic framework. Issues (sub-themes) were then identified within these broader themes, followed by a process of charting both the patient/family and staff datasets to allow comparison between cases (specific patient care/professional group). The process of synthesis also involved mapping data from the open coding onto the broad categories identified in the preliminary literature review (Table 1).

Quantitative data were analyzed using simple descriptive statistics to describe PACE use and staff opinions. For the survey of family members we used t-tests (for normally distributed characteristics), χ2 or Fisher’s exact test (for non-normally distributed characteristics), and the Mann–Whitney U-test (for experience assessments) to compare the characteristics and experience of families for cases that had PACE completed with those that had not. When equality of variances was not assumed adjusted values are given (t, degrees of freedom, P, 95% CI for mean differences). All tests were two-sided.

Qualitative samples aimed to capture different groups in terms of age, gender, length of time in ICU, diagnosis, and social and cultural background, and thus capture the range of views. In the family members’ survey, most of the analysis was descriptive. However, if we assume 20% (a likely level based on previous research) of families have serious concerns, we needed 76 respondents to achieve a margin of error of 9% (95% confidence interval). Therefore, we estimated that 150 participants would provide reasonable descriptive accuracy and allow for subgroup analysis (sample stratified by age, gender, ethnicity, and disease). Allowing for refusals, we aimed to approach 200 participants. For both the qualitative and quantitative data, the samples aimed to be sufficient for preliminary exploration, as we were not formally testing PACE but to exploring its potentially beneficial or adverse effects.

Phase I

We first interviewed 13 family members, representing 11 patients, and conducted observations on the care of these patients. Four the patients were women, age range 23 to 87 years) with diagnoses including infection, injury, and malignancy (Table 2). Observation periods for of patient care ranged from 1 to 46 days. Communication was a central theme, influencing issues such as decision-making and family support. Individualized issues of care, such as information regarding practical matters such as parking, were also important (Table 1).
Table 2

Demographics of family members involved in qualitative data collection in phases I and II

Phase 1

Phase 2

Total cases, n patients (caregivers)*

11 (13)

10 (11)

Age of patients (median) years

23, 27, 31, 45, 49, 53, 54, 59, 71, 79, 87 (53)

40, 43,52, 57, 59, 59, 62, 63, 80,83 (59)

Gender of patients

4 women, 7 men

4 female, 6 male

Gender of family members

6 women, 7 men

9 female, 2 male

Diagnosis of patients

Neurological injury (n =4); infection (pneumonia, malaria) (n = 2); hypoxic brain injury (n = 2); malignancy (n = 2); COPD plus pneumonia (n=1)

COPD plus pneumonia (n = 2); subarachnoid hemorrhage (n = 2); C4 level lesion (n = 1); gastro-intestinal bleed (n = 1); hypoxic brain injury (n = 1); cardiac arrest secondary to PE (n = 1); acute subdural hematoma (n = 1); dissecting aortic aneurysm (n=1).

Age of interviewee (median) years

28,30,30, 35, 36, 44, 47, 53 ,53, 53, 56, 59,67 (47)

30, 36, 40, 43, 46, 48, 50, 50, 54, 62, 77 (48)

Relative travel time to hospital

<30 minutes (n = 4); 30 minutes to <1 hour (n = 6); ≥1 hour (n = 3);

<30 minutes (n = 2); 30 minutes to <1 hour (n = 3); ≥1 hour (n = 6 (one of these was staying locally within 30 minutes travel time));

Ethnicity of family members

White British (n = 9); Mixed Caribbean (n = 2); Asian (n = 1); Afro-Caribbean (n = 1);

White British (n = 11)

Religion of family members

No religion (n = 5); Christian (n = 6); Muslim (n = 2);

No religion (n = 4); Christian (n = 7)

Occupation of family members

Nurse (n = 2); self-employed (n = 1); civil servant (n=1); clinic supervisor (n = 1); degree-level qualification (n = 1); care manager (n = 1); lorry driver (n = 1); carer (n = 1); masters-level qualification (n = 1); technical instructor (n = 1); manager higher education (n=1); retired executive (n=1)

No paid employment (n = 4); secretary (n = 1); waitress (n = 1); carer (n = 1); security guard (n = 1); actuary (n = 1); teaching assistant (n = 1); sales consultant (n = 1)

Relationship to patient

Partner (n = 3); child (n = 6); sibling (n = 1); parent (n = 3)

Partner (n = 5); child (n = 4); sibling (n = 2)

* note in each group for one patient two family members wanted to be interviewed.

Abbreviations: COPD chronic obstructive pulmonary disease, PE pulmonary embolism.

In total, 32 staff from the ICU, 4 members of the hospital palliative care team, and 4 referring clinicians took part in individual interviews and/or focus groups, with 25 attending individual interviews, 14 attending one of three focus groups, and 7 attending both interview and focus groups (Table 3). These results also emphasized the need for psychosocial assessment and communication to be tailored to individual needs, with documentation of who had received what information when teams changed (Table 1) to improve continuity of care. However, although documentation was needed, staff wanted to ensure any tool was ‘paper-light’ and did not result in large amounts of extensive form filling. Therefore, one challenge presented in tool development was to ensure that key aspects were captured while keeping the document to one, or maximum two, pages.
Table 3

Staff participants in phases I and II of the study

Staff participants

Phase I

Phase II

Nature of data collection

Qualitative interviews and focus groups

Questionnaire survey

Medical ICU staff

Nursing ICU staff

Staff; status not given

Nursing grade

Grade 5 (n = 11; 50%); grade 6 (n = 4; 18%); grades 7 and 8 (n = 7; 32%); total: n = 22

Grade 5: 43; 65%); grade 6 (n= 16; 24%); grade 7 (n= 7; 11%); grade not given (n = 1); total: n = 67

Hospital palliative care team

4 (focus group)

Professions allied to medicine (ICU staff)

Referring Clinicians

The intervention: PACE

PACE draws on the work by Mosenthal et al. of providing a holistic assessment for all patients and families [29]. The goal of developing the tool was to improve assessment and communication for all patients in the ICU, not just those at the end of life. Thus PACE sought to improve care for patients who may deteriorate, and equally those who may recover. PACE comprises a training program and a record in the clinical notes, as detailed below.
  1. 1.

    PACE Training program

  • One week training prior to implementation by ICU and palliative care staff - to enable all staff the opportunity to attend and to improve communication skills and awareness

  • A side room on the unit housed a poster and leaflet display of relevant materials and PACE

  • Members of the hospital palliative care team and researchers were present for 3–4 hours each day to introduce PACE and answer questions to foster collaboration between ICU and palliative care staff.

  1. 2.

    PACE record The PACE record is brief, on two sides of paper. It first asks for assessment of five aspects within 24 hours of admission to ICU:

  2. a)

    Family details: key relationships; children; guardianship issues; vulnerable adults

  3. b)

    Social details: financial concerns; religious/spiritual needs; language/cultural needs; transport/parking needs; other needs

  4. c)

    Patient preferences: previously expressed wishes; preferred place of care; presence of advance directive / statement or will

  5. d)

    Communication and information: patient / NOK awareness of situation; people to be given information; explanation of ICU

  6. e)

    Any other issues: which patient, family or staff feel is important.

The next section of PACE gives space for a continuing log of any communication update.

The final section of PACE provides a list of useful resources - as a prompt to seek additional support for patients and families. Additional file 3 shows the PACE in full.

The PACE is logged by the admitting key worker, usually an ICU nurse. It is kept in the clinical records and can be updated by any member of the clinical team. The rationale for keeping PACE in the clinical record is to avoid miscommunication and improve continuity by holding psychosocial information in one place. The goal is that the assessment prompts changes in actions by staff in response to the assessment findings. The continuing log of communication enables information to flow between teams recording communication about new issues or changes in the patient or family circumstances.

PACE requires staff to explain if an aspect is not explored (e.g. staff must give a reason if it is not appropriate to discuss preferences).

Implementation of PACE

In total, 43 nurses, 11 doctors and staff from palliative care, pharmacy, physiotherapy, occupational therapy, speech and language therapy, and chaplaincy departments attended the training during the launch week. The research process and feedback of the results led to much discussion about decision-making, communication, and end-of-life issues. In addition, there was increased input from the palliative care team on the units and psychosocial support by different providers, including chaplaincy and the palliative care team, as a consequence of the heightened awareness and identification of needs through the use of PACE.

PACE was launched in the ICU after the three piloting phases. Further revisions were undertaken on two occasions, at 6 weeks and 4 months after the original launch, to address concerns and suggestions by staff. The PACE log was usually filed in the nursing notes. An audit of the completion of PACE logs of 81 consecutive patients found that half (41) were completed within 24 hours, and the remainder within 48 hours of admission to ICU. All aspects were completed for at least some patients, the most complete being family history, next of kin, and family understanding of the condition (both completed for over 90% of cases), and social history (70% of cases).

Phase II

Effect of PACE: the views of ICU staff

Responses were received from 95/176 (54%) staff members, of whom 80% (76/95) had seen a PACE log. In the main; nurses (84%; 52/62) reported completing PACE rather than doctors (17%; 3/18). Just over half (61%; 51/84) reported completing PACE within 24 hours of admission all or most of the time (similar to the audit results), but 34% (27/80) had difficulty completing some sections, especially recording patient preferences. Most (80%; 67/84) reported having seen a completed PACE in patients’ notes. The majority (89%; 71/80) reported that PACE was very or generally useful, with only 3 respondents saying it was not useful, and 6 responses being neutral. The components of PACE most often judged to be useful were family details (65 respondents), social details (52 respondents), and communication/information (25 respondents).

Questionnaire survey of family members

Response rate from the family members was 165/213(78%). Figure 2 shows a flow chart of those eligible, and reasons for exclusion/non-response. The characteristics of the patients relating to these 165 relatives were: mean age 59 years; 48% women; 81% white, 12% black African/Caribbean/British, 5% Asian and 2% other; and had been on average 3 days on the ICU (range 1 to 56 days). We were able to compare the characteristics and experiences reported in cases when a PACE had (n = 88) and had not (n = 42) been completed (note there were instances when we could not match to PACE completion because of confidentiality and the nature of responses).
Figure 2

Flow chart of survey responses by family members.

There were no differences in the demographic and clinical characteristics of relatives or patients with and without PACE completion, except that those with PACE had more severe disease and a higher risk of death (indicated by higher APACHE II scores; mean ± SD score 15.55 ± 7.22 for those with PACE completed and 13.36 ± 5.27 for those with PACE not completed, t = 1.95, P = 0.05) (see Additional file 4). Those cases for which PACE was completed had significantly better levels of satisfaction with the assessment and treatment of all symptoms (pain, breathlessness, nausea/vomiting, agitation, and confusion and communication difficulties), and for both the honesty and consistency of the information provided to relatives about the patient’s condition (Table 4). Other aspects measured also showed a trend towards improvement in the PACE group, although this did not reach statistical significance. Secondary analysis of our data did not identify cultural or ethnic differences in the reported experience or satisfaction of relatives, or the use of the PACE.
Table 4

Differences in satisfaction of family members in cases when PACE was and was not completed a

Mann–Whitney U-test

No PACE, n

P-value two-tailed

Completed, median (range)

Not completed, median (range)

Assessment and treatment of:

1 (1 to 4)

1 (1 to 5)

1 (1 to 3)

1 (1 to 5)

1 (1 to 3)

1.5 (1 to 4)

1 (1 to 3)

2 (1 to 4)

1 (1 to 4)

2 (1 to 5)

 Communication difficulties

1 (1 to 4)

2 (1 to 4)

Consistency of information provided to relatives about patient’s condition

2 (1 to 5)

2 (1 to 5)

How well ICU staff informed relatives about what was happening to patients

1 (1 to 5)

2 (1 to 5)

Communication about patient’s condition from nurses

1 (1 to 5)

2 (1 to 4)

Communication about patient’s condition from doctors

2 (1 to 5)

2 (1 to 5)

Willingness of ICU staff to answer questions

1 (1 to 5)

2 (1 to 4)

ICU staff provided explanations that you understood

1 (1 to 5)

2 (1 to 5)

Prognostic uncertainty and decision-making

Honesty of information provided to relatives about patient’s condition

1 (1 to 5)

2 (1 to 4)

Feeling included in the decision-making process

2 (1 to 5)

2 (1 to 5)

Feeling supported in the decision-making process

2 (1 to 5)

2 (1 to 4)

Meeting individual wishes

ICU staff interest in relative’s needs

1 (1 to 5)

1 (1 to 5)

Information about patients given to the right people (that is, those close to them)

1 (1 to 5)

2 (1 to 4)

Enough time to ask questions

1 (1 to 4)

2 (1 to 4)

ICU staff provided emotional support for relative

1 (1 to 4)

2 (1 to 5)

Quality of care relative and patient received in ICU

1 (1 to 4)

1 (1 to 5)

Supporting dignity, respect, and peace

Courtesy, respect, and compassion for patient

1 (1 to 5)

1 (1 to 5)

Courtesy, respect, and compassion for relative

1 (1 to 4)

1 (1 to 5)

Care for patient from nurses

1 (1 to 5)

1 (1 to 4)

Care for patient from doctors

1 (1 to 4)

1 (1 to 5)

Atmosphere in the ICU

2 (1 to 4)

2 (1 to 4)

Atmosphere in the ICU waiting room

2 (1 to 5)

3 (1 to 5)

Abbreviations: ICU intensive care unit, PACE Psychosocial Assessment and Communication Evaluation.

aLower scores indicate higher satisfaction.

bSignificant at p<0.05.

Qualitative interviews with families and observation post-PACE implementation

In total, 11 interviews were undertaken representing 10 patients (in 7 of these cases there was a completed PACE in the clinical records). Variation in cases between phase I and II made comparison difficult; however, the comments shed light on the quantitative results (Table 5). One interviewee (in the PACE group) highlighted the value of being able to plan a meeting with the doctor out of hours. This enabled relatives who were working to attend meetings. In both phases, preferences for involvement in decision-making varied, but relatives had a positive reaction to being asked about their preferences, even though they often did not want to be more involved in actually making the decision, as they felt this should be made by the medical staff. In one of the post-PACE instances, the palliative care social worker supported the young children of the patient visiting, promoted by the PACE tool. No adverse events related to PACE use were observed.
Table 5

Quotations from post-intervention qualitative interviews with family members, which helped to interpret the quantitative results

Patient comments

…when he’s been on the bed he’s sort of moved and he’s gone ‘Oh’, and he said he’s in pain. I’ve then called the nurse over and automatically she’s given him painkillers, or she’s checked the chart to see when he’s had his last painkillers and given him painkillers… (Family member of patient 5, Phase 2)

…there were reasons why it was hard to identify that actually it was… she was complaining of the abdominal pains, but because of the complications it was hard to actually sort out the factors, you know, what was the reason for it. It turned out to be the most serious of the three but that, I mean that was identified and then they flew into action… (Family member of patient 7, Phase 2)

…because I do ask… I said to them ‘is he under any sedation and have you taken him off this, have you taken him off that?’ and they’re saying about his sodium level is a bit low and I asked them what that meant and they explained that to me so, you know, they are really good… I’ve got no qualms with asking the nurses anything.. (Family member of patient 10, Phase 2)

…some of the doctors are really good and they explain things or they say ‘do you want to talk to us?’ and then I will, I’ll ask as many questions as, you know, as I can… (Family Member of patient 1, Phase 2)

Prognostic uncertainty and decision-making

…I have to say that everybody without exception explained everything very patiently and, um, you know, could take the time to explain what was happening, what the risks were, what the likely outcomes were or could be, um, and equally to admit that on occasions they didn’t know, which was also refreshing, yeah… (Family member of patient 10, Phase 2)

…I mean it’s been a bit sort of touch and go, um, when was it, not last weekend, the weekend before, we were told he’d only got 12 to 24 hours to live, um, and it was a bit, because it was such a shock, because he’s not had any symptoms, he’s never been ill in his life… (Family member of patient 1, Phase 2)

Meeting individual wishes

…he doesn’t want any tubes down him, he’s made that quite clear. Even if he gets worse, they were telling me his breathing, they can put a tube in to help his breathing, doesn’t want it, he said he does not want it, and his wish, you know, I said ‘Well that’s his reply, then stick to that, that’s what he wants’… (Family member of patient 5 Phase 2)

Supporting dignity, respect and peace

…they move him all the time because of sores and, you know, they’ve had to put things on his legs because his legs was turning in and, you know, when I, when I said ‘oh’, you know, and they’ve said ‘oh we put them on to straighten the leg’ and I think ‘god I wouldn’t think of things like that’. They’ve been really, really marvelous, as I said I can’t knock ‘em and I take my hats off to ‘em, and they have every time I’ve come in they’re washing and shaving him, which you don’t think of stuff like that while he’s there, d’you know what I mean? And, um, absolutely fantastic really. (Family member of patient 10, Phase 2)

PACE was developed and tested to help improve care in ICU, a setting in which uncertainty is common. PACE is a straightforward tool, building on the work of Mosenthal et al. in a trauma unit of having an approach suitable for all patients irrespective of prognosis [29], but formally integrating training, an initial assessment, and an ongoing log of communication. We found that PACE was acceptable and feasible for staff to use. The close working between palliative care and ICU staff in its development and implementation led to sustained working. It was mainly completed by nurses, which this is not unexpected, as other work has suggested the central role of nurses in ICU care [27]. Results from the survey of relatives suggest that PACE improves symptom control, communication, and information provision. An examination of the qualitative responses shed light on these results; family members were appreciative of the greater emphasis on communication and managing symptoms, which might have been supported in turn by a greater emphasis on support of the family members and of the patient’s individual needs.

Comparison with other studies and wider implications

To embed palliative care principals and practice into ICUs, several countries and national and international associations have published recommendations, practice guides, and quality indicators [20, 5254]. Specific tools, care pathways, or bundles can also embed new approaches more formally into routine care. Some of these approaches have been used in general hospitals. Care pathways were proposed in the National Institute for Health and Clinical Excellence Guidance on Supportive and Palliative Care [55] as a possible means to improve end-of-life care, although needing more evaluation. In the USA, three before-and-after studies of care pathways suggested that there was a reduction in the number of therapies ordered, although outcomes were not studied [5658]. Studies on the LCP in the UK found similar data using documentation and staff appraisals [5961], and caregiver reports [60]. However, studying only processes of care rather than patient and family outcomes is flawed: Mularski et al. found that better documentation of pain does not in itself lead to better treatment [62]. Thus, we felt it was important, even in this preliminary evaluation, to assess outcomes, rather than the treatments received or other process measures.

In the ICU, it is difficult to accurately identify those who will die, and there is often a very short window to introduce palliative or end-of-life care and to support families. There is also a need to manage distressing and often complex symptoms, and at the same time, provide support and information to families at a time of clinical uncertainty and/or devastating news. A major problem is deciding on a trigger to use any pathway, something which has caused considerable debate in the UK with regard to the LCP [63, 64]. For the ICU, integrated approaches that might benefit all patients are recommended [18], and our findings support this approach. We suggest that PACE may be suitable in cases of uncertainty in general hospital settings, possibly for all patients on admission. Recent research has shown that at the point of admission, family members feel they move from being ‘conductor’ at home, to ‘second fiddle’ where their experience and perspectives are missed [65]. Indeed, the improved communication and care at an early stage may help if any difficult decisions and conversations are needed later, at which point other tools, suitable for patients who are more likely to be deteriorating or dying, are useful.

To underpin our results and to enable future evaluation, we developed a theoretical model of how PACE may be influencing the outcomes found in our study (Figure 3). This builds on the communication framework developed by Curtis et al. [66], and Nelson et al. [26, 27] in developing models based on changing skills, attitudes, and behavior to improve communication and end-of-life care in the ICU, and the work of McCorkle et al. [67] in enhancing illness self-management through improved patient/clinician partnerships. As Figure 3 shows, the combination of training plus the greater individual patient/family-focused assessment in PACE (shown in yellow) can lead to improved interactions, co-ordination, and support, which in turn leads to the improved symptom control, and feelings of honesty and communication. One major goal in developing PACE was to keep the tool short and with little paperwork. Staff wanted PACE to help them do the right thing for patients and families, but not to increase documentation. Work is now underway to integrate PACE into the electronic record.
Figure 3

Model of how Psychosocial Assessment and Communication Evaluation (PACE) may be acting to improve care in the intensive care unit (ICU) and achieve the desired outcomes.

Limitations and strengths of the study

Our study is limited by being based in two ICUs in a single hospital. However, PACE was used on a wide range of patients, with different ages, conditions, and cultural backgrounds. The findings from the surveys of staff and family members did not suggest that it was suitable for only some particular groups or circumstances. We found that PACE was used more often when patients were more critically ill, as indicated by the APACHE II score. This suggests that staff prioritized PACE for instances of greatest uncertainty. ICU wards have higher levels of staffing than general wards, and this may have supported the implementation of PACE. Therefore, wider testing of PACE in ICU units, and ideally general wards, is needed. Even if PACE is suitable only for the ICU, this represented over one-fifth of the deaths in our hospital, and so would affect a high number of patients and families.

Our comparison of family members’ satisfaction when PACE was and was not used was restricted to the ICUs participating in this study. All ICU staff had been exposed to the palliative care training and awareness engendered by PACE implementation. This may have reduced the likelihood of finding a difference between groups, because the care of all patients (including those who did not have PACE completed) was influenced. Despite this limitation, our findings of a difference between groups suggests that PACE does improve care over and above that provided by general training, although we cannot exclude the possibility that some other factor reduced the quality of care for the ‘non-PACE’ patients, which also resulted in them not receiving PACE. For example, it may have been that those staff members choosing to complete PACE were also more skilled in communication and symptom management than those who did not complete PACE. The use of PACE increased during the project, so it might also have been that care generally improved during this time. To test PACE fully, a comparative trial is required, with before-and-after assessment of care experience, including units where PACE is not used. Finally, our study was limited by the high level of satisfaction found in the survey of family members’ experiences.

PACE is an acceptable and feasible tool that has the potential to improve care of ICU patients and their families. Moreover, it appears to improve communication, information-sharing and family perceptions of symptom control. We did not find any harmful effects of the tool. PACE may help the better implementation of other tools or care bundles by establishing early an assessment of the patient and family circumstances beyond medical diagnosis and improving communication. It would need to be introduced using integrated working between specialist palliative care and ICU staff, with a shared training program, and now warrants evaluation and further development in comparative trials in the ICU. PACE may also be relevant for other hospital circumstances where there is a high level of clinical uncertainty.

Intensive Care Unit

Liverpool Care Pathway for the care of the dying patient

Methods of Researching End-of-life Care

Psychosocial Assessment and Communication Evaluation tool.

We thank the family and patients who participated in our study, and the ICU and palliative care staff for participation and PACE implementation.

This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0107-12109). The views expressed are those of the authors, and are not necessarily those of the National Health Service, the National Institute for Health Research, the NIHR, or the Department of Health.

Authors’ Affiliations

Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King’s College London, School of Medicine
Intensive Care Unit, King’s College Hospital NHS Foundation Trust
Division of Health and Social Care Research, King’s College London

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  68. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:

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Reliance Big Pictures to bid for MGM Film Studio

Posted on 17 January 2010 by BMMBoxer

After kick starting the year with the success of 3 Idiots and Paa, Reliance Big Pictures (an Anil Ambani Enterprise) is set to make all the right moves in 2010. Anil Ambani has showed interest in bidding for Metro-Goldwyn-Meyer Hollywood studio, the Hollywood studio which owns the James Bond franchise.

Anil Ambani already owns a controlling stake in Steven Spielberg’s DreamWorks studio and has partnered with Hollywood stars including Brad Pitt, Jim Carrey, Julia Roberts and George Clooney to promote their films.

Industry sources close to Anil Ambani confirmed his interest in acquiring MGM and said it would help him to achieve his ambition to become the world’s most powerful film mogul.

The MGM acquisition would empower Reliance Big Pictures and bring one of Hollywood’s greatest film libraries under their control and will certainly ensure box office hits over the next three years. MGM is slotted to release a new James Bond film in 2011, starring Daniel Craig, and two Hobbit films starring Sir Ian McKellen.

MGM, on the other side needs to strike an effective deal to avoid potential bankruptcy later this year when a series of debts must be repaid. The current estimated bid is expected to be beyond $2 million.

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Financial Planning / Tax Strategies

Subject:  IRA Rollover Tax Withholding Date:  6/25/2000  10:52 AM
Author:  Cardsany1 Number:  36878 of 125706

My fiancee recently left her job and decided to roll over her 401k account. She rolled over her account into a traditional IRA account and then converted the traditional IRA account into a Roth IRA account. Unfortunately, she did not fill in the account application section which would have waived all federal withholding tax. Her account is now 10% lighter and I suspect she is also subject to a 10% premature distribution penalty tax. Is there anyway to fix this error either now or on her tax return?
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Subject:  Bond Investing Newsletter Date:  10/27/2012  7:12 PM
Author:  azdps Number:  34474 of 36082

If anybody uses an investing newsletter they recommend, would you post contact info. I know of Steve McDonald now at Oxford Bond Trader but $995 a year is rather steep. Looking mainly for advise on corporate bonds to buy and hold. Thank you for this consideration. azdps
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Retirement Discussions / Retired Fools

Subject:  Re: Leasing a car? Date:  3/13/2013  6:51 PM
Author:  TwoCybers Number:  18277 of 20228

I am most likely in a minority here - but I do not think there is any reason for any person to lease a car, unless that person is too lazy to sell a car - keep in mind a trade is also a way to get rid of a car.

Leasing is burrowing money and last time I checked burrowing money generally involved interest. The tax code does make it advantageous for businesses in some situations to lease instead of own.

People my age (71) generally don't like the idea of not owning (or leasing) a car if they have had one most of their life - I think it is a freedom or perceived freedom issue. But from a purely economic view point I would be better off by use taxis for local trips and rent for vacations instead of buying a new car every 5 years my recent history. I drive about 8,500 miles a year.

There are a lot of costs with a car. Insurance, depreciation, maintenance, washing, parking lots, deductibles when accidents or hail damage happens, etc.

The idea of buying a 12 or 24 month old car will certainly save a lot of money. Just titling a car and driving it off the lot decreases its value in the range of 15% of sticker.

Cars are a great deal more reliable today then just 20 years ago. But they are more complex. Lots of "computers" and sensors - some of which are cheap and some are expensive.

If you are looking at a used car, do take it to a mechanic and have it gone over - that will cost a couple of hundred - but you need to know about brakes - maybe the person road the brakes and replacement is soon. Maybe the oil was never changed an some damage has been done. Maybe the car was in an accident. When you buy a new car you get a warranty. When you buy a used car, you need information.

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No. of Recommendations: 1
Unless you have small fingers and are very handy, have them install your battery.

Replacing my battery in an earlier IPod was a once in a lifetime experience. Never again.

Well, just to put forth the opposite view - I replaced mine and it wasn't bad at all. The hardest part was cracking the case. After that, it was a breeze.
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Friday, January 30, 2009

Let's Be Friends

Lynda from Lynda's Book Blog has honored me with this "Let's Be Friends Award." Thank you Lynda, I am truly honored.

The award says:
“These blogs are exceedingly charming. These kind bloggers aim to find and be friends. They are not interested in self-aggrandizement. Our hope is that when the ribbons of these prizes are cut, even more friendships are propagated. Please give more attention to these writers. Deliver this award to eight bloggers who must choose eight more and include this cleverly-written text into the body of their award.”

I will be passing this award on later - this ice storm has wrecked havoc with all my plans.

On another note, Lynda has another blog I enjoy reading: The Holistic Knitter's Blog. If you love knitting and knitters, you will love this blog!

Thursday, January 29, 2009

The Secrets of the Immortal Nicholas Flamel

The Alchemyst: The Secrets of the Immortal Nicholas Flamel (Book #1) by Michael Scott (375 pages)

Like most children - and some adults- I was disappointed when the Harry Potter series ended. But now there is a new young adult series that feels like an addition to the world of Harry Potter: The Secrets of the Immortal Nicholas Flamel. Nicholas Flamel - the 14th-century alchemist who could turn base metal into gold, and make a potion that ensures immortality - was mentioned in several of the Potter books

In The Alchemyst, Sophie and Josh Newman are 15-year-old twins who take summer jobs in San Francisco: Sophie at a coffee shop and Josh at a bookstore owned by Nick and Perry Flamel. In the vey first chapter, armed robbers storm the bookshop, take Perry hostage and steal a rare book of magical wisdom, The Codex.

The siblings, lead by Flamel are drawn into a mythology world to stage a battle between the Dark Elders and a necromancer named Dr. John Dee. This book is a fast read and is populated by the likes of werewolves and vampires. It ends with a cliff-hanger I'm sure will be picked up in the next book, The Magician: The Secrets of the Immortal Nicholas Flamel.

The Magician: The Secrets of the Immortal Nicholas Flamel (Book #2) by Michael Scott (464 pages)

In this exciting sequel to The Alchemyst, Sophie and Josh Newman are in Paris with Nicholas Flamel, when they come up against the villian Dr. John Dee and his accomplice, Niccolò Machiavelli. Dee has learned that Josh and Sophie are phophesised in The Codex - the magical book stolen in The Alchemyst - so he seeks to win them over to his side.

The twins are coming into more of their power and Flamel is teaching the children how to control and use these powers. We also get to meet Joan of Arc, several Greek gods and goddesses, as well as the gargolyes of the Notre Dame Cathedral.

This is a great installment in what is supposed to be a six book series. The next book, The Sorceress: The Secrets Of The Immortal Nicholas Flamel (Book #3) will be released on May 26, 2009.

Both of these books are great fun to read with children!

Wednesday, January 28, 2009

Way Back Wednesday - The Road to Oz

The Road to Oz by L. Frank Baum

The Road to Oz is the fifth of L. Frank Baum's Land of Oz books. It was originally published on July 10, 1909 and documents Dorothy's fourth visit to Oz.

Dorothy is near her home in Kansas when the story begins. As she travels through Oz on her way to the Emerald City, she is welcomed by old friends - Scarecrow, the Tin Woodman, Jack PumpkinHead, Tik-Tok and Billina the Yellow Hen. Everyone has gathered at Emerald City to celebrate Osma's birthday.
We meet several new characters in this book: the Shaggy Man, Button-Bright, and Polychrome. At the end of this tale, Dorothy is wished home by Ozma's Magic Belt.

Of all the Oz books by L. Frank Baum, this one is probably my least favorite. I loved meeting my favorite characters again, but the story was a little disjointed.

Wednesday, January 21, 2009

Way Back Wednesday - Dorothy and the Wizard in Oz

Dorothy and the Wizard in Oz by L. Frank Baum

Dorothy and the Wizard in Oz is the fourth book set in the Land of Oz written by L. Frank Baum and illustrated by John R. Neill. It was published on June 18, 1908 and reunites Dorothy with the Wizard from The Wonderful Wizard of Oz.

Dorothy and her kitten, Eureka, is sent to visit her uncle in California - operator Hugson's Ranch. She strikes up an acquaintance with Hugson's son and her cousin, Zeb. Dorothy, Eureka, and Zeb are riding a horse buggy when an earthquake starts and opens a crevice beneath them, sending them hurtling into the bowels of the earth. They land in the land of the Mangaboos, vegetable people who blame the earthquake on Dorothy.

Although the book has "In Oz" in the title, Dorothy and the Wizard spend very little time actually in Oz, but it doesn't matter. This is another great installment in the Oz series.

Tuesday, January 20, 2009

The Dragon's Eye (Erec Rex #1)

The Dragon's Eye (Erec Rex #1) by Kaza Kingsley

Reading level: Ages 9-12
Hardcover: 345 pages
Publisher: Firelight Press, Inc.; 1 edition
Language: English
ISBN-10: 0978655567
ISBN-13: 978-0978655563

Erec Rex is a 12 year old boy who has been living in a non-magical world, when he was actually born in a magical world. Sound familiar? Well, this is where the similarities between Erec Rex and Harry Potter end. For all those clamoring for a new fantasy series to read after the ending of Harry Potter, then look no further - Kaza Kingsley has given us a unique and interesting take on the world of magic.

Erec unknowingly enters the magical world of the Kingdom of the Keepers while searching for his mother. Erec has an unusual gift - the dark thoughts. When the dark thoughts take over Erec's mind, he must do what they say. When the dark thoughts tell him to go in search of his mother, he encounters a new friend, Bethany, who helps him search for his mother.

Erec soon finds himself in a tournament to become one of the new rulers of the Kingdom of the Keepers. The current rulers are King Piter, King Pluto and Queen Posey - but King Piter has been ill for over 10 years. It was King Piter's own children - triplets - who were to be the new rulers, but they mysteriously died as babies.

People are not always what they appear to be in the uniquely different world of magic and mayhem. Allies become enemies and enemies turn out to be friendly - it is unclear whom to trust in this newly created world.

This books gives you many unusual new items and animals, as well as magical devices:

Magical seeing eyeglasses - let you see the person you miss the most.
Cloudsicles - yummy snacks to eat.
Aniballs - different colored balls which turn into animals.
Inquizzles - will answer one question for you.
Nitrowisherine - a liquid that explodes, then grants a wish.

This is a wonderful new series for young adults, and adults who are young at heart. The second book in the series is The Monsters of the Otherness. The third book - The Search for the Truth - will be released this summer.

Visit Kaza Kingsley's blog at The Memory Mogul and the official Erec Rex website at Erec Rex

Hope Is In the Air

The enthusiasm is contagious! Everything is building to a crescendo for this all important day in history. Hope is in the air and with hope comes the emergence of a new day in America.

After agonizing over whether to allow my daughter to stay home from school today - I did decide YES - today ended up being a snow day. So now she can stay home without fear of all the work she's missing!

My hubby called last night - he is in Washington for work - and he said the crowds and the traffic are unbelievable! He said just going a short distance takes hours and hours. But he did say most people are excited and even helpful. Plus, he got to see Keith Olbermann doing Countdown from the temporary set for MSNBC!

Today is one of those "Where were you" moments in history our children and grandchildren will be talking about. Write down your hopes and feelings. Talk to your family about what is important to you. Someday, a family member will feel honored to know what YOU were feeling on this important day.

Remember to sign-up and volunteer your services to your community. Even if it is only a small step, every little small step counts towards making our nation stronger.

Happy Inauguration! God Bless America!

Monday, January 19, 2009

LOST Book Challenge

The LOST Books Challenge will be the first book challenge I have accepted so far in 2009. I like the idea of this challenge because I have become absorbed in the LOST legend over the past 6 weeks.

I didn't start out watching LOST when it first came on, but I have rented the entire series from Netflix and have been watching one episode after another. I will finish the 3-part season 4 finale tonight, so I'll be ready for the season 5 premiere on Wednesday.

Here are the books I am considering for this challenge - I am giving myself a list of 10 from which I will finally choose my 5 books:

1.) Are You There God? It's Me Margaret by Judy Blume - this book was a favorite when I was a little girl, but it's been over 30 years since I've read it.

2.) A Wrinkle in Time by Madeleine L'Engle - another favorite from my childhood, the book that started my science-fiction craze.

3.) Dune by Frank Herbert - I love this movie, but I've never read the book.

4.) Alice's Adventures in Wonderland by Lewis Carroll - actually I read this book again last year, but I plan to read the Annotated Alice. This may be a deviation from the books, but that's my plan.

5.) Through the Looking Glass by Lewis Carroll - see #4.

6.) The Stand by Stephen King - my favorite King book, but I haven't read it in years. I plan to read the expanded version which is over 1100 pages.

7.) Harry Potter series by J. K. Rowling - these 7 books will probably be bonus books. They are my comfort books, so whenever I'm sick or not feeling well, I'll pull out one and start reading.

8.) The Gunslinger by Stephen King - I have plans to re-read this entire series, but I'm not sure when.

9.) Watership Down by Richard Adams - another favorite book from my childhood. I read this one so many times before the animated movie was released. It has probably been 20+ years since I last read this one.

10.) The Chronicles of Narnia by C. S. Lewis - again, a favorite series. I re-read the books before the first movie was released, so I have plans to read again before the next movie.

Happy Reading!!

Sunday, January 18, 2009

Frost Bites

Frost Bites (Nodessy Adventures #2) by Charles Ogden

Reading level: Ages 9-12
Hardcover: 192 pages
Publisher: Aladdin
Language: English
ISBN-10: 1416954643
ISBN-13: 978-1416954644

Although I was not familiar with these books before last week, most children under the age of 12 know Edgar and Ellen from their animated television series. Ogden – who is mysteriously missing in action - has cleverly written a series of books about these michevious twins and their adventures in the town of Nod’s Limbs. The Nodessy Adventures is the second series featuring the twins.

In this book, Edgar and Ellen are in pursuit of their nemesis, Stephanie Knightleigh, who leads them to Frøsthaven, an Arctic village whose cheerful citizens and strange customs remind them of home.

Also, there are clues embedded in this book that will lead the reader closer to the missing author of this series.

Friday, January 16, 2009

Blue Moon

Blue Moon (Anita Blake Vampire Hunter book #8) by Laurell K. Hamilton

Hardcover: 384 pages
Publisher: Berkley Hardcover
Language: English
ISBN-10: 0425223833
ISBN-13: 978-0425223833

For all those interested in the vampire genre, the Anita Blake Vampire Hunter series is for you. Anita makes a living as a necromancer – someone who raises the dead. She also executes rogue vampires and other villains. Vampire marks bind her to Jean-Claude, the Master vampire of St. Louis, and to Richard, her ex-fiancé, a powerful werewolf who heads up the local pack. Anita shares some of their magic, and her own power over the dead keeps growing.

In Blue Moon, Richard has been thrown in jail and Anita arrives to save the day, only to realize the local cops are very corrupt. Once again, Anita finds herself in over her head having to rely on her quick wit and skills, in addition to reinforcements from the vampire and were-pack communities.

To better understand the world of Hamilton’s vampires, it is best to read the earlier books in this series. But if you love vampires, they are well worth the read.

Wednesday, January 14, 2009

Way Back Wednesday - Osma of Oz

Ozma of Oz by L. Frank Baum

Ozma of Oz was first published on July 29, 1907, and was the third book of L. Frank Baum's Oz series. Happily, Dorothy returns in this book, after being absent from The Marvelous Land of Oz.

Uncle Henry has been ordered by his doctor to take a vacation from his Kansas farm and he goes to Australia. He and Dorothy are aboard a steamship traveling there when they are caught in a fierce storm and separated. Dorothy is blown overboard along with a yellow hen - Billina - from her uncle's farm that was on the ship. The movie Return to Oz also gets many of its ideas from this book, especially the lunch pail tree, which I find fascinating.

Dorothy and Billina are constant companions during this tale. We also get to meet Tic-Toc, the Nome King, and the hungry Tiger. Dorothy is also reunited with the Scarecrow, the Tin Woodman and the Lion.

Monday, January 12, 2009

The Titan's Curse (Percy Jackson and the Olympians #3)

The Titan's Curse (Percy Jackson and the Olympians book #3) by Rick Riordan

Reading level: Ages 9-12
Paperback: 336 pages
Publisher: Hyperion Book CH
Language: English
ISBN-10: 1423101480
ISBN-13: 978-1423101482

This young adult book series is a great introduction to ancient Greek mythology. Percy Jackson is a teenager with half mortal and half god genes who lives in the world of ancient mythology. In order for this book to make sense, you really need to read the first two books in this proposed five book series: The Lightening Thief and The Sea Monsters.

In The Titan’s Curse, Percy is on a rescue mission to save his best friend Annabeth and the goddess, Artemis. Our hero must deal with various mythological beasts, as well as his ever growing mythological family – in particular, his distant, godly parents. Percy also learns there is a dark side to being a hero.

If you love Greek mythology and have been searching for a new series of books to read after the conclusion of Harry Potter, then Percy Jackson and the Olympians is just the place to start.

Saturday, January 10, 2009

Tales of Beedle the bard

Tales of Beedle the Bard by J. K. Rowling (111 pages)

For all you Harry Potter fans who have been in withdrawal since the 2007 release of The Deathly Hallows, this book is for you. Rowling has finally given us the fairy tale book first introduced in the 7th Harry Potter book.

This slim book contains five fairy tales: "The Tale of the Three Brothers", "The Warlock's Hairy Heart", "The Wizard and the Hopping Pot", "The Fountain of Fair Fortune", and "Babbitty Rabbitty and her Cackling Stump."

Although not in the same league as the Harry Potter series, this is a must read for fans of Rowling. It makes an excellent bedtime story book for children (and adults) of all ages.

Wednesday, January 7, 2009

Way Back Wednesday - The Marvelous Land of Oz

The Marvelous Land of Oz was published on July 5, 1904, and is the second of L. Frank Baum's books set in the Land of Oz, and the sequel to The Wonderful Wizard of Oz. It is the only book in the series in which Dorothy Gale does not appear.

A little boy named Tip is under the guardianship of a witch named Mombi in Gillikin Country. Tip makes plans to escape from Mombi by frightening her with a scarecrow. Unfortunately, he has no straw to stuff the scarecrow, so Tip makes a man out of wood and gives him a pumpkin for a head, naming him Jack Pumpkinhead. Mombi is not scared and she sprinkles the Powder of Life on Jack, bringing him to life. Mombi then threatens revenge on Tip.
Tip and Jack run away to the Emerald City, which is currently ruled by the Scarecrow. The Tin Woodman now rules the Winkie Kingdom. The Lion is mysteriously absent, just like Dorothy.

We are introduced to several new characters from the Land of Oz: General Jinjur's all-girl Army of Revolt, the Wogglebug, the flying Gump, Jackdaws, and most importantly Ozma who is the rightful ruler of the Emerald City.

Return to Oz is a 1985 Disney film which has many elements from The Marvelous Land of Oz. Of all the Oz books, I think this is my least favorite because Dorothy is missing, but I did enjoy the Return to Oz movie.

Thursday, January 1, 2009

Happy New Year

Happy New Year to all my readers!!! Here's to a bright and shiny 2009!!


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Saturday, December 21, 2013

Faith's Orchestra Concert

On December 9th Faith had her first Orchestra Concert at the high school.
Faith got to write and read about the first song that they played.
She did such a great job on it.
I wasn't suppose to use a flash but I did. he he

Here is E'lyse and Drew in the lobby of the PAC
Alan pushed them apart because they were standing next to each other.

Here is Faith I think she looks beautiful.
Her little flashy kiss
Faith & Gabby
Awkward prom picture of Faith & Gabby.

Gabby & Faith walking out to truck after concert.
Reminded me of when they were little & BFF's.
The concert was so nice.
I enjoyed the music and time with the family.
Faith did a fantastic job and looked so beautiful.
Hugs, Bobbi Jo

The Lucas Gang said...

One of these days I will be down there to see her play! She looks purty!

xiaosi90 said...

Looks very warm.There have a lot of vintage prom dresses, I think this dress fit you perfectly.

Tracy said...

Sometimes you just have to break the rules and use a flash.
Nice pictures.

Cooking classes Houston said...

good pictures.
photography classes atlanta


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Take Your Mixes To The Next Level

Monday, January 11, 2010

2010 CES Show Overview - Part 2

In part 2 of my 2010 CES overview we look at some of the more absurd audio products at the show. Keep in mind that I never even got to the high-end audio exhibits at the Venetian due to a lost show  pass. Otherwise, this report would've been filled with examples of $300 power cables, $100 wooden volume knobs and polarized speaker cables that make your stereo sound great even if there is a car parked in your driveway or it's below 50 degrees outside (if you don't get it, this is some of the foolishness that some of these companies try to pull on unsuspecting medical and legal professionals with too much money in their bank accounts).

One last thing about the video world that I forgot to mention yesterday - handheld camcorders were everywhere and most of them were capable of 1080p, even the least expensive of them. Tape as a storage medium has gone the way of the CRT, meaning there probably wasn't a machine in entire city of Vegas that uses it. What was interesting is that a few years ago the top floor of the South Hall was flooded with Chinese and Korean manufacturers who all had iPod knock-offs. This year those same manufacturers had small 1080p camcorders. We now officially live in a hi-def world.

There was a lot of this kind of table top and portable audio gear around this year, but the difference from other years was that all of it was capable of online connectivity, and/or had flash card or SD card inputs. A reasonable trend for some marginal devices.

There was also an ever expanding world of iPod docks, one stranger looking than the next. Who buys these things? Do dealers even carry them? Would a consumer actually consider purchasing such a thing? Does the color really matter?

Yet another iPod dock that left me scratching my head. This one was so special that it was behind a plexiglass case. Didn't have a name, model, price or any information. I didn't even know it was a dock until I pressed my face up against the plexi.

Here's another Internet radio from an unknown foreign company that makes you scratch your head and wonder, "Why?"

For some reason, female DJs were everywhere this year. I guess some manufacturers must think that if a DJ is cool, a good looking girl DJ is even cooler. "Yeah, that's right. It'll help us fill out our order books."

This one actually gave me a dirty look when I was taking her picture. Sorry babe, you gave up your privacy when you took this meaningful job.

It seemed like whenever there was a female DJ, there was some kind of designer audio product around. Designer headphones were big this year. They don't have to sound good, just look cool and match your outfit. Plaid was the in color this year, in someone's mind at least.

Speaking of headphones, there were a lot of 5.1 surround sound headphones at the show. Having made my living as a surround mixer for a while, this caught my interest until I learned they were aimed only at the gaming market. After I thought about it for a while, I had to agree that was a much better application for pseudo-surround than anything I could think of.

Now we come to some of the even more absurd audio products. Once again, it makes you wonder, "Who buys these things?" or even worse, "Why would a company even consider creating them in the first place?" In any event, I hope these are the guys that are building military products for the foreign governments that we're afraid of.

First we have a karaoke box, complete with microphone. Why does it look like one of those center channel soundbars for your television sound system? Maybe because it's a center channel karaoke soundbar for your television? Or maybe not.

This is only one of many speaker systems that were pretty off the wall in their design. There was no audio pumping through it to tell how it sounds, but I guess it's only supposed to look pretty. Maybe it's there to hold up that Ming vase I bought at a yard sale.

And finally, here's what must be the worlds beefiest subwoofer speaker. This is when you've tried everything to get enough volume from your car stereo to crack your windshield, but nothing will do the job. It must be good though, since the frame is made from silver colored cast iron. I'll take 4 please. Maybe I can blow my windshield right out of its socket.

Tomorrow we'll finish up with some interesting accessories that are somewhat less absurd.

1 comment:

DonD said...

I once stopped at a light next to a guy whose car was booming so loudly, I could feel it in my chest. His windows were up. MY windows were up. Still, my keys were jangling. But best of all, he was wearing headphones. Headphones!!! I just now realized the phones were a fashion statement. Or maybe they were for ambient noise reduction (like airport workers wear). Or they were for catching the blood dribbling out of his ears. So, yes, there's a market for this stuff.

Go figure.

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