Essay on Their Eyes Were Watching God - 1371 Words

Their Eyes Were Watching God In Their Eyes Were Watching God, Janie battles to find Individualism within herself. Janie, all her life, had been pushed around and told what to do and how to live her life. She searched and searched high and low to find a peace that makes her whole and makes her feel like a complete person. To make her feel like she is in fact an individual and that she’s not like everyone else around her. During the time of ‘Their Eyes’, the correct way to treat women was to show them who was in charge and who was inferior. Men were looked to as the superior being, the one who women were supposed to look up to and serve. Especially in the fact that Janie was an African American women during these oppressed†¦show more content†¦This is exactly what Janie did in her marriage to Logan. She did as she was told, or rather, expected to do. Janie didn’t want to marry Logan, but if it made her grandmother happy, then by all means, why not give it a shot. If it meant that she’d be secure. In her marriage to Logan, she found out that that’s not what she wanted. Janie wanted love, happieness, comfort and enjoyment. She didn’t want her first marriage to be like a prison sentence. â€Å"Did marriage end the cosmic loneliness of the unmated, did it compel love like the sun the day?† This is asking if marriage made love for Janie as the sun makes the day for the world. Is the basis of love marriage...just as the basis for day is the sun. To Janie, this was not true. She did not feel as though she loved Logan, and that’s all she really wanted. She didn’t want to be treated as the rest of the world was treated. She wanted to be treated as an individual and not as a slave. She was a slave to marriage. She didn’t want to be there, where there was no warmth. Joe Starks stole Janie away from Logan. He saved her from the boringness of their dull marriage. He woed her with his words of kindness. He promised her happieness. â€Å"De day you puts yo’ hand in mine, Ah wouldn’t let de sun go down on us single. You ain’t never knowed what it was to be treated lak a lady and Ah wants to be de one tuh showShow MoreRelatedTheir Eyes Were Watching God1064 Words   |  5 Pagessignificant than death. In Zora Neale Hurston’s famous novel, Their Eyes Were Watching God, the main character Janie Crawford is plagued by the deaths of loved ones. Janie moves from caregiver to caregiver searching for true love and happiness, only to have it stripped away from her once she finds it in her third husband Tea Cake. At the end of the novel, having realized true love and loss, Janie is a whole woman. Their Eyes Were Watching God portrays the growth of the human spirit through both the emotionalRead MoreTheir Eyes Were Watching G od1780 Words   |  8 Pagesshort story â€Å"Sweat† and novel Their Eyes Were Watching God, the focus is on women who want better lives but face difficult struggles before gaining them. The difficulties involving men which Janie and Delia incur result from or are exacerbated by the intersection of their class, race, and gender, which restrict each woman for a large part of her life from gaining her independence. Throughout a fair part of Zora Neal Hurston’s novel, Their Eyes Were Watching God, Janie’s low class create problemsRead MoreTheir Eyes Were Watching God932 Words   |  4 PagesJanie Crawford: The Woman Whose Clothing Conveys Her Relationships In Zora Neale Hurston’s Their Eyes Were Watching God, the protagonist, Janie, endures two marriages before finding true love. In each of Janie’s marriages, a particular article of clothing is used to symbolically reflect, not only her attitude at different phases in her life, but how she is treated in each relationship. In Janie’s first marriage with Logan Killicks, an apron is used to symbolize the obligation in her marriage. â€Å"Read More Eyes Were Watching God Essay711 Words   |  3 Pages Their Eyes Were Watching God provides an enlightening look at the journey of a quot;complete, complex, undiminished human beingquot;, Janie Crawford. Her story, based on self-exploration, self-empowerment, and self-liberation, details her loss and attainment of her innocence and freedom as she constantly learns and grows from her experiences with gender issues, racism, and life. The story centers around an important theme; that personal discoveries and life experiences help a person findRead MoreAnalysis Of Their Eyes Were Watching God 1061 Words   |  5 PagesDivision: Janie Crawford in Their Eyes Were Watching God Their Eyes Were Watching God was written in 1937 by Zora Neale Hurston. This story follows a young girl by the name of Janie Crawford. Janie Crawford lived with her grandmother in Eatonville, Florida. Janie was 16 Years old when her grandmother caught her kissing a boy out in the yard. After seeing this her grandmother told her she was old enough to get married, and tells her she has found her a husband by the name of Logan. Logan was a muchRead More Their Eyes Were Watching God Essay1757 Words   |  8 Pages Their Eyes Were Watching God Book Report 1. Title: Their Eyes Were Watching God 2. Author/Date Written: Zora Neale Hurston/1937 3. Country of Author: 4. Characters Janie Mae Crawford- The book’s main character. She is a very strong willed, independent person. She is able to defy a low class, unhappy life because of these factors, even though the environment that she grew up and lived in was never on her side. Pheoby Watson – Janie’s best friend in Eatonville. Pheoby is the only towns person whoRead MoreWhose eyes were watching God?1400 Words   |  6 PagesWhose eyes were watching God? In the movie Their Eyes Were Watching God, Oprah Winfrey manipulates events that happened in the book by Zora Neale Hurston. Oprah morphs many relationships in the movie Their Eyes Were Watching God. She changes the role of gender, and also makes changes in Janie’s character strength. Oprah also changes the symbolism in the movie to where some important symbols in the book change to less important roles. Oprah changes many important events in the book Their Eyes WereRead MoreTheir Eyes Were Watching God Essay724 Words   |  3 PagesTHEIR EYES WERE WATCHING GOD ESSAY  ¬Ã‚ ¬ Janie Crawford is surrounded by outward influences that contradict her independence and personal development. These outward influences from society, her grandma, and even significant others contribute to her curiosity. Tension builds between outward conformity and inward questioning, allowing Zora Neal Hurston to illustrate the challenge of choice and accountability that Janie faces throughout the novel. Janie’s Grandma plays an important outward influenceRead MoreEssay on Their Eyes Were Watching God921 Words   |  4 PagesTheir Eyes Were Watching God An Analysis So many people in modern society have lost their voices. Laryngitis is not the cause of this sad situation-- they silence themselves, and have been doing so for decades. For many, not having a voice is acceptable socially and internally, because it frees them from the responsibility of having to maintain opinions. For Janie Crawford, it was not: she finds her voice among those lost within the pages of Zora Neale Hurston’s famed novel, Their Eyes Were WatchingRead MoreTheir Eyes Were Watching God By Zora Hurston Essay1233 Words   |  5 PagesHurston In the novel â€Å"Their Eyes Were Watching God† by Zora Neal Hurston is about a young woman named Janie Crawford who goes on a journey of self discovery to find her independence. The book touches on many themes like gender roles, relations, independence and racism however racism isn’t mainly focused upon in the book which some writers felt should have been. Some felt that the representation of black characters should have been better role models. Zora Hurston’s novel wasn’t like other black literature

Why Absolute Rulers Believe On Divine Right - 1737 Words

Why did absolute rulers believe in divine right? How did this put them at odds with the common people? Absolute rulers believed in divine right, where monarchs are given the power to rule by God and are responsible only to God. They held this belief because it set them apart from the citizens they governed and instilled a feeling of fear and respect among their subjects. It also helped ensure that no one would question their leadership. However, this put them at odds with the common people because many citizens did not believe in divine right. They wanted to have a say in how the government was run and the decisions they made. List the 2 major contracts/documents that secured English rights and helped build a democratic gov’t. List 2 rights from each document. The Magna Carta of 1215 and the English Bill of Rights of 1689 were 2 documents that secured English rights and helped build a democratic gov’t. Both documents limited the monarch’s power and granted human rights to the subjects. The Bill of Rights included the right to petition the king, no excessive bail, and no cruel and unusual punishment The Magna Carta grants the right to trial by jury, due process, and swift justice. Did the English Civil War improve the English gov’t? Why or why not? Bill of Rights Who: William Mary and Parliament What: The Bill of Rights was a formal summary of the rights and liberties that were essential to all people. Those included the right to petition the king, no excessiveShow MoreRelatedThe View of Absolute Monarchies1125 Words   |  5 PagesThe View of Absolute Monarchies The extent to which rulers and their subjects viewed the role of an absolute monarch was different. The time of this political issue on absolute monarchies was around the 1600s. There were people for the absolute monarchies, people with their own monarchies and people against monarchies. Each one had there own idea for what the role of the monarchy was the people against it thought it was oppressive the people for it thought it was because people couldn’t ruleRead MoreThomas Hobbes : The Age Of Reason1313 Words   |  6 PagesHobbes experienced the tragedies of war, he held the belief that all humans were born evil and mischievous and that they need an absolute sovereign or they will remain in a constant state of war amongst themselves (Warrender). Increasingly Parliament and the king were in conflict over royal powers, especially regarding funds for an army. Charles I, believing in divine right, felt restricted by Parliament, while Parliament felt abused by the over-spending. In response to the growing conflict in EnglandRead MoreI Wandered Lonely as a Cloud Reflection Essay1711 Words   |  7 Pagesrealized the emotional escape they provide. of law. These strict codes made Sweden very prosperous by having well-controlled citizens and fewer riots. Soon he became a renowned ruler throughout Europe. The impact of this was very great and allowed Sweden to advance in warfare. With the citizens under control and their natural rights stripped, Charles XII went onto defeat Russia in the Battle of Narva. Russian soldiers lost about 10,000 men at the end of the battle, while the Swedish troop only lost 667Read MoreThe Pros And Cons Of King Philip II864 Words   |  4 PagesWas Philip II of Spain a successful absolute monarch during his rule? Many people believe he had what it took to be absolute monarch, but there were several constraints he faced as a ruler in Spain. Philip II was known for building one of the largest empires from creating effective domestic and foreign policies to gain leadership of his kingdom instead of the local authorities in charge, but he did face problems while ruling the kingdom. His addressed many of these policies, such as the policy againstRead MoreJohn Locke: Second Treatise of Civil Government Essay1081 Words   |  5 PagesJames, Duke of York, who would later become King James II. Shaftesbury had tried to prevent Jamess right of succession, so he fled to Holland, and Locke followed. Locke returned to England with Queen Mary when she overthrew James II in the Glorious Revolution. The support which Locke showed for Mary demonstrates his mindset of politics, and shows his opposition towards despotic rulers and divine right. Locke saw many important men while in England, including Sir Isaac Newton, of whom he wrote. ThroughRead MoreThe Theory Of Divine Right1330 Words   |  6 PagesThroughout history, new ideas have always been formed from questions and different questions create new ideas. These five documents- â€Å"The Theory of Divine Right,† â€Å"Revocation of the Edict of Nantes,† The Social Contract, What is Enlightenment?, and The Declaration of Independence- each discuss a different idea and are substantial in the demonstration of this idea. These ideas have many differences and similarities. They may be significant in different revolutions, but they all pertain to differentRead MoreDbq: the Enlightenment Essay1184 Words   |  5 PagesEnlightenment known by many as the Age of Reason was a turning point in history. Man people believe that without the Enlightenment, many of the laws, and rules would exist. For example the United States Declaration of Independence and the Constitution were greatly influenced by the Enlightenment. For example, John Locke, an Enlightenment thinker highly influenced the Declaration of Independence by stating that the natural rights of people include life, liberty and property except the founding fathers changedRead MoreThe Unexamined Life Is Not Worth Living1450 Words   |  6 Pagesphilosophical context. As with the nature of philosophy itself, living philosophically is also ambiguous, and it could very well be that one lives philosophically even if they do not necessarily realize it. Take, for instance, a person who questions why humans and all life forms must die; or one who ponders their true meaning in life - are they not thinking philosophically? Regardless of whether or not they actually study philosophy, they are still critically thinking about the nature of being andRead MoreThe Theory Of Social Contract1709 Words   |  7 PagesContractualism, in general, is whether or not an action is deemed ‘right’ or ‘wrong’ can be understood in terms of co ntracts, and is furthered with the theory of social contract. Additionally, contractualism can be distinguished from Hobbesian contractualism (also known as contractarianism) and Kantian contractualism, whereby the former looks to contracts made by individuals of a society for the sake of personal gain and benefit, while the latter sees to contracts made by individuals of any givenRead MoreIslamic Thought: Despotism Replacing Despotism1541 Words   |  6 Pagesfrom the Quran, called sharia law. As a function of Islam and sharia law, Islamists are very hands on. Islamists like Ruhollah Khomeini and Hassan al-Turabi aren’t mere theologians but politicians that seek fulfillment of their visions. Islamists believe firmly that the only true way to realize their vision of â€Å"authentic Islam† is through an Islamic state, dominated by sharia law. Naturally, with the formation of a state, a government is needed to perform a variety of functions. Islamists go as far

Phosphorus Chemical Reactions Of Phosphorus And Its Importance Essay Example For Students

Phosphorus: Chemical Reactions Of Phosphorus And Its Importance Essay Abstract: Aluminum sulfate reacts with phosphates to createaluminum phosphate and a sulfate. The conversion of the phosphateto aluminum phosphate is very important because this allows thephosphate to be easily extracted. This manipulation is used todayin industrial waste treatment sights. The removal of phosphates isvery important for if phosphates are not removed, they plaguebodies of water by feeding algae which clog the surface waters andeventually effect every living and nonliving thing in thatenvironment. Chemical Process: The reactions which occur are the following:Aluminum sulfate(alum) in combination with wastewater canflocculate phosphorus. The Flocculation that happens with aluminumsulfate addition is the formation of aluminum phosphate particlesthat attach themselves to one another and become heavy and settleto the bottom of a clarifier. The aluminum sulfate and phosphorusmixture can then be withdrawn, thereby removing the phosphate orphosphorus from the wastewater flow. Industrial Applications: The application of this reaction to theindustrial world consists of a set of processes to filter out thephosphate. The setup is the following:Purpose: Restrict phosphates to aluminum phosphates for easierdisposal of phosphorus. The first step in phosphorus removal is the Rapid Mix. Inthis stage, alum and waste or water runoff(known as effluent) isblended together as rapidly as possible with the use of a high-speed mixer called a flash mixer. After this instant mixing, aslower moving process called coagulation and flocculation followsto allow the formation of a floc. These processes occur in aFlocculation Chamber. This floc consists of suspended and colloidalmatter, mainly including the aluminum phosphate. Next, theeffluent travels to a clarifier in which sedimentation occurs. Theheavier aluminum phosphate settles to the bottom then pumps at thebottom of the clarifier pump out the aluminum phosphate via pipes. This aluminum phosphate is then disposed. Currently, there are noeconomical uses for aluminum phosphate. Also, this chemical process is similar to the process used bylaundry detergents. Many detergents contain synthetic phosphates,called tripolyphosphates(TTPs). These chemicals cling to greaseand dirt particles(alum in the previous example), keeping them insuspension until the wash water is flushed out of the washingmachine. Impact on Society: This reduction in phosphorus is very important. This added phosphorus disrupts the natural cycle of phosphorus. Oneresult of this is an algal blooms, or exponential growth in algae. When algal blooms occur, the surface of a freshwater lake isclouded with an almost finite amount of bacteria because of anincrease in a nutrient. In this case an increase in phosphate, afavorite for algae. This deprives the bottom of the lake bycutting off light. A dense mat of algae choke off the lake. Also,phosphates are nutrients for plantlife. When fall approaches, orwhen phosphate levels are decreased, the algae die and fall to thebottom, changing the bottom from a silt, sand and clay bottom to asand gravel and rock bottom. When the plants die, they aredegraded by aerobic bacteria, which can deplete dissolved oxygen,killing aquatic organisms. As oxygen levels drop, anaerobicbacteria resume the breakdown and produce noxious products. All ofthis impairs navigation, fishing, swimming and recreationalboating. Total phosphorus removal through filters after using alum asa filtering aid achieves 70 to 95 percent efficiency. Phosphatesmust be filtered out before the water or wastes are dumped backinto bodies of water. GlossaryFlocculation: The gathering together of fine particles to formlarger particles. Effluent: Wastewater or other liquid raw, partially orcompletely treated flowing from a basin, treatment process, ortreatment plant. .uc4f2ddf44d4d053cf92314871e994f76 , .uc4f2ddf44d4d053cf92314871e994f76 .postImageUrl , .uc4f2ddf44d4d053cf92314871e994f76 .centered-text-area { min-height: 80px; position: relative; } .uc4f2ddf44d4d053cf92314871e994f76 , .uc4f2ddf44d4d053cf92314871e994f76:hover , .uc4f2ddf44d4d053cf92314871e994f76:visited , .uc4f2ddf44d4d053cf92314871e994f76:active { border:0!important; } .uc4f2ddf44d4d053cf92314871e994f76 .clearfix:after { content: ""; display: table; clear: both; } .uc4f2ddf44d4d053cf92314871e994f76 { display: block; transition: background-color 250ms; webkit-transition: background-color 250ms; width: 100%; opacity: 1; transition: opacity 250ms; webkit-transition: opacity 250ms; background-color: #95A5A6; } .uc4f2ddf44d4d053cf92314871e994f76:active , .uc4f2ddf44d4d053cf92314871e994f76:hover { opacity: 1; transition: opacity 250ms; webkit-transition: opacity 250ms; background-color: #2C3E50; } .uc4f2ddf44d4d053cf92314871e994f76 .centered-text-area { width: 100%; position: relative ; } .uc4f2ddf44d4d053cf92314871e994f76 .ctaText { border-bottom: 0 solid #fff; color: #2980B9; font-size: 16px; font-weight: bold; margin: 0; padding: 0; text-decoration: underline; } .uc4f2ddf44d4d053cf92314871e994f76 .postTitle { color: #FFFFFF; font-size: 16px; font-weight: 600; margin: 0; padding: 0; width: 100%; } .uc4f2ddf44d4d053cf92314871e994f76 .ctaButton { background-color: #7F8C8D!important; color: #2980B9; border: none; border-radius: 3px; box-shadow: none; font-size: 14px; font-weight: bold; line-height: 26px; moz-border-radius: 3px; text-align: center; text-decoration: none; text-shadow: none; width: 80px; min-height: 80px; background: url(https://artscolumbia.org/wp-content/plugins/intelly-related-posts/assets/images/simple-arrow.png)no-repeat; position: absolute; right: 0; top: 0; } .uc4f2ddf44d4d053cf92314871e994f76:hover .ctaButton { background-color: #34495E!important; } .uc4f2ddf44d4d053cf92314871e994f76 .centered-text { display: table; height: 80px; padding-left : 18px; top: 0; } .uc4f2ddf44d4d053cf92314871e994f76 .uc4f2ddf44d4d053cf92314871e994f76-content { display: table-cell; margin: 0; padding: 0; padding-right: 108px; position: relative; vertical-align: middle; width: 100%; } .uc4f2ddf44d4d053cf92314871e994f76:after { content: ""; display: block; clear: both; } READ: Omar Khayyam The Enigma EssayCoagulation: The use of chemicals that cause very fine particlesto clump together into larger particles. This makes it easier toseparate the solids from the liquids by setting, skimming, drainingor filtering. Floc: Groups or clumps of bacteria and particles or coagulants andimpurities that have come together and formed a cluster. Colloidal: Very small and finely divided. Referring to solids. Does not dissolve and remains dispersed in a liquid for a long timedue to small size. Algal blooms: Rapid growth of algae in surface waters due toincrease in inorganic nutrients. BibliographyKerri, Kenneth D. Advanced Waste Treatment. Sacramento, Ca.: CSU,Sacramento, 1987. Adams, Melinda. Environmental Science. Redwood City, Ca.: TheBenjamin/Cummings Publishing Company, Inc., 1991.

Is Euthanasia a Morally Wrong Choice for Terminal Patients

Abstract Making decisions on whether to end the life of terminally ill patients is shrouded in controversies and disagreements, and is seen as an unethical act. This paper attempts to make arguments in support of euthanasia as an alternative form of healthcare for terminally ill patients whose quality of life is significantly reduced due to the effects of such an illness.Advertising We will write a custom research paper sample on Is Euthanasia a Morally Wrong Choice for Terminal Patients? specifically for you for only $16.05 $11/page Learn More The paper evaluates three perspectives in support of euthanasia: patient rights and autonomy, humanistic concern for patients’ happiness and utilitarianism view on the attainment of the highest happiness. Crucial evidence is drawn from real life and hypothetical cases to justify the arguments herein. It is imperative to note that the paper calls for euthanasia for only deserving patients, based on the quali ty of life, the terminal illnesses, patient’s consent and patients happiness. Additionally, the role of healthcare professionals becomes significantly important as it enhances professionalism as well as in helping to determine patients that deserve to be euthanized. Introduction End of life is one of the most critical periods in a person’s life, which becomes even more critical when terminal illness mediates the end of life process. Dealing with terminal illnesses is the hallmark of controversies surrounding the end of life process. As a result, various controversial views, such as assisting terminally ill patients in ending life, have emerged. Euthanasia, as assisted death is commonly referred to, generates debate, especially on ethical permissibility. . It is imperative to note that for both the opponents and proponents of euthanasia, the quality of life is usually the focal point, even though there is no agreement on the criteria of defining quality with regards to life. Nevertheless, there are situations in which euthanasia is not only justifiable but also the only ethically permissible act in alleviating pain for terminally ill patients. The paper evaluates three basic viewpoints for euthanasia and also attempts to justify the call for euthanasia through citing various forms of evidence.Advertising Looking for research paper on health medicine? Let's see if we can help you! Get your first paper with 15% OFF Learn More Defining Euthanasia It is primarily assumed that healthcare is not only intended to eliminate human suffering but also to prolong life. Healthcare at the end of life has always been an issue of great controversy. Various treatment regimens, such as use of traditional treatment methods, seeking spiritual healing as well as science-based disease elimination methods have been developed (Buse, 2008). Suffice to state that the development of various treatment methods has also led to the emergence of legal, ethical and philosophical challenges (Munson, 1996). One such challenge is how to deal with terminal illnesses, with euthanasia increasingly becoming a preferred option. Euthanasia is shrouded in mystery and controversy. But defining it helps to address such controversies. The modern perception of euthanasia borrows from two Greek terminologies â€Å"‘eu’ implying good, and â€Å"thanasia’ implying death† (Coyle, 1992). Thus, while euthanasia refers to ‘good death’, a number of controversies emerge since euthanasia involves ending the life of an innocent person. Traditional treatment methods are not only intended to eliminate pain and suffering but also for the attainment of prolonged life. However, there are instances where treatment is ineffective or further prolongs a patient’s suffering. Some treatment methods also expose terminally ill patients to increased risk of death. In such cases, terminal illness diminishes the quality and the dignity of life, making a living more problematic. Death seems to be the only way through which terminally ill patients comes out of the unendurable situation (Irish Council for Bioethics, n.d.). Euthanasia can be defined within certain parameters. For instance, a terminally ill patient, despite being in an insufferable state and with minimal chances of recovery, may be unwilling to die. A physician may propose euthanasia, against the will of the patient, as the only treatment alternative. This is referred to as involuntary euthanasia. A terminally ill patient may also degenerate into vegetative state, thus unable to give consent on euthanasia. This is referred to as non-voluntary euthanasia and has faced stiff opposition, especially from religious-based organizations.Advertising We will write a custom research paper sample on Is Euthanasia a Morally Wrong Choice for Terminal Patients? specifically for you for only $16.05 $11/page Learn More As opposed to invo luntary euthanasia, a patient may be willing to end suffering through death and may thus request for assistance to end life. This is referred to as voluntary euthanasia and is supported by humanists and human rights activists. A physician may withhold or omit treatment due to its ineffectiveness (Zdenkowski, 1996). While Zdenkowski (1996) refers to this as passive euthanasia Irish Council for Bioethics (n.d.) asks whether omission of treatment amounts to euthanasia. The definitions above portray euthanasia as an appropriate and necessary alternative for the elimination of human suffering for terminally ill patients. However, these definitions fail to exhaustively capture the confines within which euthanasia is said to be morally permissible. Thus, its appropriateness and moral permissibility is an issue that has continued to not only elicit sharp reactions from various quarters but also generate difficult questions. For instance, whether a terminally ill patient has an exclusive rig ht to determine the manner and the time of death, whether euthanasia diminishes the value of human life or whether euthanasia undermines the quality of healthcare are some of the major questions not sufficiently addressed through the definitions above. Nevertheless, an attempt is made to address some of the shortcomings in the section that follows. Major viewpoints in support of euthanasia Terminal illnesses are mostly irreversible. They also involve insufferable pain which reduces the quality and the integrity of life. Dealing with terminal illnesses is a complicated matter due to issues beyond human ability. Nevertheless, there are some instances where assisting terminally ill patients seems to be not only appropriate but also morally permissible. This generates numerous viewpoints, as seen below. Patient’s rights and free will In liberal societies, it is assumed that every individual has the right to make decisions regarding life without undue influence. It is also assumed that individuals have the right to access necessary information that allows them to make informed choices for their own benefit in a way that does not affect other people (Buse, 2008).Advertising Looking for research paper on health medicine? Let's see if we can help you! Get your first paper with 15% OFF Learn More This right also involves determining the direction of ones life, and whether an individual has the right to choose to die incase circumstances, such as terminal illness, demand so. Supporters of this viewpoint argue that a terminally ill patient has the right to choose death as a possible treatment for an insufferable and irreversible condition. As such, it is generally perceived as an act of immorality to force terminally and chronically ill patients to live against their wish (CNBC News, 2011). Additionally, such an act is considered as denial and violation of personal rights, freedoms and liberties (Irish Council for Bioethics, n.d.; Humphry, 1991). Proponents of these views argue that a terminally ill patient has the right to determine where, when and how to die. However, this viewpoint is strongly opposed by religious-based organizations on assumption that an individual’s right to life is determined by God. Since terminally ill patients lack the power to determine when t hey are born, they also lack the right to determine how and when they die (Irish Council for Bioethics, n.d.). Opponents also argue that allowing an individual the right to choose when and how to die devalues God, life and God’s Devine will (Johnstone, 2008; Bowie and Bowie, 2004). Nevertheless, as Gorsuch (2009) argues God is compassionate and would not subject anyone to prolonged suffering in the form of terminal illnesses. Thus, it is within the rights of a terminally ill patient to choose to die immediately rather than live an intolerably, without upsetting the Will of God. Humanistic genuine care and concern for patients’ happiness The thoughts illustrated above indicate that both the liberal and religious-based authorities value the dignity of human life. Similarly, humanists portray significant care and concern for human life, but from a different perspective. Humanists argue for the quality and the dignity of human life and the search for personal happiness as the absolute goal in life. If a condition, such as terminal illness lowers the quality of human life, then patients are within their right to seek any form of treatment that alleviates pain and suffering (Kuupellomà ¤ki, 2000). Humanistic beliefs suggest good quality life, the search for happiness and absolute fulfillment as the utmost goals in life. Most of the terminal illnesses are chronic in nature and result to extreme pain through which no medication can reverse or alleviate. Additionally, terminally ill patients gradually degenerate into a vegetative state. Humanists argue that in such a condition, a patient is not in a humanly dignified state and that euthanasia is not only most appropriate but also an act of mercy. Mercy killing, despite opposition from religious-based organizations, becomes morally permissible. Those inclined towards conservative views with regards to mercy killing propose palliative care as the most ethical form of healthcare for terminally ill patients. Humanists, on the other hand, argue that while palliative healthcare prolongs life amid extreme pain and suffering, it nevertheless fails lessen patients suffering (de Casterlà ©, Verpoort, De Bal and Gastmans, 2006). As such, despite the best palliative care practices, terminally patients remain in a humanly indignified state (Musgrave and Soudry, 2000). While humanists argue that euthanasia remains to be the only morally permissible solution, de Casterlà © et al. (2006) assert that physicians ought to approach euthanasia with â€Å"active openness† since terminally ill patients â€Å"request for euthanasia out of fear and ignorance†. While â€Å"active openness† is likely to offer the terminally ill patients some level of emotional relief and reassurance, it is only applicable to self-conscious patients and not those in vegetative state. Nevertheless, whether vegetative or self-conscious, euthanasia seems to be the only morally permissible act, if terminal illness significantly reduces the quality of life (Verpoort, Gastmans and de Casterlà ©, 2004). Utilitarianism view on the attainment of the highness happiness The assertions made above show genuine concern for the quality of human life. Nevertheless, the ideal definition of quality with reference to terminally ill patients differs significantly depending on underlying perspective. Similarly, utilitarian thinkers argue that euthanasia is a morally permissible and merciful act aimed at not only easing a patient’s suffering but also for the attainment of the highest possible happiness. The utilitarian view of quality is perceived from the intrinsic considerations to end human suffering instead of prolonging suffering (Kasule, n.d.). Utilitarianism assumes that there is no pain and suffering in death and as such, terminally ill patients ought to be helped to attain such a painless state, if living becomes unbearable and irreversible. Additionally, death ought to be achieved in highest possible happiness. Therefore, delivering euthanasia ought to be as painless as possible (Edwards and Graber, 1988). Utilitarian views presuppose that there is a minimum standard under which life is said to be worth living. Should terminal illness lower the quality of life below the minimum standard, personal happiness is jeopardized and therefore judgment ought to be made on whether living is necessary or not. Utilitarian thinkers argue that the judgment process is mostly subjective. As such, it is possible to euthanize undeserving patients or deny euthanasia to deserving ones. Nevertheless, utilitarian euthanasia seems appropriate where pain and suffering significantly deteriorates, is irreversible, and lowers the quality of life making living unbearable. Putting terminally ill patients under palliative care only leads to a slow, painful and indignified death. Since every person deserves to die in dignity and happiness, euthanasia is the only morally permissible act throug h which this is attained (Singer, 1993). Approaches and evidences for euthanasia To support the assertions made above, it is imperative to cite crucial evidence that validates the views made therein. Consequently, it is also imperative to enumerate a number of approaches made by the authors. Three major approaches seem to be overarching. Personal liberty and autonomy in making end of life decision, the role of healthcare professionals as well as the attainment of positive balance between suffering and personal happiness are the three overarching approaches adopted by the authors herein. Crucial evidence is derived from survey reports, real-life as well as hypothetical cases. Healthcare, personal liberty and autonomy at the end of life End of life is one of the most important periods in a person’s life. Matters involving end of life are critical and therefore, involvement of each individual in making decision regarding healthcare at the end of life is crucial (Buse, 2008). Mos t terminal illnesses involve insufferable pain that significantly lowers the quality of life. In humanistic view, such patients live and die in conditions not humanly dignified (Musgrave and Soudry, 2000). As such, request for euthanasia by patients in such conditions ought to be respected and granted (Kuupellomà ¤ki, 2000; Bowie and Bowie, 2004). Such conclusions have been arrived at based on varied evidence gathered form existing cases. For instance, the right and autonomy of terminally ill patients are highlighted through Sue Rodriguez, a Canadian woman suffering from Lou Gehrig’s disease, an extremely painful and irreversible condition. The doctors had agreed to her request for euthanasia, but The Canadian Justice System refused Miss Rodriguez the right to die and effectively prolonged her suffering, leading to a slow, painful death (CNBC News, 2011). In light of Miss Rodriguez’s case, questions linger on the applicability of personal liberty and autonomy for term inally ill patients lacking self-consciousness, such as Louis Repouille’s son. Described as ‘incurably imbecile’, Repouille’s son was said to be as good as dead. Singer (1993) asserts that such patients have the right to die in dignity and that doctors have an obligation to deliver euthanasia for such patients. While unconsciousness waives the right to life, assisting terminally ill patients in ending life does not amount to violation of personal liberty and autonomy (Singer, 1993). The role of healthcare professionals in the delivery of euthanasia Miss Rodriguez’s case exposes critical issues, such as the role of healthcare professionals in the delivery of euthanasia. A study conducted by de Casterlà © et al. (2006) in Belgium indicates that euthanasia is only ethical if healthcare professionals are actively involved in its delivery. de Casterlà © et al. (2006) study focuses on 12 healthcare givers and reveals that the role of healthcare profess ionals is not to limited to technical elements of euthanasia; it also involves offering professional and emotional support to patients and families. Additionally, healthcare professionals have an obligation to help terminally ill patients understand euthanasia and the underlying implications. This helps terminally ill patients and their relatives to obtain relief and assurance at the end of life (Verpoort, Gastmans and de Casterlà ©, 2004). Singer’s (1993) text further alludes to the active role that healthcare professionals ought to undertake in ensuring that euthanasia is delivered within professional and ethical boundaries. Singer (1993) cites George Zygmaniak example; Zygmaniak was completely paralyzed by a motor accident and as a result, his life became unbearably painful. Zygmaniak’s brother, upon request by Zygmaniak, smuggled a gun in the hospital and killed Zygmaniak. While this constitutes voluntary euthanasia, it was nevertheless conducted unethically since no professional healthcare provider was actively involved in euthanizing Zygmaniak. The principle of positive balance between suffering and personal happiness Humanist and utilitarian thinkers portray genuine concern for the welfare of the terminally ill. They acknowledge that the pursuit of personal happiness is the absolute goal in life. Since extreme pain significantly lowers the quality of life, the balance â€Å"between misery and suffering† seems relevance (Singer, 1993; Kasule, n.d.). The call for euthanasia is thus necessitated by condition in which suffering supersedes happiness (Edwards and Graber, 1988). In arriving at such conclusions, Singer (1993) cites several hypothetical situations, such a child suffering from spina bifida, a condition that affects the spinal cord, subsequently lowering nerve activity. In moderate cases, a child requires more than 40 surgeries to sustain life, while in extreme cases no medical intervention improves the quality of life. A mod erate case of spina bifida may not necessarily require euthanasia since the child may experience a high balance of happiness as compared to the level of suffering. On the other hand, extreme cases experience a higher level of suffering as compared to happiness and as such is deserving of euthanasia. The balance of happiness and suffering is also alluded to in Miss Rodriguez case; her condition involved extreme and irreversible pain that significantly reduced the level of personal happiness. Making end of life decisions, especially with regards to end of life healthcare is a personal prerogative. As such, in staking a claim for euthanasia defending the autonomy of a terminally ill patient in determining when, where and how to die is crucial. But it is also important to consider the balance between suffering and happiness and only allow euthanasia for those patients in insufferable and irreversibly painful states. To ensure that euthanasia is delivered within professional and ethical parameters, it is also important to enlist the help of healthcare professionals. This ensures that euthanasia is not only conducted ethically and professionally but delivered only to those patients for whom euthanasia is the only way to alleviate pain and suffering. Conclusion Euthanasia involves ending the life of innocent persons. Nevertheless, this does not necessarily make it unethical. Terminal illnesses involve extreme pain and suffering, which significantly lowers the quality of life. A terminally ill patient is thus justified to request for euthanasia, if living is cumbersome and insufferable. However, in granting the request for euthanasia, there is need to enlist the help of healthcare professionals, whose role extends beyond providing crucial information to offering professional as well as emotional support. Additionally, healthcare professionals ought to be involved in the delivery of euthanasia to ensure that the dignity of life is respected in the process. Furthermore, the involvement of healthcare professionals is vital in determining which patients deserve to be euthanized. This does not necessarily imply that all terminally ill patients deserve to be euthanatized. While patients consent is crucial, is imperative to consider several other factors such as the happiness of the patient, the quality of life, the chances of recovery and the method through which euthanasia is to be delivered. All these issues ought to be considered in determining the balance between happiness and suffering. Only in those cases where the scale of suffering significantly outweighs the scale of happiness qualify for euthanasia. Therefore, euthanasia is moral. Reference List Bowie, B. and Bowie, A. (2004). Ethical studies: euthanasia. London: Neslon Thornes Buse, A. (2008). Euthanasia: forms and their differences. Berlin: GRIN Verlag CNBC News. (2011). The Fight for the Right to Die. CNBC Canada. Retrieved from http://www.cbc.ca/news/canada/story/2009/02/09/f-assisted-su icide.html Coyle N. (1992). The euthanasia and physician assisted suicide debate: issues for nursing. Journal of Medical Ethics. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/1528779 de Casterlà ©, B., Verpoort, C., De Bal, N. and Gastmans, C. (2006). Nurses’ views on their involvement in euthanasia: a qualitative study in Flanders (Belgium). Journal of Medical Ethics. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2565778/ Edwards R. and Graber G. (1988). Bio-ethics. New York: Harcourt Brace Jovanovich Publishers. Gorsuch, M. (2009). Euthanasia- the future of assisted suicide. Princeton: Princeton University Press. Humphry, D. (1991). Let me die before I wake. Eugene: Hemlock Society. Irish Council for Bioethics. (n.d.). Euthanasia: your body, your death, your choice? Retrieved from http://www.bioethics.ie/uploads/docs/Euthanasia.pdf Johnstone, M. (2008). Euthanasia: contradicting perspectives. Elsevier  Health Sciences. 2(4) Kasule, H. (n.d.). Euthanasia: ethic-legal issues. Retrieved from http://www.missionislam.com/health/euthanasia.htm Kuupellomà ¤ki, M. (2000). Attitude of cancer patients, their family members and health professionals toward active euthanasia. European Journal of Cancer Care. 916(21) Munson, R. (1996). Intervention and reflection: basic issues in medical ethics. New York: Wadsworth Publishing Company. Musgrave C. and Soudry, I. (2000). An exploratory pilot nurse study of nurse†midwives’ attitudes toward active euthanasia and abortion. International Journal of Nursing. 9(2) Singer, P. (1993). Practical ethics. Cambridge: Cambridge University Press Verpoort C, Gastmans C, Dierckx de Casterlà © B. (2004). Palliative care nurses’ views on euthanasia. Journal of Advanced Nursing . Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15324425 Zdenkowski, G. (1996). Human rights and euthanasia: an occasional paper of the human rights and equal opportunity. Retrieved from http://www.hreoc.gov.au/pdf/h uman_rights/euthanasia.pdf This research paper on Is Euthanasia a Morally Wrong Choice for Terminal Patients? was written and submitted by user Karis R. to help you with your own studies. You are free to use it for research and reference purposes in order to write your own paper; however, you must cite it accordingly. You can donate your paper here.

Dreaming in the 1960s essays

Dreaming in the 1960s essays In 1962, Dr. Martin Luther King, Jr. said his most famous words: "I have a dream." He was not the only one who felt this way. For many, the 1960s was a decade in which their dreams about America might be fulfilled. For Martin Luther King Jr., this was a dream of a truly equal America; for John F. Kennedy, it was a dream of a young vigorous nation that would put a man on the moon; and for the hippy movement, it was one of love, peace, and freedom. The 1960s was a tumultuous decade of social and political upheaval. We are still confronting many social issues that were addressed in the 1960s today. In spite of the turmoil, there were some positive results, such as the civil rights revolution. However, many outcomes were negative: student antiwar protest movements, political assassinations, and ghetto riots excited American people and resulted in a lack of respect for authority and the law. The first president during the 1960s was John F. Kennedy. He was young, appealing, and had a carefully crafted public image that barely won him the election. Because former President Eisenhower supported the Republican nominee, Richard Nixon, and because many had doubts about Kennedy's youth and Catholic religion, Kennedy only received three-tenths of one percent more of the popular vote than Nixon. The first thing Kennedy did during his brief presidency was to try to restore the nation's economy. Economic growth was slow in 1961 when Kennedy entered the White house. The President initiated a series of tariff negotiations to stimulate exports and proposed a federal tax cut to help the economy internally. John F. Kennedy was known as one of the few presidents in history who made his own personality a significant part of his presidency and a focus of national attention. Nothing illustrated this more clearly than the reaction to the tragedy of November 22, 1963. Kennedy was driving through the streets of Dallas. The streets were...

Define and Explain Revolution in Astronomy

Define and Explain Revolution in Astronomy Revolution is an important concept to understand when youre studying the stars. It refers to the movement of a planet around the Sun. All of the planets in our solar system revolve around the sun. The path of the earth around the sun which is one complete cycle of an orbit is approximately 365.2425 days in length. Planetary revolution can sometimes be confused with planetary rotation but they are two separate things. Difference Between Revolution and Rotation While revolution and rotation are similar concepts each is used to describe two different things. Planets, like Earth, revolve or travel around the sun. But the Earth is also spinning on what is called an axis, this rotation is what gives us our night and day cycle. If the Earth didnt spin then only one side of it would face the sun during its revolution. This would make the other side of the Earth very cold as we need the sun for light and heat. This ability to spin on an axis is called rotation. What Is a Terrestrial Year? A full revolution of the Earth around the Sun is known as a terrestrial, or earth year. It takes roughly 365 days for the Earth to complete this revolution. This is what our calendar year is based on.  The Gregorian Calendar is based on the revolution of the earth around the sun to be 365.2425 days in length. The inclusion of a leap year, one where we have an extra day happens every four years to account for the .2425. As Earths orbit changes the length of our years changes as well. These types of changes usually happen over millions of years. Does the Moon Revolve Around Earth? The moon orbits, or revolves, around the Earth. Each planet affects the other one. The moon has some interesting effects on the Earth. Its gravitational pull is responsible for the rise and fall of the tides. Some people believe that the full moon, a stage in the moons revolution, causes humans to act strangely. However, there is no scientific proof to back up the claim that strange things happen during the full moon. Does the Moon Rotate? The moon does not rotate because it is gravitationally locked with the Earth. The moon has synched up with the Earth in such a way that the same side of the moon is always facing the earth. This is why the Moon always looks the same. Its known that at one point the moon did rotate on its own axis. As our gravitational pull on the  moon got stronger the moon stopped rotating. What Is a Galactic Year? The time it takes for the solar system to orbit the center of the Milky Way Galaxy is referred to as a galactic year. Its also known as a cosmic year. There are 225 to 250 Million terrestrial (earth) years in one galactic year. Thats a long trip!

Juvenile Justice System Essay Example | Topics and Well Written Essays - 1500 words

Juvenile Justice System - Essay Example The most important facet of all this is the "best interest of the child" theory that guided the courts lingers in the purpose clauses of juvenile codes throughout the world.4 However, it seems to have failed to address the concerns raised by victims or communities about the juvenile justice system. The therapeutic intervention and punishment models of justice also appear to be incomplete. If these two models coexist in a jurisdiction, they are in constant conflict. However, if either one of these exists by itself, it fails to serve all stakeholders in the system. There are further studies according to the framers of the code that is the balanced consideration of community protection, offender accountability and competency development. This could bring clarity and reason to juvenile system issues. Through this comprehensive philosophy it will deal with every aspect of delinquency, punishment, treatment and prevention. With the concept of these three principles, if fully implemented, it could create a juvenile system that truly operates in the best interest of the child and the community.5 In all the instances when a dual or multi-diagnosis of several problems result, experts recommend that sources of treatment if not available at the moment, should be developed and reflect the developmental needs of juveniles in conflict with the law and are not merely replications of service delivery systems originally designed for adults. According to the recommendations of specialists, useful interventions for juveniles must ensure a close match between risk of re-offending, nature, level, duration of intervention. They must employ practitioners whose teaching approaches correspond to the learning capacities of children and use material tailored for a certain juvenile. It must be community-based and closely connected to the youth's home environment than like an institution. A drawn range of methods must be developed to cover anger management, social skills training and problem solving.6 Furthermore, many practitioners suggest that a continuum of care and a set of protocols must be established to determine who will provide services to the youth. There must be a case manager whose selection will be based

Organization behavior Case Study Example | Topics and Well Written Essays - 1000 words

Organization behavior - Case Study Example This is caused by the fact that people have different attitudes and different motivations in their endeavors. For instance, in this case, it can be argued that the two managers have different attitudes towards people. There are many learning theories such as behaviorism and humanism. Behaviorism for instance argues that people learn based on stimuli. If a person knows that his actions will cost them, they are likely to refrain from these actions. Other theories of learning articulate that individuals learn as a way of making their own knowledge. In the above case, it seems that Susan is a behaviorist and believes that if Don is made to suffer from his actions, he will change his bad behavior. On the other hand, Bob seems to subscribe to humanism as a theory of learning. As such, he believes that if given the right resources, Don will learn in order to meet his needs. Employees expect to be rewarded for their hard work and their contribution to the firm. Sometimes employees can contribute more to the firm than is required by their employment agreement. This is what Jackie has been doing because she has been going beyond her expected outcomes. However, in most cases, when the employees do this, they also expect the employer to go beyond his formal responsibilities when rewarding them. This passive agreement between the employer and the employee is called psychological contract and if one side breaches it, the other will feel demotivated. In this case, Steelfab Corp has failed to honor its side of the psychological contract with Jackie. To remedy this, Steelfab Corp must be able to meet its side of the psychological contract by rewarding her more for the work she is doing. This can be achieved by having a performance-based work environment where employees will be rewarded not based on how close they are to the seniors but in accordance to their con tribution to the firm. Amy should have assigned her a job description with proper roles. This could have

Ethnomedicine Essay Example for Free

Ethnomedicine Essay Since the beginning of man, there have been ailments that have plagued the human race without concern of who it is inflicting or why they occur. These ailments had to have been combated by some sort of medicine by each culture and their remedies must have been plenty. The plethora of different kinds of medicines and remedies to these ailments among the different kinds of cultures is what we, Team Bloodnut, define as ethnomedicine. Many cultures throughout the world practice some form of ethnomedicine. A field of anthropological research, ethnomedicine seeks to describe the medical systems and practices utilized in different cultures. It examines the origins of what people believe cause illness, as well as examine the ways in which individual cultures treat such maladies. Team Bloodnut wanted to discover the healing beliefs and practices held by Amazonian shamans. Through the use of a life history interview, we sought to understand the traditions held by a people through the experiences of a man working with a former shaman of the tribe. Team Bloodnut formed a hypothesis regarding ethnomedicine in today’s modern world. We hypothesized that the remedies and medicines indigenous cultures use to heal the ill are unorthodox from the stand point of western civilization. Western society will view these remedies as barbarian and a total fallacy. We conducted our research through a life history interview, contacting a filmmaker named Matthew Vincent. Possessing an interest in natural medicines, Vincent spent over half a year living in Peru documenting the experiences of an American Shaman’s journey into the depths of Amazonian Shamanism. Together, they discovered the origins and methods involved in practicing shamanism in relation to this particular cultural group. Matthew trained under the ‘gringo shaman’ Ron Wheelock, learning the techniques and methods required to effectively heal members of the community in which they lived. In order to effectively film his documentary in a realistic manner, Matthew Vincent needed to integrate himself into the rituals, learning their practices and lifestyles. Researching through a life history interview best utilized our information since it enabled us to capture the personal experience of a man submerging himself into such a specific aspect of a community’s life. Our group set out to understand the origins of Amazonian shamanism. We wished to learn about the beliefs of the roots of illnesses as well as the methods used to treat them. Ethnomedicine seeks to understand what illnesses mean within a culture and how to remedy these ailments. According to Vincent, shamans believe people contract illnesses due to a variety of reasons. Culturally, the soul brings balance to the physical body and makes it strong. If presumed damaged or corrupt by devious spirits, souls must undergo ritualistic healing in order to return to a healthy state. Physical illness is thought to be a manifestation of corruption within the soul. In order to correct this corruption, patients go through a mixture of ritualistic songs, plant gnosis, and trances. Shamans utilize trances in order to enter different states of consciousness, allowing them to interact with souls and spirits to perform healing to the soul and bring the spirits back to the sick physical body. One extremely common way to remedy an ailment in Amazonian Shamanism is through the use of ayahuasca. Ayahuasca is an extremely hallucinogenic vine used in brews that are consumed by the Shaman along with the patient so the Shaman can conjure the spirits of the plants used in the brew to foresee any future ailments, cure any immediate ones, and try to prevent any others from manifesting themselves within the patient’s body and or soul. The ayahuasca brew can take any time from a couple of hours to brew, all the way to up to two days, being cooked three times. Wheelock told Vincent that he has treated people who have visited a psychiatrist for over a year and with one ayahuasca ceremony, the patient feels more rejuvenated and alive than ever before. Ayahuasca can also be used for other uses as well, depending on the ingredients used in the brew. For example, if brewed with shapishico, moonshine, and rainwater, and left to sit together for about nine days, this brew acts as an extremely potent aphrodisiac. Shamans are not only medicine men, but spiritual guides. Shamans can choose from two different paths when immersing themselves in their practices. They can choose to be curandero or a brujo. A curandero is a healer. He is the medicine man that can heal physical and psychological ailments that one might have. He does this through plant gnosis and conjuring the spirits of the plants to help cure the patient. A brujo, on the other hand, focuses on the dark arts of Shamanism, although he can also heal. In a Shamans training, they are visited by spirits and are given magical darts. These magical darts are a brujo’s weapon of choice when it comes to causing harm or kill another. He can use those towards anybody in the world as long as he has their name, a mental image of the person, a picture, or some sort of memorabilia that depicts who their target is. A curandero will only use these magical darts, usually, to defend himself. When a curandero sends a magical dart to a brujo, it’s usually with the intention to kill him. After conducting our life history interview, Team Bloodnut came to a conclusion on our hypothesis. We concluded that our hypothesis was correct regarding the differences between western medicines and Amazonian Shamanistic medicines. Western medicines include all of the technologies, modern medicines, and commodities that these indigenous cultures do not have access to; therefore we are much more technologically advanced. These countries are at a disadvantage when it comes to the commodities and technologies but that doesn’t mean that the quality is any less. These medicine men spend most of their lives learning how to conjure and interact with these spirits of nature so that they can heal in their favor. The way in which they do so shouldn’t be frowned upon. If these Shamans have found ways to cure, not just treat these illnesses and ailments, then why haven’t we, Western Civilization, adopted these methods? Is it the fear or the skepticism of failure? We think that it’s not so simple. We believe that the reason for these medicines not being accepted into our country is simply so the government won’t lose money and control. Wheelock cured a patient that had been visiting a shrink for over a year. In that time how much money did that psychiatrist earn? From that income how much did the government take from the psychiatrist in taxes? This is only for one person, too. Some people spend half of their lives, if not longer visiting some kind of medical practitioner or some form of psychedelic help. There will never be a shortage of sick people, so if they are simply just cured with a couple of ayahuasca ceremonies, that’s a pretty significant chunk out of the United States’ money supply. Not only is it a monetary issue, but also a control issue. If these practices were administered in the United States, people would gain insight and enlightenment to its effects. There is a chemical in ayahuasca that is an intense psychedelic. Dimethyltryptamine is the psychedelic in the ayahuasca that puts the body in the state in which it can be visited by manifesting spirits of the vine. If this psychedelic were to fall into the wrong hands, it could be very harmful to not only to America’s economy, but also to the ones who abuse it. Ergo, ethnomedicine is a sensitive subject because it is not only a way to treat people within a certain country or tribe, but it is also the way of life and the way generations upon generations have practiced these remedies. Just because different cultures do things differently, it doesn’t mean that one way is right and the other is wrong. If we, as a species and inhabitants of this Earth, all worked together and shared our practices with each other in the field of medicine, maybe we could find cures, not just treatments to malignant diseases such as cancer. Ayahuasca ceremonies are not just a ritual to heal patients that come to Shamans, but also a lifestyle.

The Role of Language in Shakespeares Play The Tempest Essay -- The Te

The Role of Language in Shakespeare's Play The Tempest 1 The role of language in Shakespeare’s play â€Å"The Tempest† is quite significant. To Miranda and Prospero the use of language is a means to knowing oneself. Caliban does not view language in the same light. Prospero taught Caliban to speak, but instead of creating the feeling of empowerment from language, Caliban reacts in insurrectionary manner. Language reminds him how different he is from Miranda and Prospero, and also how they have changed him. It also reminds him of how he was when he wasn’t a slave. He resents Prospero for â€Å"Civilising† him, because in doing so he took away his freedom. Language and knowledge is the key to power on the island. Prospero is a well educated man, and has many books, which gives him his magical power. Prospero rules the island and has many creatures under his command. He possesses so much power that he can even cause weather to change and indirectly the fate of the people who were shipwrecked on the island. William Sherman has the opinion â€Å"Knowledge was magical, and sometimes even entailed magic. But the attacks on libraries, the condemnations for conjuring, and the polemical complaints betray a deeper and more significant phenomenon: there were in early modern England dramatic uncertainties about the power of information and those who possessed it. (Cited in Jardine 1996: 105) Throughout the whole play there is evidence of power, someone in possession of it and another subordinate to the person with the power. Mostly this happens in the scenes with prospero, as he is almost an omniscient and omnipotent character, with god-like qualities. He has the means to change many things not possible for humans, because of his magic and his power over magical creatures such as Ariel. Caliban also does the will of Prospero; But, as ‘tis, We cannot miss him: he does make our fire, Fetch in our wood, and serves in offices That profit us. What, ho! Slave! Caliban! (I.ii.351-53) The shipwrecked people also play into Prospero’s hand, but they don’t even realize this. Even Miranda is dutiful to her father, and does what he says with little complaint. There is a hierarchy on the island, with Prospero on top of the list. Lorie Jerrell Leininger writes in her article â€Å"Miranda is given to understand that she is the foot in the family ... ...epresents every person that has been colonized by Europe, and their attempt to civilize the savages. Their method of civilizing and to maintain a firm grip on their savage labourers was language. It was their means to communicate and control the people who they didn’t consider as themselves and a means to discriminate against it. This is reason why Caliban resists and rebels against Prospero and disparage the language he has been taught. To him it is the loss of freedom and the agency through which he is being discriminated against. References: Knight,G.Wilson. â€Å"The Shakespearean Superman: An essay on The Tempest.† The Crown of life: Essays in Interpretation of Shakespeare’s Final Plays. Oxford: Oxford University Press, 1947. 203-255 Leininger, Lorie Jerrel. â€Å"The Miranda Trap: Sexism and Racism in Shakespeare’s Tempest.† The Woman’s Part: Feminist Criticism of Shakespeare. Eds Carolyn Ruth Swift Lenz et al. Urbana: University of Illinois Press, 1983. 285-294 Smith, Ian. "When we were capital, or lessons in language: Finding Caliban's roots." Shakespeare Studies 28 (2000): 252-256 Tomlinson, Gary. "The matter of sounds." Shakespeare Studies 28(2000):236-239

Celiac Disease Paper

Celiac Disease Unit 4: Assign 2- Disorders Affecting the Immune System April 9, 2013 Celiac disease is an autoimmune disorder. It affects the small intestine in the person’s body. It can affect people who have been linked genetically or pre-disposed from infancy to adulthood (www. mayoclinic. com). This disease can be asymptomatic. Which means that the person can be a carrier of this disease and pass it on to their children. The carrier would not have any symptoms of this disease or even know they are a carrier.Celiac disease can affect 1 in 105 people in the United States (www. webmd. com). Celiac disease is caused by a reaction to gliadin, or a gluten protein. The gluten protein is found in wheat, barley, rye, and oats. When the person affected with this disease is exposed or ingests the gluten protein, their immune system has an inflammatory reaction in the small bowel. The inflammatory reaction can be an acute or chronic response within the bowel tissue. The inflammation i n the small bowel blocks the person’s ability to absorb vital nutrients from their food (www. ebmd. com). Signs and symptoms of Celiac disease can range from mild to severe. Diarrhea is the most common symptom of this disease. Abdominal pain, bloating, cramping, and distention of the abdominal wall from gas are also other signs/symptoms of Celiac disease. The blocking or malabsorptio of nutrients such as Calcium and Vitamin D can lead to weight loss, fatigue, and anemia. The person can then get mouth ulcerations as well, and become lactose intolerant.As the disease continues to progress it can cause more damage and it puts the person at risk for small intestine cancer (adenocarcinoma) or Lymphoma. If left untreated Celiac disease can also lead to more complications within the affected person. Some of the complications they would experience are, ulcerations and strictures in the bowel (www. webmd. com). The only affective treatment for Celiac disease is a lifelong goal of diet change. Once diagnosis has been confirmed gluten must be completely removed from the person’s diet.Certain diets that are gluten free will need to be followed to prevent inflammation. Depending on the extent of the damage done, or the stage of progression there may need to be more strict changes to follow. There are websites and support groups to help people become educated with the steps necessary to prevent further flare ups from this condition. The first step to becoming aware of this disease is to be seen by your physician if you are having any of the above signs and symptoms (www. csaceliacs. com). www. mayoclinic. com,2013. www. webmd. com,2013.

Conflict Analysis in Bend It Like Beckham Essay

What you want and what your parents will accept is a common disagreement in most households these days. In the movie ‘Bend it like Beckham’ they showed the conflict between Jess between and her parents. The conflict was how they feel and what they want for her, how Jess sees the situation and how it is resolved. Throughout the movie Jess is constantly pulled in different directions for what she wants and what her parents and culture expect from the Indian girl Jess. Jess’s dreams are more important to her then her culture. They are more important to her because they are who she is as a person. Jess does not want to be the traditional Indian girl her parents want her to be. Jess wants more from her life then the day-to-day life of the traditional Indian girl. Jess decides that instead of following the traditional path of the Indian girl life style she goes off on a limb and decides to play soccer. Despite what her parents want from their little girl, she wants to be free and chase her dreams. Jess’s passion for soccer trumped her feelings for her culture that she was willing to bend all the rules to do what she loved to do, and that was to play soccer. Her parents are her major downfall. Jess’s father worried about Jess playing soccer in fear that she will get hurt just like he did when he wanted to play cricket. Her father was treated differently because of the way he looked. In the movie her father talked about how they made fun of the towel he wore on his head and was not allowed to play on any of the teams. Her father is afraid that she will be disappointed and end up just like he did. Jess’s mother seems to be caught up way more then her father in this soccer situation. Her mother does not agree with Jess playing soccer at all. Jess’s mother thinks that she should be spending all her time cooking and trying to be a traditional Indian girl. For example when her mother talks about running around outside playing soccer with a bunch of guys with her legs showing she says â€Å"you bring shame to our family!† Jess’s mother says this because it is against their cultural beliefs. The conflict is present due to many reasons. Jess loves to play soccer, but also respects and loves her family and culture. She is drawn to decide to keep her soccer life hidden from her family. She does not want to keep it a secret because everyone believes she is amazing at soccer, but she does not want to disappoint her parents. Jess tries so hard to meet her mother and father’s expectations to avoid disappointment. The fact of the matter is that Jess loves soccer and is not willing to give it up just for some silly tradition. This story shows us that if you are always trying to please your parents you are going to not be happy were you are in life. It is always important to follow your dreams. When different cultures come together it can be difficult to combine them both without losing original cultural values. Bend it like Beckham shows it is possible to incorporate the values of another culture into Jess’s lifestyle while still maintaining her cultural identity. It also shows that regardless of what culture a person is, there are always challenges that you must overcome in order to be who you want to be.

Marketing and Samsung Electronics Samsung Essays

Marketing and Samsung Electronics Samsung Essays Marketing and Samsung Electronics Samsung Essay Marketing and Samsung Electronics Samsung Essay Planning Dream Home road shows. Expanding its sales network. Revamping sales infrastructure. Samsung Marketing Academy  ± set up to train renting sales force and shop demonstrators. Core value: Approach market through technology and design leadership. Launching hi-tech and contemporary products with hazel and speed. Target is not only number driven but also about acquiring and retaining customers. Created a Unique Brand Image for itself as a high end value driven brand. The Samsung Marketing Academy Approach market through technology and design leadership: a slow process. Not targeting the mass market Not spreading the brand all over India OPPORTUNITIES LAG: its slowing down and has not had any product innovation in the last 6-8 months. 6th Indian Mass Market. The high end value driven proposition helps increase the Market Share. Samsung is well known for it product differentiation THREATS Animal Mass Market may De captured Day a rival company, LAG, Oneida, Evidence;etc. The consumer durable industry is not in the best of health. Due to increased price of inputs and continuing price erosion there is downtrend in the consumer durables market. Increased emergence of modern retail chains- a comprehensible as Samsung is investing in building a retail network across the country Any Queries (Everyones invited) THANK YOU

4 Reasons Why Trees Drop Nuts Early

4 Reasons Why Trees Drop Nuts Early Sometimes nut-bearing trees, such as hickory, walnut, and pecan, drop their fruit before full maturity. At times, it can be a natural shedding of a portion of the nut crop. Other causes can be more problematic, including adverse weather conditions, poor tree health, inadequate  pollination, insects, and disease. How Nut Trees Set Fruit Most nut-bearing trees have male pollinators and female flowers, both called catkins. Female flowers produce nuts during the current seasons growth and have to survive through that years growth before the crop of nuts is set. Not all flowers on a tree will produce a nut each year; in fact, they may alternate years.   There can be several natural nut drops between mid-Mays pollination through the end of Augusts fruit set, and they can be minimized by proper tree fertilization. For example, if a tree wasnt adequately pollinated or didnt have enough potassium to set good fruit, there will be nuts that may be malformed with few seeds inside (fruits on the tree grow but embryos inside dont develop). The tree will drop this fruit early because its not biologically sufficient for the trees reproduction. The tree will concentrate its energy on growing fruits that are going to set good seeds. A Trees Physical Condition Poor tree health can cause premature dropping of nuts. A trees health is often compromised because of inadequate nutrient uptake, which is most evident during drought. Insect and disease infestations increase during these times of tree stress and can further degrade a trees condition, especially if trees are growing in poor soil. Any early defoliation will cause nut drop and low-quality fruit. Water and fertilize your tree adequately to make sure it has the proper nutrients to set and grow its fruits. Weather Influence on a Trees Nut Crop Excessive rain or frost during late spring/early summer pollination will cause inadequate pollination of female flowers. Those poorly-pollinated flowers may produce a nut that will drop early or produce no nut at all. Sometimes, male pollen can mature either before or after the female flower is receptive, and this condition is usually weather-related. An extended drought during nut growth may also result in the dropping of tree nuts, particularly if the plant is in sandy soil that dries out quickly. Thats a resource competition drop, or a so-called June drop, as the tree is concentrating its energy on the number of nuts it can support.   Mechanical injury to leaves, flowers, and nuts from hail and wind may cause premature dropping as well. Insects and Diseases of Nut Trees Early pecan scab infection of young nuts will cause nuts to drop and is a major cause of pecan crop failure. Black walnut is highly vulnerable to anthracnose, and the disease is of much concern in commercial orchards. Leaf diseases in nut trees such as scab, scorch, mildew, blotch, brown spot, and downy or vein spot may also cause nut shedding. The pecan nut casebearer probably causes more nut shedding than all other insects combined in pecan orchards. Codling moth causes significant premature nut drop in black walnut groves. Other insects, such as black aphids, walnut caterpillar, shuckworms, stink bugs, and pecan weevils may cause early nut dropping. Avoid using pesticides during flowering, as chemicals can kill beneficial insects and result in inadequate pollination.

RUSSIAS'S GOVERNMENT CORRUPTION AND HUMAN RIGHTS VIOLATIONS Term Paper

RUSSIAS'S GOVERNMENT CORRUPTION AND HUMAN RIGHTS VIOLATIONS - Term Paper Example ts to demonstrate how political corruption impacts the judiciary and individual human rights in a transitioning state by drawing on the details of the Yukos company trials. Gorbachev’s new Russian economy gave way to several conglomerates known as the Financial-Industrial Groups (FIGs).4 The FIGs were engaged in the privatizing the Soviet Union’s economy.5 The Menatep Group, founded by Mikhail Khodorkovsky was one of these business conglomerates.6 By the middle of the 1990s the Russian government made a decision to divest itself of its holdings in Yukos, an oil production company.7 Menatep obtained government approval for the purchase of Yukos and together with a number of commercial banks, individuals and companies placed a bid for 78 percent of Yokus’ shares.8 As a result of these efforts, Group Menatep which was controlled by Khodorkovsky was able to acquire Yukos for a sum equivalent to US$300M.9 By 1997, Menatep owned approximately 85 percent of Yukos’ share holdings.10 By the year 2001, Yukos had earned its place among the echelons of Russian oil industries as a giant, and was similarly recognized globally as a one of the world’s top private oil companies.11 With Mikhail Khodorkovsky at the helm, Yukos established a reputation for best global practices which included elements of transparency, efficiency, performance, valuable shareholdings and sound corporate governance.12 Political changes were taking place that would ultimately have a role to play in the Yukos trials that followed. When Vladamir Putin took office as Russia’s president successor to Boris Yeltsin, the colour of government-commercial relations would shift somewhat. Those changes would be reflected in Putin’s desire to restore the state’s power, despite his public manifestations of support for democratic evolution.13 Ultimately, Putin was predisposed to the adaptation of twin policies, the revival of the Russian economy and the strengthening of state power.14

Introduction to campylobacter Literature review

Introduction to campylobacter - Literature review Example 163–189). Since campylobacter is present in large quantities in stool, isolation may be considered from this point. However, it is important to note that isolation requires certain conditions of microphilic atmosphere and a media that contains antibiotics. Several methods have been developed to isolate campylobacter. One of them is the membrane filtration. This is used in isolating the microorganism from low turbidity water. Filters of pore size of 0.45 microns are used, and the water is passed as the platting is done face down for the selective agar for the campylobacter. The selective agar is described below in another isolation method. The filters in this process are removed after an overnight incubation. The streaking of plate for isolation before re-incubation then follows this. Prior lab tests have indicated that in the presence of pre-filtration with filters of pore sizes of 6.0 and 5.0 has consistent results of recovery of about 30 jejuni CFU per 250 ml of the seeded water that is nat ural (Line 1711–1715). The other method of isolation is the conventional cultural method. In the laboratory, the sampled specimen is prepared for isolation. If, for example, the sample of raw chicken, a sample of filtrated, chicken rinse water may be used. The water is taken and centrifuged at a rate 16000 times the weight for a period of ten minutes in a minimum temperature of 4 degrees. With an enrichment media of Preston broth, the supernatant is discarded while the pellet is suspended. After the sampled pellet is re-suspended, incubation of the sample at a microbic atmosphere that has 10 percent carbon dioxide, 5 percent oxygen and 85 percent nitrogen. All this happens at a temperature of 3 degrees for 24 hours. The enrichment broth is made consistent with the nutrient broth with supplementation including trimethoprim 10 mg/l, cefoperazone 15 mg/l, rifampicin 5 mg/l, polymyxin B 2500 iu/l and amphotericin 2mg/l. This enriched culture is then placed in

Leadership management assignment 1 Essay Example | Topics and Well Written Essays - 1500 words

Leadership management assignment 1 - Essay Example This is in line with the company’s recruitment policy to help them get the most qualified at affordable remuneration (Luecke 2003). This is therefore done to ensure that the selected individual to fill the position of the manager is the best across the region. They received several applications for the position of the managing director; the group underwent a rigorous recruitment process and finally was left with an individual to negotiate with their starting salary on the job. The remaining individual was from Mexico. In the negotiation process different negotiation skills were outlined that resulted into a successful with a few instances of messing up. Its Human resource manager represented the company on the salary negotiation table while the other side was the individual whose starting salary was to be negotiated (Jacks 2011). Person Position Character A Human resource Manager He is a highly Sociable, Extrovert and democratic B Newly recruited employee Also quite extroverte d, friendly, polite, and highly conscious For new employees of any given firm it is normally safe to negotiate for higher starting salaries before accepting the job offer because after this the new employee will be subjected to the normal salary increase payment plans of the company, which depends on extraordinary performance (Young 1975). The new recruit therefore needed to negotiate for a higher pay than what they used to earn in their former position hence the need for the negotiation skills. The HR manager of company X also needs to be a good negotiator to make sure that they provide the company with manageable expenses and it is willing to negotiate the starting salary of the employee as a whole. The employee is though considering the option of first negotiating the basic pay because given their character they are likely to be confused if they combined the negotiations together with those for the other benefits. This would be to the disadvantage of the employee if the pre-deter mined salary were already advertised (Zartman 1978). A â€Å"Hello Mr. F, this is X company as we talked over the phone, I gaze you are here to talk about the remuneration package of the job offer that we just shortlisted you for the other day. According to the company policy, we would be glad to offer you a salary package of $60,000 yearly plus the benefits, which would vary depending on several variables. Would you be ok with that?† B :I am interested in the job yes but I would not mind if you offered me a salary package of $68,000 per year plus the packages as we would negotiate if it is at the best interests of the company,† A â€Å"$68,000 is not even the average industry rate leave alone what we normally start offering our employees. However, because of your skills and presumed competence, we would not mind offering you a $65,000 package yearly and the benefits as it would be negotiated. How about that?† B "Thank you for your offer and I am certainly intere sted in the position and Company. Can I get back to you later this afternoon or first thing in the morning" A â€Å"You are most welcome and highly appreciate the time that you took to present yourself for interviews. Please make a point of communicating tomorrow given that we need to fill the position immediately. Anyway, your positive response will be highly appreciated. Nice time.†

COPD Case Study Assignment

COPD Case Study Assignment 1) CASE SUMMARY Mr TLT is a 58 year old taxi driver who was admitted to Hospital Batu Pahat due to newly diagnosed chronic obstructive pulmonary disease. He has had hypertension for the past one year and is taking T Amlodipine 5mg od. He is also a chronic smoker for the past 40 years who smokes about 20 sticks of cigarettes a day. Mr TLT presented with shortness of breath which progressively increased in severity for the past 4 days. The shortness of breath was associated with a wheeze. There was also cough with production of mucoid sputum. The dyspnoea occurred after an episode of upper respiratory tract infection. Mr TLT has been having intermittent chronic cough associtaed with mucoid sputum for the past 3 years. He has also been having persistent breathlessness for the past 1 year especially on exertion. He has not sought treatment prior to this admission. On physical examination, Mr TLT was tacypnoiec with a respiratory rate of 28 breaths per minute. There was no cyanosis. Repiratory system examination showed use of accesory muscles as well as increased anterior posterior diameter of the chest and reduced cricosternal distance. On auscultation, vesicular breathing was heard with generalised rhonchi and coarse early inspiratory crepitations at the lower zone of both lungs. The cardiovascular system examination was normal. There were no other abnormalities on physical examination. Investigations done include chest plain radiograph which showed a hyperinflated chest, tubular heart and absence of vascular markings at the peripheries. The ECG showed sinus rhythm with low voltage. No P pulmonale indicative of right atiral hypertrophy seen. A working diagnosis of acute exacerbation of chronic obstructive airway disease due to upper respiratory tract infection was made. Mr TLT was given nebulization of ipratropium bromide, salbutamol and normal saline for 2 times. His symptoms improved after being given the nebulization. He was discharged after three days when the dyspnoea had resolved. He was given metered dose inhaler of Ipratropium Bromide 40microgrammes tds and MDI salbutamol 200microgrammes PRN. He was given an appointment to assess his symptoms at the outpatient department in one month time. STUDENT NAME: Tan Hai Liang ID NO : M0409146 NAME OF SUPERVISOR : Prof Khin ROTATION: Internal Medicine PATIENTS DETAILS I/C NUMBER : 510912-01-6343 AGE : 58 SEX : Male DATE OF ADMISSION : 2 June 2009 R/N NUMBER : 1143451 2) CLINICAL HISTORY Chief complaint: Mr TLT is a 58 year old taxi driver who presented with shortness of breath for the past four days. History of present illness: Mr TLT is a chronic smoker for the past 40 years who has been smoking about twenty sticks of cigarettes a day. He had been diagnosed with hypertension for the past one year and is currently on T Amlodipine 5 mg od. Mr TLT has been having intermittent chronic cough for the past 3 years. The cough is productive at times. The sputum produced is mucoid in nature and about one tablespoonful in amount. There is no blood in the sputum. It is also not foul-smelling. Mr TLT then proceeded to have shortness of breath for the past one year. The dyspnoea is persistently present and described as requiring increased effort to breathe. It is worse on exertion and Mr TLT experinces reduced effort tolerance. He is now able to climb one and a half flights of stairs before becoming breathless. He has not consulted any doctors for these symptoms prior to admission. Mr TLT then developed symptoms of upper respiratory tract infection such as rhinorrhea and sore throat one week prior to admission. He had fever of 38 degress celcius at that time which resolved with paracetamol. He also had a productive cough with mucoid sputum at this time. Mr TLT then developed increasing shortness of breath 4 days prior to admission. The shortness of breath worsened over the 4 days and was associated with noisy breathing. He was breathless even at rest but was still able to speak in sentences. There was also an increase in cough as well as production of sputum. The sputum was mucoid and non purulent. He also did not notice any blueness around his lips or at his fingers. Systemic review: There was no loss of appetite or loss of weight. He had mild ankle oedema but no other signs of heart failure such as orthopnoea or paroxysmal nocturnal dyspnoea. Past medical history Mr TLT has not had any hospital admissions prior to this. He was diagnosed with hypertension last year as an incidental finding during a visit to the kilinik kesihatan for an upper respiratory tract infection. He is currently taking tablet Amlodipine 5 mg once daily. Family history Mr TLT is the eldest of 5 siblings. There is a strong family history of hypertension in that his mother as well as two other siblings are also hypertensive. There is no family history of asthma, diabetes or ischaemic heart disease. Social history Mr TLT used to work as a taxi driver but has stopped working full time 2 years ago. He still occasionally drives his taxi but spends more time at home with his family. He is a chronic smoker for the past 40 years and smokes about 20 sticks of cigarrettes a day. He drinks alcohol with his friends on weekends. He drinks one to two bottles of beer each time. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine ____________________________________________________________________________ 3) FINDINGS ON CLINICAL EXAMINATION On general examination, Mr TLT was well nourished and alert but was tachypnoiec. He was able to speak in sentences but there was use of his accessory muscles. There was no clubbing or cyanosis seen. There was also no peripheral oedema, pallor or jaundice. Vital signs: Pulse rate: 72 beats per minute, regular with good volume. No bounding pulse. Respiratory rate: 28 breaths per minute Blood pressure: 129/73 Temperature: 37 degrees Celsius SpO2: 95% under nasal prong oxygen 3 litres per minute Examination of the respiratory system: On inspection of the hands, there was no peripheral cyanosis or flapping tremors seen. There was also no clubbing, muscle wasting or palmar erythema seen. There was presence of nicotine stains. The jugular venous pressure is mildly elevated at 3.5 cm above the sternal angle. On palpation of the trachea, the trachea is central but the cricosternal distance is 2 fingers which is reduced. The apex beat could not be palpated. On inspection of the chest, there is an increased anterior posterior diameter giving rise to a barrel shaped chest. The chest moves equally with respiration and there is use of accessory mucles with intercostal, subcostal and suprasternal retraction. There are no chest wall deformities. On palpation, chest expansion is reduced on both sides. Tactile fremitus is equal on both sides. On percussion, there is hyperresonance over both lungs with loss of liver and cardiac dullness. On auscultation vesicular breathing is heard. There is generalised expiratory rhonchi. There is also fine early inspiratory crepitations heard at the lower zones of both lungs. Examination of the cardiovascular system: The apex beat could not be palpated. There were no parasternal heaves or thrills palpable. On auscultation, normal first and second heart sounds were heard. There was mild bilateral pitting oedema. Examination of the abdomen: On inspection, the abdomen is flat and moves with respiration. There was no guarding or tenderness. The liver and spleen were not palpable. There was no organomegaly. Examination of the neurological system was normal. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 4) PROVISIONAL AND DIFFERENTIAL DIAGNOSES WITH REASONING Provisional diagnosis: Acute exacerbation of newly diagnosed chronic obstructive airway disease due to upper respiratory tract infection. Evidence for: Patients with chronic obstructive airway disease (COPD) usually present with a persistent dyspnoea and reduced effort tolerance which was present in the history given by Mr TLT. He is also at increased risk of developing COPD due to exposure to associated risk factors such as tobacco smoke. He has been a chronic smoker for the past 40 years. There is also the presence of chronic cough occasionally associated with mucoid sputum which further suggests COPD. Physical findings of a hyperinflated chest and vesicular breathing with generalised expiratory rhonchi also point to an obstructive airway disease. During this admission Mr TLT had increasing severity of shortness of breath even at rest. This was associated with a wheeze that was described as noisy breathing. Sudden worsening of symptoms suggest an episode of acute exacerbation. The history of upper respiratory tract infection symptoms suggest that it was the trigger for this episode of exacerbation. Differential diagnosis: 1) Congestive cardiac failure. Mr TLT may have developed congestive cardiac failure as a primary event or as a complication of chronic lung disease. There is history of reduced effort tolerance. Patients with congestive cardiac failure may also present with a wheeze and sudden increase in dyspnoea. Physical examination of fine crepitations at both bases of the lungs may also indicate congestive cardiac failure. There is also evidence of mildly raised JVP as well as mild pittint ankle oedema. Evidence against: There is no history of any cause of heart failure such as ischaemic heart disease or cardiac valve defect. Mr TLTs previous records during follow-up show well controlled blood pressure. Additional investigations need to be carried out in order to rule out this condition. A chest plain radiograph may be done in order to look for evidence of heart failure such as cardiomegaly. An ECG may be done to look for right atrial hypertrophy. An echocardiogram should also be performed in order to assess the function of the ventricles. 2) Bronchiectasis Patients with bronchiectasis have a history of chronic cough as well as production of copious amounts of sputum. They may also have persistent shortness of breath, reduced effort tolerance and wheeze. Evidence against: The sputum produced by Mr TLT is mucoid in nature and not purulent which is typical in bronchiectasis. It is also not copious and foul smelling in nature. On physical examination, coarse crepitations would be heard in bronchiectasis as opposed to the fine crepitations heard in Mr TLT. There is also no evidence of clubbing. Chest plain radiograph should be done in order to look for thickened bronchial walls or cystic shadows. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 5) IDENTIFY AND PRIORITISE THE PROBLEMS 1. Shortness of breath and reduced effort tolerance Mr TLTs chief complaint is shortness of breath. This may be attributed to the increase in number of goblet cells and later on fibrosis of the bronchial walls causing airway obstruction seen in chronic obstructive airway disease. The shortness of breath may be partially relieved with the use of nebulization of ipratropium bromide, salbutamol and normal saline or with the use of metered dose inhalers. Chest physiotherapy may also be useful. Mr TLT also has had reduced effort tolerance and persistent dyspnoea for the past a year. As such he may require the use of ipratropium bromide in a metered dose inhaler upon discharge in order to feel less breathless due to the bronchodilator effect of the ipratropium bromide. 2. Upper respiratory tract infection Mr TLT may require antibiotics as he still has symptoms of upper respiratory tract infection such as sore throat. Furthermore patients who present with an acute exacerbation are at greater risk of having a bacterial infection. This is because of the depressed immune state that the patient is in as a result of the acute illness as well as due to any steroids that would be given as part of the management plan. The appropriateness of usage of antibiotics in chronic obstructive airway disease will be further discussed below. 3. Adequate inhaler technique Mr TLT would need to be taught about the correct technique to be used when using metered dose inhalers. He would probably require daily use of ipratropium bromide metered dose inhalers to reduce his breathlessness. In the event that he is unable to learn proper technique, he may be encouraged to buy an aerochamber. 4. Smoking cessation Mr TLT should be counseled on smoking cessation as it has been proven that smoking cessation would alter the course of progression in COPD and is associated with lower all-cause mortality. He should be counseled on the various options of smoking cessation which will be discussed further below. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 6) PLAN OF INVESTIGATION, JUSTIFICATIONS FOR THE SELECTION OF TESTS OR PROCEDURES, AND INTERPRETATION OF RESULTS 1) Full Blood Count Justification: In order to view the total white count as well as the differential count to see if there is an infection which has caused this episode of exacerbation. There may also be secondary polycythemia if the patient has chronic pulmonary hypertension. Results: White cell count : 7.91 X 109/L Red blood cell : 4.48 X 1012/L Haemoglobin : 133.00 g/dl Haematocrit : 42.00 ratio Mean cell volume : 93.80 fL Mean cell haemoglobin : 29.70 pg Mean cell haemoglobin conc. : 317.00 g/l Platelets : 141.00 X 109/L Differential count Neutrophils : 60.10% 4.76 X 109/L Lymphocytes : 25.30% 2.00 X 109/L Monocytes : 13.80% 1.09 X 109/L Eosinophils : 0.50% 0.04 X 109/L Basophils : 0.30% 0.02 X 109/L Interpretation: This is a normal full blood count result with normal total white count as well as normal haemoglobin levels. 2) Plain chest radiograph Justification: Done in order to look for evidence of chronic obstructive airway disease such as hyperinflated chest or evidence of congestive cardiac failure such as cardiomegaly and prominent upper lobe vessels. Results: Hyperinflation of the chest with the 7th anterior rib crossing the diaphragm. No other abnormalities seen. Interpretation: Hyperinflation of the lung fields is consistent with the provisional diagnosis of chronic obstructive airway disease. 3) Sputum FEME, culture and sensitivity (not done) Justification: In order to look for any bacteria which may have been the cause of the exacerbation . If there any organism cultured, proper antibiotics can be given based on the sensitivity test. 4) Arterial blood gas (not done) Justification: May be necessary in severe cases of breathlessness to look for respiratory failure and associated changes in blood pH. 5) Blood urea serum electrolytes and creatinine Justification: To look for renal impairment which may be present due to Mr TLT having hypertension. Renal impairment may also affect the dosage and type of antibiotics used. Results: Urea : 3.7mmol/L Sodium : 135 mmol/L Potassium : 3.7 mmol/L Creatinine : 65 umol/L Interpretation: Normal result. There is no renal impairment 6) Electrocardiogram Justification: To look for evidence of right ventricular hypertrophy or right atrial hypertrophy which may be seen in chronic lung disease. Results: ECG with sinus rhythm. There is no P pulmonale seen. There is low voltage seen. No ischaemic changes seen. No left ventricular hypertrophy. Interpretation: Normal ECG with low voltage is seen in a hyperinflated chest such as in patients with COPD STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 7) WORKING DIAGNOSIS AND PLAN OF MANAGEMENT ON ADMISSION Working diagnosis: Acute exacerbation of chronic obstructive airway disease due to upper respiratory tract infection My proposed plan of management is as follows: Acute management 1. Provide supplemental oxygen via nasal prong 3L/min and maintain SpO2 above 90%. Arterial blood gas should be done in order to ensure adequate oxygenation without carbon dioxide retention of acidosis. 2. Close monitoring of vital signs and SpO2 hourly until the patients breathlessness improves. Nursing staff to inform if patient deteriorates such as increased respiratory rate or drop in oxygen saturation below 92%. 3. Give nebulization of Ipratropium Bromide:Salbutamol:Normal Saline in ratio of 2:2:1 every four hours until breathlessness decreases. 4. Oral prednisolone 40mg once daily for 10 days 5. Postural drainage and chest physiotherapy may be performed. 6. Oral antibiotics such as T. Cefuroxime may be given. This was not given in this patient with further discussion below. Long term management 1. MDI ipratropium bromide 40 microgrammes tds 2. MDI salbutamol 200 microgrammes PRN 3. Counseling on proper inhaler technique. 4. Couseling on smoking cessation. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 8) SUMMARY OF INPATIENT PROGRESS (INCLUDING MAJOR EVENTS, CHANGE OF DIAGNOSIS OR MANAGEMENT AND OUTCOMES) Mr TLT was warded for a total of 3 days. His breathlessness improved after nebulization with ipratropium bromide, salbutamol and normal saline for one day. He no longer required nebulization after one day. Mr TLT was also able to ambulate without feeling breathless. He was able to eat and to sleep well without being bothered by the dyspnoea. His vital signs were also normal and his respiratory rate improved to about 20 breaths per minute. There was still some ronchi heard on auscultation but it was much reduced. He was afebrile during his stay. Mr TLT was discharged after 3 days of admission and educated on chronic obstructive airway disease. He was also counseled on the importance of smoking cessation. He was given an appointment with the medical outpatient department in one month time in order to review his symptoms after being given MDI ipratropium bromide. He was told to return to the hospital if he had similar episodes. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 9) DISCHARGE PLAN, COUNSELLING AND MOCK PRESCRIPTION Discharge Plan 1. Medications: i. MDI Salbutamol 200 µg PRN ii. MDI Ipratropium Bromide 40 µg TDS iii. T. Amlodipine 5mg once daily iv. T. Prednisolone 20mg od for 7 days. 2. Counseling on COPD and use of metered dose inhaler Mr TLT should be taught about the correct technique in using a metered dose inhaler. The technique should then be assessed before discharge. In the event that Mr TLT is unable to coordinate well, he may be advised to purchase an aerochamber. 3. Counseling on smoking cessation The approach to counseling a patient on smoking cessation as well as various options will be further discussed below. 4. Education on the symptoms of an acute exacerbation and advise to return to the hospital if there is development of those symptoms. 5. For follow-up at the medical outpatient department for review of symptoms while on MDI ipratropium bromide. He should also be taught about pulmonary rehabilitation. A spirometry appointment may also be made. STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 10) REFERRAL LETTER (MANDATORY) Dr Tan Hai Liang Medical Department, Hospital Batu Pahat Family physician, Klinik Kesihatan Batu Pahat, 83000 Batu Pahat, 10 June 2009 Dear esteemed colleague, Patients name: Teo Lai Thing Patients I/c number: 510912-01-6343 Problem: Chronic Obstructive Airway disease Thank you for seeing this 58 year old gentleman who is hypertensive for the past 1 year currently on T. Amlodipine 5mg once daily. He presented to Hospital Batu Pahat with shortness of breath for 4 days that was increasing in severity. A diagnosis of chronic obstructive airway disease was made. He was discharged uneventfully on the third day of admission with the following medication: MDI Salbutamol 200 µg PRN, MDI Ipratropium Bromide 40 µg TDS and T. Amlodipine 5mg once daily. Mr Teo has been a chronic smoker for the past 40 years and smokes up to 20 sticks of cigarettes a day. We have counselled him about the benefits of smoking cessation while in the ward. He is currently considering it and would like to learn more about the various options of smoking cessation. Kindly assess the patients keenness for smoking cessation as well as provide him with additional information on the options available to quit smoking. Thank you. Sincerely ____________ (Tan Hai Liang) Medical Department Hospital Batu Pahat STUDENT NAME: Tan Hai Liang ID NO: M0409146 NAME OF SUPERVISOR: Prof Khin ROTATION: Internal Medicine 11) LEARNING ISSUES IN THE 8 IMU OUTCOMES 1) Communication skills What are the benefits of smoking cessation in COPD patients and how should counseling be done? Counseling for smoking cessation should play a significant role in the holistic management of a patient with chronic obstructive airway disease. This is because studies have shown that smoking cessation changes the clinical course of COPD by preserving lung function. One study of patients reviewed at 14.5 years after stopping smoking showed that smoking cessation intervention showed 18% reduction in all-cause mortality compared with usual care without smoking cessation intervention. Patients who had stopped smoking had lower rates of death due of coronary heart disease , cerebrovascular disease, lung cancer, and other respiratory disease as compared with those assigned to usual care who continue to smoke. [1] Fig. 4. Effect of smoking cessation on mortality cause at 14.5 years in the Lung Health Study. (A) Comparison of smoking cessation intervention with usual care. (B) Comparison according to smoking status. I therefore looked up for counseling methods for smoking cessation. The American College of Chest Physicians recommend that physicians should be the first line in introducing smoking cessation. [2] There are 5 As that a doctor should perform for a patient who is a smoker: †¢ Ask about tobacco use at every visit †¢ Advise tobacco users to quit †¢ Assess the willingness to attempt quitting †¢ Assist the patient with methods for quitting †¢ Arrange for follow-up contact via phone or face to face If the patient is not yet willing to quit, there are 5 Rs which should be identified together by the patient and the doctor: †¢ Relevance of quitting for the patient †¢ Risks of illness related to continued tobacco use †¢ Rewerds/benefits of smoking cessation †¢ Roadblocks for quitting, internal and external †¢ Repetition of the motivation intervention at each encounter There are two means of intervention in smoking cessation namely pharmacological and behavioural. The pharmacological means include nicotine replacement therapy or buproprion. Behavioural interventions include counseling programs that teach problem-solving skills and support groups. [3] In conclusion, I learned that doctors have an important role in actively encouraging patients who smoke to stop as there are many proven benefits of smoking cessation. The steps discussed above on techniques in the counseling of patients would be helpful to me in the future. 2) Professionalism, ethics and personal development Should antibiotics be given for episodes of exacerbation of chronic obstructive airway disease? Mr TLT was not given antibiotics during this episode of exacerbation. Certain quarters support the use of prophylactic antibiotics in all exacerbations due to the knowledge that most exacerbations are caused by the common organisms of Streptococcus pneumoniae (S. pneumoniae), Haemophilus influenzae (H. influenzae), Pseudomonas aeruginosa (P. aeruginosa) and Moraxella catarrhalis (M. catarrhalis). Sputum culture may not be useful as even in the clinical stable state, some patients have sputum positive for bacteria. As such a broad spectrum antibiotic is usually used to cover different bacteria. However, is this use of antibiotics justified in that do patients benefit from it or is the overjudicious use of antibiotics merely promoting antibiotic resistant bacteria? Current Global initiative for chronic Lung Disease guidelines [4] recommend that antibiotics should be given in: i) patients with exacerbations of COPD and the three cardinal symptoms of increased dyspnoea, increased sputum volume and increased sputum purulence. ii) patients with exacerbation of COPD with two of the cardinal symptoms if increased purulence of sputum is one of the two symptoms iii) patients with severe exacerbations of COPD that requires mechanical ventilation A meta-analysis by Ram et al [5] of 11 placebo controlled RCTs with 917 patients attempted to analyse the value of antibiotics in the management of acute COPD exacerbations. The results show that there is a decrease in short-term mortality, treatment failure and sputum purulence with antibiotic therapy compared to placebo. The authors concluded that antibiotics therapy is appropriate in exacerbations of COPD associated with increased cough and sputum purulence. They further found that antibiotics have the greatest effect for patients with severe exacerbations who are admitted to the hospital. They were unable to comment on exacerbations with non-purulent sputum, what antibiotics were the best to be used and also the duration of therapy due to the lack of RCTs done on these aspects. In conclusion, it was appropriate that Mr TLT was not given antibiotics as he did not have the cardinal signs as mentioned by the GOLD guidelines and further supported by the systemic review. 3) Self directed life long learning What are extrapulmonary manifestations of COPD and what are its therapeutic implications? Chronic obstructive lung disease has long been known as a localized pulmonary disorder. However new evidence have shown that COPD may be a systemic disease that involves pathology in several extra-pulmonary systems. An article by Remels et al [6] summarized the extrapulmonary manifestations as well as its implications on the holistic management of chronic obstructive airway disease. The article showed that there is skeletal muscle dysfunction as well as systemic inflammation in chronic obstructive airway disease. There is loss of muscle mass associated with impaired protein metabolism. The loss of muscle mass which is called sarcopenia may progress to cachexia. Studies have also shown that there is increased apoptosis of muscle cells at the cellular level. Independent of the loss of muscle mass is the reduced muscle endurance. This finding has been attributed to abnormalities in mitochondria or to hypoxia. These findings have significant implications on management of a COPD patient which will be discussed below. Systemic inflammation is also seen in patients with COPD. This is evidenced by elevated levels of the proinflammatory cytokines such as tumor necrosis factor-alpha (TNF-a), interleukin-6, interleukin-8, and TNF-a receptors. The origin of the systemic inflammation is thought to be independent of the pulmonary manifestation of COPD. One postulation is the increase systemic inflammatory mediators such as neutrophils and lymphocytes in the circulation of patients with COPD. Another proposed mechanism is increased cytokine production due to chronic hypoxia. The therapeutic implications of these findings is that muscle atrophy should be prevented by resistance exercise as well as combined strength and endurance exercise. Current Malaysian guidelines on the management of COPD [7] recommend pulmonary resistance including lower and upper limb exercises as well as inspiratory muscle training. This concurs with a Cochrane metaanalysis by Lacasse et al [8] which strongly support respiratory at least four weeks of exercise training as part of the of management for patients with COPD. The authors found that there was clinically and statistically significant improvements in quality of life as measured by dyspnea, fatigue and emotional function. 4. Critical thinking and research What is the efficacy of systemic corticosteroids for acute exacerbations of chronic obstructive airway disese? The use of systemic oral or intravenous corticosteroids is recommended by GOLD guidelines in the management of acute exacerbations of chronic obstructive airway disease. However the patient, Mr TLT was not given any systemic corticosteroids. This could be because he merely had a mild exacerbation. I therefore looked up a Cochrane metaanalysis on the use of systemic corticosteroids for acute exacerbations of chronic obstructive airway disease [9]. The authors reviewed randomized controlled trials comparing parenteral or oral corticosteroids with placebo for the treatment of exacerbation of COPD. The primary outcomes measured were treatment failure (hospital readmission, return to emergency department), relapse and mortality. The authors reviewed 11 studies involving 1081 participants. The results show a statistically significant difference between placebo and use of corticosteoids. There was less treatment failure in patients given corticosteroids. Relapse within 30 days were also reduced. However there was no statistically significant reduction in mortality. As such the authors concluded that administration of oral or parenteral corticosteroids in the treatment of acute exacerbations of COPD reduces the likelihood of treatment failure. This is associated with early and continuing improvement during treatment with corticosteroids in lung function, breathlessness and blood gases and with a shorter hospital stay. This in turn has a positve impact on the economic cost of treating exacerbations, with fewer follow-up visits and hospital admissions. The authors also found that although there is an increased incidence of corticosteroid side effects such as fluid retention, hypertension and adrenal suppression, the effects are unlikely to persist after treatment ceases. EVIDENCE BASED MEDICINE WORKSHEET FOR REVIEW OF THERAPY STUDIES ASKING QUESTION Patient (P): Patients who present with stable COPD Intervention (I): Oral corticosteroids Comparison (C): Placebo Outcome (O): Effects on health status ACCESSING EVIDENCE THE SEARCH PATH How was the article identified: The Cochrane Library Search keywords : corticosteroids, stable COPD Citation: Walters JAE,Walters EH,Wood-Baker R.Oral corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2005, Issue 3. 1. Is