jurisdiction: US

text: b"Department of Health and Human Services\n\n OFFICE OF\n INSPECTOR GENERAL\n\n\n\n\n Psychotropic Drug Use\n in Nursing Homes\n\n\n\n\n JANET REHNQUIST\n Inspector General\n\n NOVEMber 2001\n OEI-02-00-00490\n\x0c OFFICE OF INSPECTOR GENERAL\n\nThe mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to\nprotect the integrity of the Department of Health and Human Services programs as well as the\nhealth and welfare of beneficiaries served by them. This statutory mission is carried out through a\nnationwide program of audits, investigations, inspections, sanctions, and fraud alerts. The\nInspector General informs the Secretary of program and management problems and recommends\nlegislative, regulatory, and operational approaches to correct them.\n\n Office of Evaluation and Inspections\n\nThe Office of Evaluation and Inspections (OEI) is one of several components of the Office of\nInspector General. It conducts short-term management and program evaluations (called\ninspections) that focus on issues of concern to the Department, the Congress, and the public. The\ninspection reports provide findings and recommendations on the efficiency, vulnerability, and\neffectiveness of departmental programs.\n\nOEI's New York regional office prepared this report under the direction of John I. Molnar,\nRegional Inspector General, and Renee C. Dunn, Deputy Regional Inspector General. Principal\nOEI staff included:\n\nREGION HEADQUARTERS\n\nDemetra Arapakos, Project Leader\n Brian Ritchie, Director, Technical Support Staff\n\nPatricia Banta, Lead Analyst\n Bambi Straw, Program Specialist\n\nMiriam Gareau, Program Analyst\n Barbara Tedesco, Mathematical Statistician\n\nThomas Zimmerman, Program Analyst\n\nRobert Gibbons, Region IX\n\n\n\n.\n\n\n\n To obtain copies of this report, please call the New York Regional Office at (212) 264-2000.\n Reports are also available on the World Wide Web at our home page address:\n\n http://www.hhs.gov/oig/oei\n\x0c EXECUTIVE SUMMARY\n\nPURPOSE\n\n To assess the extent and nature of inappropriate psychotropic drug use in nursing homes\n and how it relates to chemical restraints.\n\nBACKGROUND\n The Senate Special Committee on Aging requested that the Office of Inspector General\n look at the extent to which psychotropic drugs in nursing homes are being used as\n inappropriate chemical restraints. Usage rates for these drugs have been increasing since\n 1995. A chemical restraint is the use of a drug to control an individual\xe2\x80\x99s behavior and is\n legally appropriate only if used to ensure the physical safety of residents or other\n individuals.\n\n Psychotropic medications are drugs that affect brain activities associated with mental\n processes and behavior. They are divided into four broad categories: anti-psychotic; anti-\n depressant; anti-anxiety; and hypnotic medications. The Centers for Medicare & Medicaid\n Services established guidelines for the appropriate use of these drugs in nursing homes.\n Several programs exist to monitor the quality of care in nursing homes, including the\n appropriate use of psychotropic drugs. These include the nursing home survey and\n certification process and the State Long Term Care Ombudsman program.\n\n We combined five methods for this inspection: 1) a medical record review of 485 nursing\n home residents taking psychotropic drugs; 2) an analysis of survey and certification and\n ombudsman program data; 3) an assessment of 135 nursing home Drug Regimen Reviews;\n 4) on-site visits to 10 nursing homes; and 5) a telephone survey of 20 survey and\n certification and ombudsmen staff. We excluded anti-depressants from our review.\n\n\nFINDINGS\n\nPsychotropic drug use in nursing homes is generally appropriate\n\n Eighty-five percent of residents\xe2\x80\x99 psychotropic drugs use is medically appropriate. Nearly\n all have the potential to benefit functionally from their drug therapy and are using the\n drugs within Medicare guidelines for appropriate use.\n\n Another 8 percent of residents are using psychotropic drugs inappropriately. These drugs\n are inappropriate for one or more of the following reasons: the dose is too high because\n\n\nPsychotropic Drug Use in Nursing Homes i OEI 02-00-00490\n\x0c appropriate dose reductions are not followed; there is unjustified chronic use of the drug;\n there is no documented benefit to the resident; the wrong type of drug is being given for a\n particular diagnosis; and there is unnecessary duplicate drug therapy. The use of\n psychotropic drugs as an inappropriate chemical restraint does not appear to be\n widespread; our medical record reviewers could not conclusively determine that any of the\n inappropriate drug use was a chemical restraint. Finally, for 7 percent of residents,\n reviewers could not determine the appropriateness of their psychotropic drug use due to\n insufficient medical record documentation.\n\nData from survey and certification and ombudsman programs support the\nfindings of the medical record review\n\n Deficiencies from the Online Survey Certification Reporting System that directly cite the\n misuse of chemical restraints and psychotropic drugs are not common. Deficiency tag\n F222, (inappropriate chemical restraints) comprises 0.08 percent of all deficiencies in the\n current survey and has decreased slightly over the past four surveys. Further, tag F329\n (unnecessary psychotropic drugs) comprises 2 percent of all deficiencies in the current\n survey and has remained constant. Also, most surveyors in our sample States concur that\n inappropriate chemical restraints are not common.\n\n Similarly, Ombudsman complaints specific to the inappropriate use of chemical restraints\n and psychotropic drugs are not prevalent. In 1999, complaints about physical and\n chemical restraints accounted for 1 percent of all nursing home complaints, while those\n about the use of psychoactive drugs comprised just 0.25 percent of the total.\n\nA growth in the proportion of nursing home residents with mental disorders may\ncontribute to increasing psychotropic drug rates\n\n Data from the Online Survey Certification Reporting System show that from 1995 to 1999\n the overall national drug usage rate for anti-psychotics grew from 16 to 19.4 percent.\n During this time period, anti-anxiety drug rates increased from 14.3 to 15.7 percent. At\n the same time, data from this system show that over the last four surveys the proportion of\n residents with a documented psychiatric disorder, excluding dementia, increased from 13\n to 16 percent and the proportion with behavioral symptoms grew from 29 to 31 percent.\n Further, numerous articles have linked the increasing prevalence of mental disorders\n among nursing home residents to higher psychotropic drug rates.\n\n\nCONCLUSION\n\n In response to concerns expressed by the Senate Special Committee on Aging about the\n use of psychotropic drugs as inappropriate chemical restraints in nursing homes, this\n report finds that these drugs are generally being used appropriately. While drug usage\n\n\nPsychotropic Drug Use in Nursing Homes ii OEI 02-00-00490\n\x0c rates for anti-psychotic and anti-anxiety medications have been rising, most psychotropic\n drug use in nursing homes is medically appropriate. Where it is inappropriate, the\n problems do not appear to be related to inappropriate chemical restraints but rather to\n inappropriate dosage, chronic use, a lack of documented benefit to the resident, and\n inappropriate duplicate drug therapy. We do note, however, that lack of adequate\n documentation for residents\xe2\x80\x99 psychotropic drug use is of some concern. The Centers for\n Medicare & Medicaid Services may consider educating providers to better document the\n appropriate use of these drugs.\n\nAGENCY COMMENTS\n\n We received comments on the draft report from the Centers for Medicare & Medicaid\n Services. They believe that the report will contribute to a better understanding of\n psychotropic drug use in nursing homes and in identifying areas for further focus. The\n CMS also notes that training related to psychotropic drug use and related documentation\n issues is already underway or planned.\n\n\n\n\nPsychotropic Drug Use in Nursing Homes iii OEI 02-00-00490\n\x0c TABLE OF CONTENTS\n\n\n PAGE\n\n\nEXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i \n\n\nINTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1\n\n\nFINDINGS\n\n\n Nursing home psychotropic drug use generally appropriate . . . . . . . . . . . . . . . . . . . . . . 8\n\n\n Survey and certification and ombudsman data support medical record review . . . . . . . . 10\n\n\n Growth in resident mental disorders may contribute to increasing drug rates . . . . . . . . . 11\n\n\nCONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14\n\n\nAPPENDIX\n\n\n A: Confidence intervals for key medical record review findings . . . . . . . . . . . . . . . . . . 15\n\n\n B: Agency Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16\n\n\n\n\n\nPsychotropic Drug Use in Nursing Homes iv OEI 02-00-00490\n\x0c INTRODUCTION\n\nPURPOSE\n\n To assess the extent and nature of inappropriate psychotropic drug use in nursing homes\n and how it relates to chemical restraints.\n\n\nBACKGROUND\n\n The Senate Special Committee on Aging requested that the Office of Inspector General\n look at the extent to which psychotropic drugs in nursing homes are being used as\n inappropriate chemical restraints. Usage rates for these drugs have been increasing since\n 1995. A chemical restraint is the use of a drug to control an individual\xe2\x80\x99s behavior and is\n legally appropriate only if used to ensure the physical safety of residents or other\n individuals.\n\n We are also releasing a companion report entitled \xe2\x80\x9cPsychotropic Drug Use in Nursing\n Homes Supplental Information - 10 Case Studies,\xe2\x80\x9d OEI-02-00-00491, which presents\n information from on-site visits to ten nursing homes.\n\nPsychotropic Medications\n\n Psycho-pharmacologic medications are drugs that affect brain activities associated with\n mental processes and behavior. These drugs are also called \xe2\x80\x9cpsychoactive\xe2\x80\x9d or\n \xe2\x80\x9cpsychotherapeutic\xe2\x80\x9d medications. For clarity, we will refer to this class of drugs\n throughout our study as \xe2\x80\x9cpsychotropics.\xe2\x80\x9d Psychotropic medications are divided into four\n broad categories: anti-psychotic; anti-depressant; anti-anxiety; and hypnotic medications.\n\n Anti-psychotic Drugs. Anti-psychotic medications are used to treat various psychoses\n and neurologic conditions. These include schizophrenia, schizoaffective disorder,\n delusional disorder, psychotic mood disorder, acute psychotic episode, Tourette\xe2\x80\x99s\n syndrome, and Huntington\xe2\x80\x99s disease. Other indications for long-term anti-psychotic use in\n the elderly are organic mental syndromes (including dementia with associated psychotic\n and/or agitated features defined by \xe2\x80\x9ccertain behaviors\xe2\x80\x9d that are harmful to self or others)\n and mood disorders with psychotic features.\n\n Anti-psychotics are classified as either \xe2\x80\x9cconventional\xe2\x80\x9d or \xe2\x80\x9catypical.\xe2\x80\x9d Conventional anti-\n psychotics have several serious side effects. These side effects prompted the development\n of newer drugs called atypical anti-psychotics, which came onto the market\n\n\n\nPsychotropic Drug Use in Nursing Homes 1 OEI 02-00-00490\n\x0c in the mid 1990s. Clinical trials have demonstrated their effectiveness for a variety of\n disorders in the elderly, including schizophrenia and other psychoses. Although atypical\n anti-psychotics elicit fewer adverse reactions, other characteristics of these drugs, such as\n the effects on resident\xe2\x80\x99s cognition, have not been thoroughly tested.1\n\n Anti-depressant Drugs. Anti-depressant drugs are usually used in the treatment of\n depression and agitation. Anti-depressants in low dosages are also used to treat insomnia.\n Side effects include excessive sedation, anti-cholinergic effects (dry mouth, constipation,\n urinary retention, blurred near vision, rapid heart rate, confusion, and disorientation),\n orthostatic hypotension (which can predispose a resident to falls), and electro\n cardiographic changes. Most anti-depressants have a long enough half-life that the\n elderly, who have lower tolerance levels for most drugs, require smaller and less frequent\n doses.\n\n Anti-anxiety and Hypnotic Drugs. Anti-anxiety drugs are used for the short-term\n management of anxiety and insomnia. Hypnotics are medications used for short-term\n sleep aids. However, even lower dosages of these two categories of drugs in the elderly\n population are associated with impairment of daytime functioning and may in some cases\n increase confusion and disorientation, which may in turn exacerbate problem behaviors.2\n\nOmnibus Budget Reconciliation Act of 1987\n\n On December 22, 1987, Congress enacted comprehensive nursing home reform with the\n Omnibus Budget Reconciliation Act (OBRA) of 1987 (P.L. 100-203). As part of OBRA\n 1987, Congress passed the comprehensive Nursing Home Reform Act (NHRA). This Act\n mandates that residents be free from \xe2\x80\x9cphysical or chemical restraints imposed for the\n purposes of discipline or convenience.\xe2\x80\x9d It also states that restraints may only be imposed\n to ensure the physical safety of the resident or other residents and only upon the written\n order of a physician that specifies the duration and circumstances under which the\n restraints are to be used. Further, NHRA limits the use of \xe2\x80\x9cas needed\xe2\x80\x9d (P.R.N.) orders\n and requires efforts to withdraw the drug or decrease dosage be made for residents who\n are receiving psychotropic drugs.\n\n Additionally, the Omnibus Budget Reconciliation Act (OBRA) of 1990 requires the\n regulation of certain drugs in nursing homes and the establishment of Drug Regimen\n Reviews for nursing home residents. The provisions of Section 4401 of OBRA 1990\n\n\n 1\n Cohen, Lawrence, J., Burke, William, J. (1999) \xe2\x80\x9cAppropriate Use of Anti-psychotics for\nResidents with Dementia in the Long-Term Care Setting,\xe2\x80\x9d Consultant Pharmacist 14, (2).\n 2\n Stimmel, Glen (1996) \xe2\x80\x9cUse of Sedation in Patients with Behavioral Disturbances of Dementia,\xe2\x80\x9d\nConsultant Pharmacist 11, (Supplement D): 9-11.\n\n\nPsychotropic Drug Use in Nursing Homes 2 OEI 02-00-00490\n\x0c involve pharmacists more actively in patient care by refocusing pharmacists from a\n product oriented role to one involving clinical practice responsibilities for reducing\n potential drug therapy problems.\n\nThe Centers for Medicare and Medicaid Services Regulations\n\n To implement the requirements of OBRA 1987, on February 2, 1989, the Center for\n Medicare & Medicaid Services (CMS), formerly known as the Health Care Financing\n Administration, finalized regulations (42 C.F.R \xc2\xa7483.25(1)) on anti-psychotic medications\n and unnecessary drugs. These regulations were further refined in 1991. The CMS\n regulations state that each resident\xe2\x80\x99s drug regimen must be free from unnecessary drugs\n and define what is considered an unnecessary drug. An unnecessary drug is any drug\n used:\n\n C in excessive dose; \n\n C for excessive duration; \n\n C without adequate monitoring or without adequate indications for its use; \n\n C in the presence of adverse consequences, which indicate the dosage should\n\n be reduced or discontinued; or\n C without specific target symptoms.\n\n In addition, the CMS regulations state that residents who have not previously used anti-\n psychotic drugs should not be given these drugs unless anti-psychotic drug therapy is\n necessary to treat a specific condition as diagnosed and documented in the clinical record.\n Further, the regulation mandates that residents who use anti-psychotic drugs receive\n gradual dose reductions and behavioral interventions, unless clinically contraindicated, in\n an effort to discontinue these drugs.\n\n In July 1995, the CMS completed the final step in the implementation of OBRA 1987 by\n introducing new tasks into the nursing home survey process. Further refinements to\n survey procedures and interpretive guidelines were implemented on July 1, 1999. Some of\n these are specific to psychotropic drug therapy, including: new investigative protocols and\n the incorporation of quality indicators (QIs) based on the Minimum Data Set (MDS) into\n the off-site survey process; an update to the list of anti-psychotic drugs that can be cited\n as unnecessary or misused under tag number F329; the addition of drug therapy\n guidelines; and a revised definition of medication error. Additionally, the updated CMS\n regulations change some anti-psychotic dosing restrictions and list medications considered\n potentially hazardous to the elderly.\n\nNursing Home Monitoring Programs\n\n Several programs exist to monitor the quality of care in nursing homes. These programs\n can act as a safeguard against the use of psychotropic drugs as inappropriate chemical\n\n\nPsychotropic Drug Use in Nursing Homes 3 OEI 02-00-00490\n\x0c restraints and provide a venue for receiving and handling complaints about such misuse.\n\n Nursing Home Survey and Certification. All Medicare and/or Medicaid participating\n nursing homes must be certified in meeting certain Federal requirements. Nursing home\n certification is achieved through routine surveys. The CMS contracts with States to\n perform these surveys for Medicare and dually-eligible nursing homes. All nursing homes\n are subject to an unannounced standard survey \xe2\x80\x9cno later than 15 months after the date of\n the previous standard survey.\xe2\x80\x9d If during the standard survey a nursing home is found to\n have provided substandard quality of care, an additional extended survey will be\n conducted within 2 weeks. During either type of survey, a surveyor may cite the nursing\n home for a deficiency if that facility fails to meet specific requirements.\n\n Survey deficiencies are categorized, collected, and reported in the Online Survey\n Certification and Reporting System (OSCAR). Several deficiencies relate directly to\n pyschotropic drug misuse. For example, tag number F329 is cited for all unnecessary\n drugs including: anti-anxiety, anti-depressant, anti-psychotic, and hypnotic drug use. Tag\n number F330 is specific to anti-psychotic drug use in residents who do not have a specific\n condition as diagnosed and documented in the medical record, and tag number F222 is\n cited for inappropriate chemical restraints. In addition, other tags that address quality of\n care, resident\xe2\x80\x99s rights, and drug regimen reviews also indirectly relate to the misuse of\n psychotropic drugs.\n\n Ombudsman Program. The State Long Term Care Ombudsman program was\n established in 1978 by the Older Americans Act to ensure quality of care and advocacy on\n behalf of long term care residents. It requires that each State have an Ombudsman\n program, which are run by States and local communities and use both paid and volunteer\n staff. The programs have multiple functions including: identifying, investigating, and\n resolving complaints made on behalf of residents; protecting the legal rights of residents;\n and providing information and consultation to residents and families.\n\n All of the States systematically collect and report data relating to their Ombudsman\n Program under the National Ombudsman Reporting System (NORS). Two of the\n complaint categories in NORS specifically relate to the use of psychotropic drugs - one for\n chemical and physical restraints and the other for psychotropic drug assessment, use, and\n evaluation. Other categories indirectly address this problem, such as weight loss,\n assistance in eating, and functionality.\n\n\nMETHODOLOGY\n\n We combined five methods for this inspection: 1) a medical record review of residents\n taking psychotropic drugs; 2) an analysis of nursing home survey and certification and\n\n\n\nPsychotropic Drug Use in Nursing Homes 4 OEI 02-00-00490\n\x0c ombudsman program data; 3) an assessment of nursing home Drug Regimen Reviews; 4)\n on-site visits to 10 nursing homes; and 5) a telephone survey of State survey and\n certification and ombudsmen staff. The findings of the on-site visits are presented in a\n companion report, \xe2\x80\x9cPsychotropic Drug Use in Nursing Homes Supplemental Information -\n 10 Case Studies,\xe2\x80\x9d OEI-02-00-00491.\n\n We excluded anti-depressants from our review because depression in nursing home\n residents has historically been under-diagnosed and under-treated. Therefore, the increase\n in anti-depressant use is generally considered to be appropriate.\n\nNursing home and resident sample\n\n We used a two-stage cluster sample for this inspection. In the first stage of sampling, we\n used the OSCAR current survey file to select a random sample of 203 nursing homes.\n For each of the nursing homes in our sample, we requested their enrollment census for the\n month of November 2000. From this census, we asked the nursing homes to identify\n which residents received a psychotropic drug and what type (anti-psychotic, anti-anxiety,\n hypnotics, and/or anti-depressants) they received. We obtained a response from 196 of\n the 203 nursing homes, for an overall response rate of 97 percent.\n\n In the second stage of sampling, we selected a random sample of 587 nursing home\n residents. From each of the 196 nursing home enrollment lists we randomly selected 3\n residents who received either an anti-psychotic, anti-anxiety, and/or a hypnotic during\n November 2000 (we excluded residents solely on anti-depressants). One nursing home\n had only two residents who met these criteria and we sampled both residents.\n\nMedical record review\n\n For each of the residents in our sample, we requested their complete clinical records for\n May 2000 through November 2000. Among the documentation we requested were\n admission sheets, plans of care, nurses\xe2\x80\x99 and physicians\xe2\x80\x99 notes, medication administration\n records, psychiatric and neurological assessments, behavior management records, and\n physician orders.\n\n We received 574 of the 587 medical records that we requested, for a medical record\n response rate of 98 percent. If we had obtained a response from all 203 nursing homes in\n our first stage of sampling and had sampled 3 residents from each one, our overall\n response rate for medical records would have been 94 percent. Of the 574 medical\n records we did receive, we sent 485 for medical record review. The other 89 residents did\n not meet our sampling criteria and were excluded from the medical record review. While\n they were identified by their nursing home as having received a psychotropic drug in\n November 2000, their record showed no evidence that they had actually used the drug.\n Many of these residents had PRN (\xe2\x80\x9cas necessary\xe2\x80\x9d) orders that were not administered in\n November. Other residents were taking these drugs for non-psychiatric reasons.\n\n\n\n\nPsychotropic Drug Use in Nursing Homes 5 OEI 02-00-00490\n\x0c We used an independent contractor to conduct the medical record review. First, together\n with the contractor, we developed a screening instrument to review the residents\xe2\x80\x99 records.\n The screening instrument was based on the CMS guidelines for the appropriate use of\n psychotropic drugs. We also obtained input on this instrument from the American\n Association of Geriatric Psychiatrists and the American Medical Directors Association.\n Nurse screeners with geriatric experience initially reviewed all the records; the cases that\n did not pass this initial screening were passed on for second level review.\n\n Both a geriatric psychiatrist and a consultant pharmacist conducted the second level\n review. These reviewers determined a drug to be inappropriate if, based on the clinical\n documentation in the medical record, the drug was not medically necessary or reasonable.\n See Appendix A for confidence intervals on key findings of the medical record review.\n\nAnalysis of nursing home survey and certification and ombudsman program data\n\n We examined data from both the OSCAR and NORS. In OSCAR, we looked at nursing\n home deficiencies for chemical restraints (F222), unnecessary psychotropic drugs (F329),\n and psychotropic drug use in the absence of a documented diagnosis (F330). In NORS,\n we looked at complaints made to Ombudsman about physical and chemical restraints\n (H60) and psychoactive drugs (H62). For both sets of data, we looked at both the\n prevalence of and changes over time for each of the specific deficiencies and complaints.\n\nAssessment of Drug Regimen Reviews\n\n From the 196 nursing homes that responded to our request for an enrollment list, we\n requested 6 months of drug regimen reviews (DRRs). Overall, 135 nursing homes\n submitted these DRRs. We did not follow-up with the other 61 nursing homes. We\n reviewed a selection of these DRRs to determine how they assure that psychotropic drugs\n are being used appropriately.\n\nSite visits\n\n We selected a purposive sub-sample of 10 nursing homes in different States to visit on-\n site. These 10 nursing homes were selected based on five criteria: 1) geographical\n location, 2) number of residents in November 2000, 3) drug usage rate, 4) urban/rural\n location, and 5) ownership status. We chose nursing homes in California, Florida, Idaho,\n Maryland, Massachusetts, Missouri, New York, Ohio, Texas, and Wisconsin. Five of the\n facilities were large (more than 100 residents), four were medium (61-99 residents), and\n one was small (less than 60 residents). Also, four of the homes had a high psychotropic\n drug usage rate (greater than 34 percent), four had a moderate rate (18 to 34 percent),\n and two had rates of less than 18 percent. Lastly, eight of the nursing homes were located\n in an urban area while two were rural, and nine were for-profit while one was non-profit.\n\n While on-site at these 10 facilities, we interviewed both administrative as well as direct\n care staff. Our administrative interviews included discussions with nursing home\n\n\nPsychotropic Drug Use in Nursing Homes 6 OEI 02-00-00490\n\x0c administrators, directors of nursing, medical directors, consultant pharmacists,\n psychiatrists, social workers, and psychologists. We spoke with these respondents about\n how psychotropic drugs are being used and monitored in their facility.\n We also interviewed nurses and certified nurse aides in each facility separately from\n administrative staff about how they care for and monitor residents on psychotropic drugs\n and handle aggressive residents. Lastly, while on-site we spoke with and observed the\n residents in our sample and toured the facility, including observing at least one structured\n activity and meal time.\n\nTelephone interviews with State surveyors and ombudsmen\n\n For the States represented in our purposive sub-sample, we conducted two structured\n telephone interviews - one with the State ombudsman and the other with the State survey\n and certification director or other manager. During these interviews, we discussed with\n respondents how pyschotropic drugs are being used by nursing homes in their State, the\n nature and extent of inappropriate chemical restraints, and the processes that their State\n has in place to handle such complaints.\n\nLimitations\n\n Our methodology has two main limitations. First, we assessed the appropriateness of\n psychotropic drugs based solely on a medical record review and not on in-person clinical\n assessments of the residents in our sample. For example, our reviewers state that they\n could not conclusively determine if any inappropriate drug use was an inappropriate\n chemical restraint without a physical examination of the resident. Second, the nursing\n homes in our sample self-identified the residents that were receiving psychotropic drugs in\n November 2000.\n\n This inspection was conducted in accordance with the Quality Standards for\n Inspections issued by the President\xe2\x80\x99s Council on Integrity and Efficiency.\n\n\n\n\nPsychotropic Drug Use in Nursing Homes 7 OEI 02-00-00490\n\x0c FINDINGS\n\nPsychotropic drug use in nursing homes is generally appropriate\n\n Our medical record review shows that 85 percent of nursing home residents who take\n psychotropic drugs are taking drugs that are medically appropriate. Another eight percent\n are using psychotropic drugs inappropriately, and for seven percent our reviewers could\n not determine the appropriateness of their psychotropic drug therapy due to insufficient\n medical record documentation. See Graph 1 below.\n\n Graph 1\n Nursing Home Residents\xe2\x80\x99 Psychotropic Drug Use\n\n\n\n\n Source: Medical Record Screening Instrument, 2001\n\nEighty-five percent of residents\xe2\x80\x99 psychotropic drug use is medically appropriate\n\n Most nursing home residents taking psychotropic drugs are taking drugs that are medically\n appropriate. Nearly all of these residents have the potential to benefit functionally from\n their drug therapy and there is evidence that, for most, their therapeutic goal has been or\n can be achieved. Also, in accordance with the CMS guidelines, in most cases the\n psychotropic drugs are being used at appropriate dosages and duration and not as\n inappropriate duplicate therapy. The drugs are also generally being used with adequate\n indications and monitoring and without adverse consequences.\n\n\n\n\nPsychotropic Drug Use in Nursing Homes 8 OEI 02-00-00490\n\x0c Nearly all residents taking anti-psychotic drugs (95 percent) or anti-anxiety drugs (93\n percent) have a documented diagnosis of mental illness. More specifically, among\n residents on anti-psychotic drugs, the most common diagnosis is dementia with associated\n psychotic or agitated behaviors (71 percent), while 14 percent have a diagnosis of\n schizophrenia. Close to half of residents taking anti-anxiety drugs (43 percent) have a\n diagnosis of dementia of the Alzheimer\xe2\x80\x99s type with behavioral disturbance. For the few\n residents with no documented mental health diagnosis, most are appropriately taking an\n anti-psychotic or anti-anxiety drug due to an acute problematic behavior.\n\n We noted several features of nursing homes\xe2\x80\x99 Drug Regimen Reviews (DRRs) that may\n help to assure that psychotropic drugs are used appropriately. These DRRs are conducted\n on a monthly basis by pharmacists to assess residents\xe2\x80\x99 drug treatment plans. Many of the\n DRRs we reviewed include the pharmacist\xe2\x80\x99s recommendation to change a medication in\n order to improve the management of a resident\xe2\x80\x99s behavioral symptoms, as well as a\n recommendation to re-evaluate or discontinue PRN (\xe2\x80\x9cwhen necessary\xe2\x80\x9d) drug orders. The\n DRRs also commonly include a suggestion to decrease dosage, a reminder that reduction\n attempts are past due, or an identification of medication errors, such as when\n inappropriate duplicate drugs are being given. In many cases, the resident\xe2\x80\x99s physician\n concurs with the pharmacist\xe2\x80\x99s recommendation and indicates this agreement on the DRR.\n\nEight percent of residents are using psychotropic drugs inappropriately\n\n Eight percent of residents who take psychotropic drugs are using these drugs\n inappropriately. These drugs are inappropriate for one or more of the following reasons:\n the dose is too high because appropriate dose reductions are not followed; there is\n unjustified chronic use of the drug; there is no documented benefit to the resident; the\n wrong type of drug is being given for a particular diagnosis; and there is inappropriate\n duplicate drug therapy. For example, in a few cases an additional anti-psychotic drug is\n being given to treat symptoms without dose adjusting on the first drug to a level that\n would effectively treat the resident. In many instances there is no clear documentation to\n support continued need for duplicate or triplicate drug therapy. Residents on more than\n one psychotropic drug are more likely than residents on just one psychotropic drug to be\n taking a medication inappropriately.\n\n There do not appear to be any nursing home characteristics associated with inappropriate\n use. Neither ownership type nor urban or rural setting are linked with inappropriate use of\n these drugs. Also, nursing homes with higher psychotropic drug usage rates are not more\n likely than homes with medium and low rates to inappropriately use these drugs.\n However, nearly all nursing home surveyors and some ombudsmen we interviewed say\n that inadequate nursing home staffing ratios, training, and experience may be associated\n with a greater likelihood of inappropriate drug use.\n\n Inappropriate chemical restraints do not appear to be widespread. Our medical record\n reviewers could not conclusively determine that any of the inappropriate drug use was an\n inappropriate chemical restraint. In follow-up discussions with reviewers, all agree that\n\n\nPsychotropic Drug Use in Nursing Homes 9 OEI 02-00-00490\n\x0c based on their medical record review, the use of psychotropic drugs as inappropriate\n chemical restraints, solely for the convenience of staff, does not appear to be common.\n\nSeven percent of residents\xe2\x80\x99 medical records lack sufficient documentation to\ndetermine the appropriateness of their psychotropic drug use\n\n Seven percent of residents we sampled have such inadequate records that our medical\n record reviewers are unable to determine if their drug use is appropriate. Some of these\n residents\xe2\x80\x99 records lack information about their mental health history, while others\xe2\x80\x99 lack\n physician notes on the medical rationale for why the drug is being used. For example,\n several residents were taking hypnotic drugs without any note of sleeping problems in\n their records. However, based on their clinical judgement and other documentation in the\n record, our reviewers believed that these drugs may have been appropriate.\n\n There are two other ways in which nursing home documentation for these drugs is\n insufficient. Of the records that went for second level review, there was not always\n adequate documentation to explain why residents were taking psychotropic drugs outside\n of the CMS dosage guidelines (even though the medical reviewers determined that the\n dosage was appropriate). Also, some records do not have adequate documentation to\n support the duration of time the resident has been receiving the drug. In fact, our medical\n reviewers cite this as one of the biggest documentation problems. They state that\n documentation to justify the appropriateness of chronic use of pyschotropic drugs is often\n lacking since residents\xe2\x80\x99 records commonly lack physician notes to support ongoing drug\n therapy.\n\n\nData from survey and certification and ombudsman programs support\nthe findings of the medical record review\n\n The OSCAR deficiencies that directly cite inappropriate psychotropic drugs and chemical\n restraints are not common. Deficiency tag F222, cited for inappropriate chemical\n restraints, comprises 0.08 percent of all deficiencies in the current survey, and the number\n of these deficiencies has been decreasing slightly over the past three surveys. Further, tag\n F329, cited for unnecessary psychotropic drugs, comprises 2 percent of all deficiencies in\n the current survey; the number of these deficiencies has remained constant. Lastly, tag\n F330, cited for the use of a psychotropic drug in the absence of a documented diagnosis,\n accounts for 0.13 percent of all deficiencies; these deficiencies have also seen a small\n decrease. It should be noted that other deficiencies, such as pressure sores and weight\n loss, may indicate that psychotropic drugs are being used as inappropriate chemical\n restraints.\n\n Similarly, ombudsman complaints specific to the inappropriate use of psychotropic drugs\n and chemical restraints are not prevalent. In 1999, complaints about physical and chemical\n restraints accounted for 1 percent of all nursing home complaints, while those about the\n use of psychoactive drugs comprised just 0.25 percent of the total.\n\n\nPsychotropic Drug Use in Nursing Homes 10 OEI 02-00-00490\n\x0c Furthermore, the number of these complaints, while increasing slightly from 1996 to 1998,\n have decreased from 1998 to 1999.\n\n Also, most surveyors and some ombudsmen in our sample States concur that\n inappropriate chemical restraints are not common. Most of the 10 surveyors we\n interviewed say that use of psychotropic drugs as inappropriate chemical restraints is\n uncommon. While fewer ombudsmen agree, most say that only a small number of nursing\n homes are using the drugs inappropriately. Further, a majority of both surveyors and\n ombudsmen in our sample report that over the past three years, the inappropriate use of\n these drugs as inappropriate chemical restraints has decreased or remained the same.\n\n Several respondents in our sample States say that chronic drug use may be more of a\n problem. One surveyor says: \xe2\x80\x9cThe decision to use the drug might be right but [nursing\n homes] might not handle it correctly as [they] go along.\xe2\x80\x9d An ombudsman agrees: \xe2\x80\x9c[It]\n may have been appropriate to use the drug at the start, but not keep the resident on the\n drug for 5 years.\xe2\x80\x9d\n\n\nA growth in the proportion of nursing home residents with mental\ndisorders may contribute to increasing psychotropic drug rates\n\nMore residents are taking psychotropic drugs\n\n Since 1995, nursing home psychotropic drug usage rates have increased. This increase\n occurred after initial drops in usage rates following the implementation of OBRA 87. The\n largest increase has occurred with the use of anti-psychotics. Based on OSCAR data,\n from 1995 to 1999 the national rate for anti-psychotics grew from 16 percent to 19.4\n percent, and anti-anxiety drug rates increased from 14.3 percent to 15.7 percent.3\n However, hypnotic drug rates have remained relatively steady at 5 percent for this time\n period.\n\n Based on our sample, which excluded residents taking only anti-depressants, anti-\n psychotics appear to be the most prevalent of the different groups of psychotropic drugs.\n Sixty-seven percent of residents on psychotropic drugs are taking an anti-psychotic\n medication, while 42 percent are taking an anti-anxiety drug, and far fewer (17 percent)\n are taking a hypnotic medication. Overall, more than half of these residents are taking two\n or more psychotropic drugs.\n\nNursing homes have a higher proportion of residents with mental disorders\n\n The population of residents with mental disorders in nursing homes has also been growing.\n Data from OSCAR show that the proportion of all residents with a documented\n\n\n 3\n American Society of Consultant Pharmacists Fact Sheet, September (2000).\n\n\nPsychotropic Drug Use in Nursing Homes 11 OEI 02-00-00490\n\x0c psychiatric disorder, excluding dementia, increased from 13 percent to 16 percent over the\n last four surveys. Also, the proportion of all residents with behavioral symptoms grew\n from 29 percent to 31 percent over the same period. Further, in our telephone interviews\n two ombudsmen say they are seeing more problem behavior and dementia among nursing\n home residents in their States. Lastly, one of our medical record reviewers, a geriatric\n psychiatrist, mentions that nursing homes are different now than they were when OBRA\n 87 was first implemented, due to the higher proportion of psychiatric residents.\n\n Numerous articles have also documented the increasing prevalence of mental disorders\n among nursing home residents. In one article examining the effects of OBRA 87 on\n psychotropic prescribing rates, the authors argue that \xe2\x80\x9cthe prevalence of psychiatric\n disorders in long-term care facilities is formidable, and nursing homes have become\n defacto mental health facilities.\xe2\x80\x9d4 When discussing the impact this has had on\n psychotropic drug use, they caution against \xe2\x80\x9ctrends that equate low utilization ... with\n high-quality care, without considering other factors such as improvements in the quality of\n life associated with appropriate use of psychotropic medications.\xe2\x80\x9d5 In another article from\n the Consultant Pharmacist, the authors state that \xe2\x80\x9cthe small but meaningful increase in\n usage seen in several categories ... may be explained by an increase in [behavioral] acuity\n of patients.\xe2\x80\x9d6\n\n Lastly, nursing homes appear to be accepting more residents with a history of\n psychotropic drug use. At least one third of the residents in our sample entered the\n nursing home already on their medication. Several of our medical record reviewers point\n out that hospitals\xe2\x80\x99 common use of these drugs results in new nursing home admissions\n who already have a prior history of taking psychotropic medications. Finally, a few of the\n administrators at the nursing homes we visited say that they try to reduce drug levels for\n residents entering the home already taking high dosages.\n\nFour of the 10 nursing homes we visited are actively seeking out psychiatric\npatients\n\n Four of the 10 nursing homes we visited specifically target psychiatric patients. All four\n have psychotropic drug usage rates that are above the national average. These nursing\n homes actively seek out such patients because they have developed the expertise and\n staffing structure necessary to care for residents with a mental illness. Some\n\n\n\n 4\n Lantz, Melinda, Giambanco, Vincent, and Buchalter, Eric. (1996) \xe2\x80\x9cA Ten-Year Review of the\nEffect of OBRA-87 on Psychotropic Prescribing Practices in an Academic Nursing Home,\xe2\x80\x9d Psychiatric\nServices.\n 5\n Lantz, (1996).\n 6\n Tobias, Dianne and Pulliam, Charles. (1997) \xe2\x80\x9cGeneral and Psychotherapeutic Medication Use in\n878 Nursing Facilities: A 1997 National Survey,\xe2\x80\x9d Consultant Pharmacist.\n\n\nPsychotropic Drug Use in Nursing Homes 12 OEI 02-00-00490\n\x0c administrators mention that in order to remain financially viable, they need to target this\n segment of the nursing home population; residents with lesser care needs or with less\n advanced dementia or Alzheimer\xe2\x80\x99s disease are increasingly going to other long term care\n settings, such as assisted living centers.\n\n\n\n\nPsychotropic Drug Use in Nursing Homes 13 OEI 02-00-00490\n\x0c CONCLUSION\n\n\n In response to concerns expressed by the Senate Special Committee on Aging about the\n use of psychotropic drugs as inappropriate chemical restraints in nursing homes, this\n report finds that these drugs are generally being used appropriately. While drug usage\n rates for anti-psychotic and anti-anxiety medications have been rising, most psychotropic\n drug use in nursing homes is medically appropriate. Where it is inappropriate, the\n problems do not appear to be related to inappropriate chemical restraints but rather to\n inappropriate dosage, chronic use, a lack of documented benefit to the resident, and\n inappropriate duplicate drug therapy. We do note, however, that lack of adequate\n documentation for residents\xe2\x80\x99 psychotropic drug use is of some concern. The Centers for\n Medicare and Medicaid Services may consider educating providers to better document the\n appropriate use of these drugs.\n\n\nAGENCY COMMENTS\n\n We received comments on the draft report from the Centers for Medicare & Medicaid\n Services. They believe that the report will contribute to a better understanding of\n psychotropic drug use in nursing homes and in identifying areas for further focus. The\n CMS also notes that training related to psychotropic drug use and related documentation\n issues is already underway or planned.\n\n\n\n\nPsychotropic Drug Use in Nursing Homes 14 OEI 02-00-00490\n\x0c APPENDIX A\n\n\n\n Confidence Intervals for Key Medical Record Review Findings\n\n We calculated confidence intervals for the medical record review key findings. The point\n estimate and 95% confidence intervals are given for each of the following:\n\n\n\n POINT CONFIDENCE\n KEY FINDINGS\n ESTIMATE* INTERVAL\n Nursing home residents who are taking\n psychotropic drugs that are medically\n appropriate 85 % 81 % - 89%\n\n\n Nursing home residents who are taking\n psychotropic drugs that are medically\n inappropriate 8% 5 % - 11%\n\n\n Nursing home residents whose medical records\n lack sufficient documentation to determine the\n appropriateness of their psychotropic drug use 7% 4 % - 10 %\n\n\n * N = 485\n\n\n\n\nPsychotropic Drug Use in Nursing Homes 15 OEI 02-00-00490\n\x0c APPENDIX B\n\n\n\n Comments on the Draft Report\n\n\n In this appendix, we present in full the comments from the Centers for Medicare &\n Medicaid Services.\n\n\n\n\nPsychotropic Drug Use in Nursing Homes 16 OEI 02-00-00490\n\x0cPsychotropic Drug Use in Nursing Homes 17 OEI 02-00-00490\n\x0cPsychotropic Drug Use in Nursing Homes 18 OEI 02-00-00490\n\x0c"


type: legislation

jurisdiction: EU

text:
 Nr. L 282/ 54 NL Publikatieblad van de Europese Gemeenschappen 1 . 11 . 96
 VERORDENING (EG) Nr. 2108 /96 VAN DE COMMISSIE
 van 31 oktober 1996
 tot vaststelling van de restituties bij uitvoer voor granen en meel, gries en
 griesmeel van tarwe of van rogge
 DE COMMISSIE VAN DE EUROPESE Overwegende dat de restitutie eenmaal per maand moet
 GEMEENSCHAPPEN , worden vastgesteld; dat de restitutie tussentijds kan
 worden gewijzigd;
 Gelet op het Verdrag tot oprichting van de Europese
 Gemeenschap, Overwegende dat de toepassing van deze regelen op de
 huidige situatie in de sector granen en met name op de
 Gelet op Verordening (EEG) nr. 1766/92 van de Raad van noteringen of prijzen van deze produkten in de Gemeen
 30 juni 1992 houdende een gemeenschappelijke ordening schap en op de wereldmarkt voert tot het vaststellen van
 der markten in de sector granen ('), laatstelijk gewijzigd bij de bedragen van de restitutie zoals vermeld in de bijlage;
 Verordening (EG) nr. 923/96 van de Commissie (2), en
 met name op artikel 13, lid 2, Overwegende dat bij Verordening (EEG) nr. 990/93 van
 de Raad (5), gewijzigd bij Verordening (EG) nr. 1380/95 (6),
 Overwegende dat volgens artikel 13 van Verordening een verbod is vastgesteld voor handelsverkeer tussen de
 (EEG) nr. 1766/92 het verschil tussen de noteringen of de Europese Gemeenschap en de Federatieve Republiek
 prijzen op de wereldmarkt van de in artikel 1 van die Joegoslavië (Servië en Montenegro); dat dit verbod niet
 verordening bedoelde produkten en de prijzen van deze geldt voor bepaalde omstandigheden die limitatief zijn
 produkten in de Gemeenschap kan worden overbrugd opgesomd in de artikelen 2, 4, 5 en 7 van die verordening
 door een restitutie bij uitvoer; en in Verordening (EG) nr. 462/96 van de Raad (7); dat
 Overwegende dat de restituties moeten worden vastgesteld daarmee rekening moet worden gehouden bij de vaststel
 met inachtneming van de elementen als bedoeld in ling van de restituties;
 artikel 1 van Verordening (EG) nr. 1501 /95 van de Overwegende dat de in deze verordening vervatte maatre
 Commissie van 29 juni 1995 tot vaststelling van toepas gelen in overeenstemming zijn met het advies van het
 singsbepalingen van Verordening (EEG) nr. 1766/92 van Comité van beheer voor granen,
 de Raad voor de toekenning, in de graansector, van
 uitvoerrestituties en van bij verstoring van de graanmarkt
 te treffen maatregelen (3), laatstelijk gewijzigd bij Verorde HEEFT DE VOLGENDE VERORDENING VASTGESTELD :
 ning (EG) nr. 95/96 (4);
 Overwegende dat voor meel, gries en griesmeel van tarwe Artikel 1
 of van rogge de restitutie moet worden berekend met
 inachtneming van de hoeveelheid granen benodigd voor De restituties bij uitvoer in ongewijzigde staat van de in
 de vervaardiging van de betreffende produkten; dat deze artikel 1 , onder a), b) en c), van Verordening (EEG)
 hoeveelheden zijn vastgesteld in Verordening (EG) nr. 1766/92 bedoelde produkten, met uitzondering van
 nr. 1501 /95; mout, worden op de in de bijlage aangegeven bedragen
 vastgesteld.
 Overwegende dat de situatie op de wereldmarkt of de
 specifieke eisen van bepaalde markten voor sommige Artikel 2
 produkten een differentiatie van de restitutie naar bestem
 ming nodig kunnen maken ; Deze verordening treedt in werking op 1 november 1996.
 Deze verordening is verbindend in al haar onderdelen en is rechtstreeks toepasselijk in
 elke Lid-Staat.
 Gedaan te Brussel, 31 oktober 1996 .
 Voor de Commissie
 Franz FISCHLER
 Lid van de Commissie
 (') PB nr. L 181 van 1 . 7. 1992, blz. 21 .
 (2) PB nr. L 126 van 24. 5. 1996, blz. 37. (5) PB nr. L 102 van 28 . 4. 1993, blz. 14.
 O PB nr. L 147 van 30 . 6. 1995, blz. 7. (*) PB nr. L 138 van 21 . 6. 1995, blz. 1 .
 4 PB nr. L 18 van 24. 1 . 1996, blz. 10 . O PB nr. L 65 van 15. 3. 1996, blz. 1 .
 ---pagebreak--- 1 . 11 . 96 | NL | Publikatieblad van de Europese Gemeenschappen Nr. L 282/ 55
 BIJLAGE
 bij de verordening van de Commissie van 31 oktober 1996 tot vaststelling van de restituties bij
 uitvoer voor granen en meel, gries en griesmeel van tarwe of van rogge
 (in ecu / ton) (in ecu / ton)
 Bedrag van de Bedrag van de
 Produktcode Bestemming (') restitutie (2)
 Produktcode Bestemming (')
 restitutie (2)
 0709 90 60 000 1101 00 11 000
 0712 90 19 000 — —
 1101 00 15 100 01 27,00
 1001 10 00 200 — —
 1101 00 15 130 01 25,50
 1101 00 15 150 01 23,50
 1001 10 00 400
 1101 00 15 170 01 21,50
 1001 90 91 000
 1101 00 15 180 01 20,00
 1001 90 99 000 01 0
 1101 00 15 190
 1002 00 00 000 01 0
 1101 00 90 000
 1003 00 10 000
 1102 10 00 500 01 41,00
 1003 00 90 000 01 0
 1102 10 00 700 —
 —
 1004 00 00 200 — —
 1102 10 00 900 _
 1004 00 00 400 — —
 1103 11 10 200 01 27,00 (-1)
 1005 10 90 000 1103 11 10 400 -o
 — —
 —
 1005 90 00 000 — —
 1103 11 10 900 —
 1007 00 90 000 — —
 1103 11 90 200 01 27,00 0
 1008 20 00 000 — —
 1103 11 90 800 —
 —
 (') De bestemmingen zijn de volgende :
 01 alle derde landen ,
 (2) De restituties voor uitvoer naar de Federatieve Republiek Joegoslavië (Servië en Montenegro) mogen slechts worden toegekend met inachtneming van het
 bepaalde in de gewijzigde Verordeningen (EEG) nr. 990/93 en (EG) nr. 462/96.
 (') Als dit produkt geagglomereerd griesmeel bevat, wordt geen restitutie verleend .
 NB: De zones zijn die welke worden omschreven door de gewijzigde Verordening (EEG) nr. 2145/92 van de Commissie (PB nr. L 214 van
 30 . 7. 1992, blz. 20).


type: caselaw

text:
 311 Md. 335 (1988)
 534 A.2d 1337
 CAROLINA FREIGHT CARRIERS CORPORATION ET AL.
 v.
 MICHAEL E. KEANE ET AL.
 No. 59, September Term, 1987.
 Court of Appeals of Maryland.
 January 6, 1988.
 M. Albert Figinski (Robert E. Cahill, Sr., Robert E. Cahill, Jr. and Melnicove, Kaufman, Weiner, Smouse & Garbis, P.A., on the brief), Baltimore, for appellant.
 Bernard J. Sevel (Marc K. Sloane, on the brief), Baltimore, for appellee.
 Argued before MURPHY, C.J., and ELDRIDGE, COLE, RODOWSKY, McAULIFFE, ADKINS and BLACKWELL, JJ.
 ADKINS, Judge.
 The age limitation set forth in § 3-904(e)(1) of Maryland's Wrongful Death Act[1] states that solatium damages may be recovered by parents of a deceased person if that person was a child "21 years old or younger." We shall decide in this case whether that section allows respondents Michael E. and C. Patricia Keane ("the Keanes") to recover for the wrongful death of their son, Gregory Thomas Keane, who was 21 years, 7 months, and 28 days old on the day he died. Petitioners Carolina Freight Carriers Corporation and Curnell McKinley Crockett (for convenience, both hereinafter referred to as "Carolina") claim that the statutory language limits recovery to those children who have not passed their twenty-first birthday. We disagree and in so doing will affirm the judgment of the Court of Special Appeals, Keane v. Carolina Freight Carriers Corp., 70 Md. App. 298, 520 A.2d 1142 (1987).
 I. Facts
 Gregory Thomas Keane, born on 11 March 1962, was unmarried and living with his parents (though not dependent on them) when he was killed on 7 November 1983 in a head-on collision. That collision was caused by the negligence of petitioner Carolina. Gregory's parents, the Keanes, instituted this action in the Circuit Court for Howard County making claims under the Wrongful Death Act. The jury awarded the Keanes solatium damages totaling $220,000 for the loss of their son.[2]
 Carolina moved for judgment notwithstanding the verdict, or in the alternative, a partial new trial on the issue of solatium damages only. It contended the Keanes lacked standing to recover damages under § 3-904(e)(1) because Gregory was too old; he was not "21 years old or younger" at the time of his death. Judge Fischer granted the motion and entered judgment in favor of Carolina. As earlier noted, the Court of Special Appeals, Keane v. Carolina Freight Carriers Corp., supra, reversed and reinstated the judgments.
 II. Statutory Construction
 The sole issue in this case is what is meant by the words "21 years old or younger" as that phrase is used in the Wrongful Death Act. Pointing to what it sees as the importance of the age of majority in Maryland law and to the legislative history, Carolina insists that the phrase must exclude anyone who has passed his or her twenty-first birthday. It bolsters this argument by asserting that statutes altering the common law, such as the Wrongful Death Act, should be strictly construed so that their words are given a limited and narrow construction. See, e.g., Dunnigan v. Cobourn, 171 Md. 23, 25, 187 A. 881, 882 (1936); Demczuk v. Jenifer, 138 Md. 488, 493, 114 A. 471, 473 (1921); and Flores v. King, 13 Md. App. 270, 274, 282 A.2d 521, 523 (1971). But see, State v. Sherman, 234 Md. 179, 184, 198 A.2d 71, 73 (1964) ("[these] statutes[3] are remedial and designed to close a gap in the preexisting law"); and Van Beeck v. Sabine Towing Co., Inc., 300 U.S. 342, 350-351, 57 S. Ct. 452, 456, 81 L. Ed. 685, 690 (1937) ("Death statutes have their roots in dissatisfaction with the archaisms of the law.... It would be a misfortune if a narrow or grudging process of construction were to exemplify and perpetuate the very evils to be remedied").
 The Keanes, for their part, devote much ink to supporting the proposition that "21 years old or younger" is completely unambiguous. This being so, they aver, there is no need to look at legislative history; no need to construe. The plain language of the statute is enough. The words should be given their ordinary and natural meaning. This meaning must be that the phrase embraces anyone who has not reached his or her twenty-second birthday.
 We recently faced a similar "battle between contending canons of construction" in Kaczorowski v. City of Baltimore, 309 Md. 505, 512, 525 A.2d 628, 631 (1987). In that case we concluded that "legislation usually has some objective, goal, or purpose. It seeks to remedy some evil, to advance some interest, to attain some end." Id. at 513, 525 A.2d at 632. We should search for legislative intent, the purpose, aim, and policy of the legislation, by looking at the words of the statute, as "controlled by the context in which they appear," and as "read in the light of other external manifestations of that purpose." Id. at 514, 525 A.2d at 632. Kaczorowski teaches that canons of construction, while sometimes useful guidelines, are not a set of Procrustean beds, to the dimensions of which all statutory language must be made to conform, however poor the fit. We decline to enter the debate about ambiguity or to engage in an exchange of slogans. We look at the words of the statute in the context of their adoption and from that perspective determine the meaning of the language in a manner consistent with the goal the legislature was trying to achieve.
 III. Legislative History
 At common law, relatives had no recovery for the death of a person caused by negligence or the wrongful act of another. In England, this shortcoming was remedied in 1846, with the passage of Lord Campbell's Act. 9 & 10 Vict. Ch. 93. Maryland followed suit with Ch. 299, Acts of 1852. See generally, McKeon v. State, Use of Conrad, 211 Md. 437, 127 A.2d 635 (1956), and Stewart v. United Elec. L. & P. Co, 104 Md. 332, 65 A. 49 (1906). The 1852 Maryland statute was "almost a literal transcript of LORD CAMPBELL'S Act...." Stewart, 104 Md. at 334, 65 A. at 50.
 That first act permitted recovery for pecuniary loss suffered by a spouse, parent and child of a person killed by the wrongful act, neglect or default of another. McKeon, 211 Md. at 442, 127 A.2d at 637. In the case of a deceased minor child, pecuniary loss was limited to compensation for the loss of that child during minority only, that is, for the period from death until the time the child would have reached the age of majority. Coughlan v. B. & O.R.R. Co., 24 Md. 84, 107-108 (1866). See also, Morrell v. Williams, 279 Md. 497, 366 A.2d 1040 (1977); and State v. Prince George's County, 207 Md. 91, 113 A.2d 397 (1955). With a deceased adult, the compensation was to be equivalent to the pecuniary benefits which might have reasonably been expected from the continuance of the deceased's life. B. & O.R.R. v. State, Use of Hauer, 60 Md. 449, 467 (1883). See also B. & O.R.R. Co. v. State, Use of Mahone, 63 Md. 135 (1885), and B. & O.R.R. Co. v. Kelly, 24 Md. 271 (1866), both citing Dalton v. South Eastern Railway Co., 93 Eng.C.L. 296 (1858) (27 year old son), and Franklin v. South Eastern Railway Co., 3 Hurl. & Nor. 211 (1858) (21 year old son).
 The list of persons entitled to recover was enlarged in 1937[4] and then again in 1952.[5]McKeon, 211 Md. at 442, 127 A.2d at 637. It was not until 1969, however, that the type of damages recoverable was expanded from pecuniary loss alone, to include also an amount for solatium damages. Md.Code (1967 Repl.Vol., 1969 Cum.Supp.) Art. 67, § 4(b) (now codified at § 3-904(d)) added:
 In the case of the death of a spouse or a minor child, the damages awarded by a jury in such cases shall not be limited or restricted to the "pecuniary loss" or "pecuniary benefit" rule, but may include damages for mental anguish, emotional pain and suffering, loss of society, companionship, comfort, protection, marital care, parental care, filial care, attention, advice, counsel, training, guidance, or education where applicable.
 The statute stated it allowed recovery only for the death of a spouse or minor child although it included damages for loss of parental care and other lost parental benefits.
 In 1973 the Governor's Commission to Revise the Annotated Code pointed out this defect in the statute. Commission Report No. 3F to the General Assembly of Maryland Regarding the Revised Article on Courts and Judicial Proceedings (16 July 1973). The General Assembly thus considered further the solatium damage section and enlarged the recovery in 1975 to allow damages for the death of the "parent of a minor child". Acts of 1975, Ch. 120.
 It is obvious that all of these changes were designed to expand the coverage of the Wrongful Death Act by adding to the categories of persons for whose deaths recovery could be had, by augmenting the categories of potential claimants, or by expanding the categories of damages recoverable. The remedial purpose discerned by Judge Henderson for the Court in Sherman, 234 Md. at 184, 198 A.2d at 73, was still operating. And that purpose remains evident in the legislative activity leading to the language now before us, the language adopted by Ch. 520, Acts of 1983.
 That activity began with S.B. 156 of 1982, sponsored by Senator O'Reilly. It would have amended § 3-904(d) by deleting the adjective "minor" as a modifier of "child" and the phrase "of a minor child" as a limitation on "parent." The effect, then, would have been to allow recovery of solatium for, among other things, the death of any child or parent, not just the death of a minor child or the parent of a minor child. S.B. 156 did not pass, but was in substance reintroduced by Senator O'Reilly as S.B. 121 of 1983, with the adjective "minor" again deleted.
 In the Senate Judicial Proceedings Committee, many of the witnesses testifying in support of the bill had lost adult children (e.g., 20 and 22 year olds) to drunk drivers.[6] Senator O'Reilly also commented that the original drafter of the then-existing wrongful death statute never intended the law to exclude payments to parents for the deaths of non-minor children. The Committee accepted the bill as introduced, with the deletion of the adjective "minor," and rejected a "dependent child" amendment as being narrower than then-existing law  a "minor" might not be "dependent" on a parent. Under "Legislative Intent" in the "Summary of Committee Report" it was noted:
 This bill is intended to change the existing wrongful death statute so that all children or parents of a deceased person may recover for their emotional losses.
 S.B. 121 was reported favorably by the Committee and adopted by the Senate, then referred to the House Judiciary Committee.
 On the House of Delegates side, the 1983 action began with H.B. 461, which was a variation on S.B. 156 of 1982. Instead of proposing to delete the references to a "minor" child from § 3-904(d), it left that subsection unchanged. Instead, in its first reader form, it added a new subsection (e):
 For the death of a child, who is not a minor child, the damages awarded may include damages for mental anguish, emotional pain and suffering, loss of society, companionship, comfort, protection, care, attention, advice, counsel, training, or guidance where applicable if:
 (1) The child resides with at least one parent;
 (2) The child was a student enrolled in an educational institution at the time of the child's death; or
 (3) A parent contributed 50 percent or none [sic] of the child's support.
 Delegate Palumbo, the lead sponsor, proposed to substitute for paragraphs (1), (2), and (3), the following:
 (1) The child is 21 years of age or younger.
 (2) A parent contributed 50 percent or more of the child's support.
 And as the bill emerged from the House Judiciary Committee, the conditions attached to subsection (e) were essentially those:
 (1) the child is 21 years old or younger; or
 (2) a parent contributed 50 percent or more of the child's support.
 This version, then, left intact what is now subsection (d), dealing with damages for the death of a spouse, minor child, or parent of a minor child. And it added new subsection (e), dealing with damages for the death of an unmarried child who is not a minor. H.B. 461 passed the House, which also amended S.B. 121 to conform to it. The Senate, in the meantime, passed H.B. 461. Both bills were enacted, with S.B. 121 containing the House language we have just reviewed, eventually becoming Ch. 520.
 When the Judicial Proceedings Committee was considering H.B. 461, in its "Summary of Committee Report" it reported under "Background":
 The bill is similar in its intent to Senate Bill [121] which the Senate has already passed. This House Bill is more narrowly drawn so that it only permits parents to recover for those unmarried children with whom they were likely to have had a close relationship, either because the child was under 21 (i.e., still in college) or because they contributed half of the child's support.
 Whereas under the "Legislative Intent" section it stated:
 This bill intends to compensate parents under the Wrongful Death Act for the death of an unmarried child who is 21 years or younger, or whom the parents supported in a substantial way.
 This legislative history shows that the legislature certainly intended to expand the possibilities of recovery upon the death of a child. It shows, also, concern that there be some limits on the new remedy. At various times these limits were described in terms of residence, educational status, or partial dependency. Eventually, the limits were stated in terms of age or partial dependency.
 The educational provision that was in the introductory version of H.B. 461 tends to suggest that recovery up to age 22 and perhaps even beyond was within the legislative intent. One who enters first grade at age six is likely to graduate from college at an age beyond the twenty-first birthday  and even older, if graduate school is contemplated. Did the substitution of the "21 years old or younger" for the educational (and residential) provisions mean that the legislature intended to reduce the probable age in question, or that it believed the age provision was simply restating in other terms the basic thrust of the educational provision so far as age was concerned, the educational provision itself being unacceptable because of its elitist implications? The history can be read either way. The only thing we can be sure of is that the General Assembly was moving in a remedial direction  its goal was to allow damages not just in connection with the death of a minor child (already provided for in subsection (d)) but to extend recovery to the case of "the death of an unmarried child who is not a minor...." And in light of all this, we turn to the specific language of § 3-904(e)(1).
 IV. "21 Years Old or Younger"
 Section 3-904(e)(1) had not been construed in any reported opinion until the Court of Special Appeals decision in this case.[7] We proceed, therefore, to interpret the phrase "21 years old or younger" without the benefit of much Maryland case law. Like the Court of Special Appeals, we note that "or" serves to establish a contrasting or opposing relationship. Keane v. Carolina Freight Carriers, 70 Md. App. at 302, 520 A.2d at 1144. Since people cannot be both 21 years old and younger at the same time, neither term is surplusage but rather they are descriptive alternatives representing two groups  the set of all people "21 years old" and the set of all people "younger".
 There is no issue concerning the people to be included in the "younger" group  those who are under the age of 21 years. Instead, what we need to examine is the set of people "21 years old" and determine who is in that group. A. Does the set include only people who have not yet reached their twenty-first birthday? B. Does it include only people who have reached the day or moment of their twenty-first birthday? Or, C. Does it include those people who have passed their twenty-first birthday but have not yet reached their twenty-second birthday?
 A. Have Not Yet Reached the Twenty-First Birthday
 This set of people should be considered "younger" and thus not in the "21 years old" set. It was argued, though, that under the common law "one attains a given age at the first moment of the day preceding the anniversary of birth." 86 C.J.S. Time, § 8 (1954). So we could separate those not yet reaching the twenty-first birthday into two subgroups  the group before the eve of the birthday, thus in the "younger" set, and the group having reached the first moment of the eve, but not yet having reached the twenty-first birthday. Therefore, under the common law rule, this set of people "21 years old" would include only a 24 hour time span of people on the eve of their twenty-first birthday.
 B. Day or Moment of the Twenty-First Birthday
 This set of "21 year olds" would include at most a 24 hour time span of people, if one allowed the entire day of the birthday to be included. But, it might only include a moment's span of people if once the anniversary of the time of their birth was passed, they were no longer 21 years old but rather over 21 years old.
 For example, Gregory Keane was born at 3:32 a.m. on 11 March. In the first interpretation, at most he would have had the whole day of 11 March to be considered 21 years old. In the second interpretation, he would have been considered 21 years old only at the moment of 3:32 a.m. on 11 March. After that he would be considered over 21 years old. Could the legislature reasonably have intended the set of people "21 years old"  to include only a day's group of people, or only a moment's group?
 C. Have Reached the Twenty-First Birthday But Not Yet the Twenty-Second
 This set of people encompasses all those in their twenty-first year from their twenty-first birthday up until the eve of their twenty-second. This is the more common or traditional use of the term "21 years old" as referring to one who has not yet reached the twenty-second birthday but is over 21. A person is normally considered 21 throughout the entire birthday year. Thus this set of people would span a time of 365 days (366 in leap years). We believe this gives to the statutory language a meaning consistent with both grammar and legislative purposes.[8]
 To return to history for a moment, the Senate had originally wanted to include all deceased children. The House had wanted to limit recovery to those children still in college. The compromise was to include those children "21 years old or younger". The "traditional" college-age student is in the middle of the junior year if under 21 but in his or her senior year when 21 years old. By interpreting the phrase "21 years old or younger" to include the entire twenty-first year of children 21 years old but under the age of 22 years, we give the fullest effect to both the House and Senate "general purpose, aim, or policy" reflected in the words of the statute. Kaczorowski, 309 Md. at 513, 525 A.2d at 632.[9]
 JUDGMENT AFFIRMED. APPELLANT TO PAY THE COSTS.
 NOTES
 [1] See Md.Code (1984 Repl.Vol., 1987 Cum.Supp.), §§ 3-901 to 3-904 of the Courts and Judicial Proceedings Article. Future citations to specific sections of statutes will be to that Article unless otherwise noted.
 [2] Section 3-904(e) states "For the death of an unmarried child, who is not a minor child, the damages awarded under subsection (c) are not limited or restricted by the `pecuniary loss' or `pecuniary benefit' rule but may include damages for mental anguish, emotional pain and suffering, loss of society, companionship, comfort, protection, care, attention, advice, counsel, training, or guidance where applicable if:
 (1) The child is 21 years old or younger; or
 (2) A parent contributed 50 percent or more of the child's support."
 There was also an award, not at issue here, in favor of Gregory Keane's estate, to compensate it for the emergency medical and funeral expenses.
 [3] The Wrongful Death Act and former Art. 93, §§ 18 and 112 (personal representative's action for funeral expenses, etc.).
 [4] Acts of 1937, Ch. 38, allowed recovery by an illegitimate child for the death of its mother and by the mother for the death of her illegitimate child. Fathers of illegitimate children were not added until the Acts of 1974, Ch. 494.
 [5] Acts of 1952, Ch. 16, allowed recovery by any person related by blood or marriage, who was wholly dependent upon the deceased, if there was no spouse, parent or child of the deceased entitled to recover.
 [6] Unless otherwise noted, information about the history of S.B. 121 of 1983 and its counterpart, S.B. 461, comes from the notes, reports, and summaries in the respective Senate and House Bill files.
 [7] Smith v. United States, 608 F. Supp. 1270 (D.Mass. 1985) allowed recovery of solatium damages under the Maryland Wrongful Death Act when the child, at the time of his death, was 21 years, one month and 22 days old. In that case, however, the construction of § 3-904(e)(1) was not at issue.
 [8] The parties cite various out-of-state decisions construing statutes imposing variously worded age limits. Carolina sees its position supported by Gibson v. People, 44 Colo. 600, 99 P. 333 (1909), and Knott v. Rawlings, 250 Iowa 892, 96 N.W.2d 900 (1959), while the Keanes and the Court of Special Appeals derive comfort from cases like Allen v. Baird, 208 Ark. 975, 188 S.W.2d 505 (1945); People ex rel. Makin v. Wilkins, 22 A.D.2d 497, 257 N.Y.S.2d 288 (N.Y. App. Div. 1965); People v. Cooper, 207 Misc. 845, 143 N.Y.S.2d 855 (1955); Wilson v. Mid-Continental Life Ins. Co. of Oklahoma City, 159 Okl. 191, 14 P.2d 945 (1932); Watson v. Loyal Union Life Ass'n of Muskogee, 143 Okl. 4, 286 P. 888 (1930); and Covell v. State, 143 Tenn. 571, 227 S.W. 41 (1921). These cases are interesting but each involves statutory language and legislative background unlike ours. None of these cases is decisive one way or the other. See Maus v. State, 311 Md. 85, 100, 532 A.2d 1066, 1074 (1987).
 [9] The Statutory Revision Division, Department of Legislative Reference, has developed a Maryland Style Manual for Statutory Law (1985) that at p. 5 offers a precise and clear way of stating the ideas of "younger than a specified age" ("[a]n individual under the age of 12 years ...") and "at least a specified age" ("[a]n individual at least 19 years old...."). Similar guidelines are found, e.g., in the Style Manual of the Commission to Revise the Annotated Code of Maryland (Dec. 1983) at 7 and the Governor's Commission to Revise the Annotated Code of Maryland: Revisor's Manual (2d ed. Nov. 1973) at 42. It is interesting to note that when the legislature has had occasion to translate from cloudy language like that now before us to something more precise, it has adopted essentially the same construction we have. For example, Md.Code (1982 Repl.Vol.) Art. 27, former § 399A read: "In Anne Arundel [and several other counties], any person who is charged with the care of a child age seven (7) or less shall not allow that child to be locked ... in any dwelling...." This was repealed by Ch. 296, Acts of 1984, and reenacted as Md.Code (1984) § 5-801 of the Family Law Art. which in pertinent part read: "(b) A person who is charged with the care of a child under the age of 8 years may not allow the child to be locked ... in a dwelling...."


text:
 16.10.2017
 HR
 Službeni list Europske unije
 C 347/32
 Tužba podnesena 25. srpnja 2017. – TO protiv EEA-a
 (Predmet T-462/17)
 (2017/C 347/41)
 Jezik postupka: francuski
 Stranke
 Tužitelj: TO (zastupnici: N. Lhoëst, odvjetnik)
 Tuženik: Europska agencija za okoliš
 Tužbeni zahtjev
 Tužitelj od Općeg suda zahtijeva da:
 —
 poništi odluku Europske agencije za okoliš (EEA) od 22. rujna 2016. o prestanku radnog odnosa tužitelja kao člana ugovornog osoblja;
 —
 poništi odluku EEA-e od 20. travnja 2017. o odbijanju prigovora tužitelja od 21. prosinca 2016.;
 —
 naloži EEA-i da tužitelju isplati naknadu obračunatu na temelju gubitka plaće u traju od četiri godine umanjeno za naknadu za nezaposlene koju je primio u tom razdoblju;
 —
 naloži EEA-i da tužitelju isplati iznos od 3 500,00 eura s osnova naknade troškova vezanih uz prijevremeni raskid njegovog ugovora o najmu stana u Kopenhagenu, s time da si pridržava pravo povisiti zahtjev ako je to potrebno;
 —
 poništi obračun plaće tužitelja za mjesec rujan 2016., osobito u dijelu u kojem nije obuhvaćena plaća za 22. rujna 2016.;
 —
 naloži EEA-i da tužitelju isplati naknadu u iznosu od 50 000,00 eura s osnove neimovinske štete koja je nastala donošenjem odluke o otkazivanju od 22. rujna 2016.;
 —
 naloži EEA-i da tužitelju isplati naknadu u iznosu od 5 000,00 eura s osnova neimovinske štete koja je nastala time što je EEA prekršila članak 26. Pravilnika o osoblju Europske unije;
 —
 naloži EEA-i da tužitelju isplati naknadu u iznosu od 10 000,00 eura s osnova neimovinske štete koja je nastala uslijed psihičkog pritiska koju je EEA izvršila na njega za vrijeme njegove nesposobnosti za rad;
 —
 podredno, naloži EEA-i da tužitelju isplati naknadu plaće za jednomjesečni otkazni rok i naknadu koja odgovara trećini osnovne mjesečne plaće za svaki mjesec probnog rada koji je izvršio sukladno odredbama članka 84. Uvjeta zaposlenja ostalih službenika;
 —
 naloži EEA-u snošenje svih troškova postupka.
 Tužbeni razlozi i glavni argumenti
 U prilog osnovanosti tužbe tužitelj ističe osam tužbenih razloga.
 1.
 Prvi tužbeni razlog, koji se temelji na neprimjenjivosti članka 48. točke (b) Uvjeta zaposlenja ostalih službenika.
 2.
 Drugi tužbeni razlog, koji se temelji na povredi članka 48. točke (b) i članka 16. stavka 2. Uvjeta zaposlenja ostalih službenika.
 3.
 Treći tužbeni razlog, koji se temelji na prigovoru nezakonitosti zbog diskriminacije u odnosu na članak 48. točku (b) Uvjeta zaposlenja ostalih službenika.
 4.
 Četvrti tužbeni razlog, koji se temelji na povredi članka 26. Pravilnika i na povredi prava obrane.
 5.
 Peti tužbeni razlog, koji se temelji na povredi Uredbe (EZ) br. 45/2001 Europskog parlamenta i Vijeća od 18. prosinca 2000. o zaštiti pojedinaca u vezi s obradom osobnih podataka u institucijama i tijelima Zajednice i o slobodnom kretanju takvih podataka (SL 2001., L 8, str. 1.) (SL, posebno izdanje na hrvatskom jeziku, poglavlje 13., svezak 34., str. 6.) i članka 8. Povelje Europske unije o temeljnim pravima.
 6.
 Šesti tužbeni razlog, koji se temelji na povredi članka 84. Uvjeta zaposlenja ostalih službenika, članka 41. Povelje Europske unije o temeljnim pravima i obveze dužne pažnje.
 7.
 Sedmi tužbeni razlog, koji se temelji na očitoj pogrešci u ocjeni.
 8.
 Osmi tužbeni razlog, koji se temelji na zlouporabi ovlasti.


type: other

text:
Dom Arkiv - IntegraLaw
 Er din open source-licensaftale nu også en open source-lincensaftale?
 Med open source software har du adgang til kildekoden og kan ændre i den, men open source er ikke en beskyttet betegnelse, og du bør derfor være opmærksom på, hvad du reelt får. Open source-licensen er en aftale på lige fod med alle andre typer aftaler, din virksomhed har indgået og du skal derfor se [...]
 Er din open source-licensaftale nu også en open source-lincensaftale? piccoline 2017-06-17T12:39:12+00:00
 Integra kunde vinder i Højesteret
 Højesteret har givet en Integra kunde fuldt medhold i, at vores kunde ikke anvendte erhvervshemmeligheder, da han gjorde sin opfindelse og skrev sine patentansøgninger. Der er tale om en meget kompliceret og omfattende sag, der har verseret i mere end 6 år for domstolene. Sagen endte den 23. juni 2015 med fuld frifindelse af vores [...]
 Integra kunde vinder i Højesteret robert.adm 2016-04-01T07:58:23+00:00
 Integra advokat oplægsholder på iværksætterkonference
 Et af konferencens emner var samarbejde mellem iværksættere og etablerede virksomheder. Ud over Robert Jønsson fra Integra advokater deltog bl.a. Jens Ole Pedersen fra Philips Healthcare. Læs mere om konferencen her.
 Integra advokat oplægsholder på iværksætterkonference admin 2017-04-16T12:13:57+00:00
 Integra kunde uberettiget bortvist ifølge Højesteret
 Højesteret gav vores kunde medhold i at en bortvisning var uberettiget. Højesteret lempede til gengæld beviskravene for, at en afskedigelse ikke er i strid med ligebehandlingsloven i forhold til kendt praksis og den indankede dom. Højesteret nåede i sagen frem til, at da der var tale om en masseafskedigelse og da den ansattes projekt ikke [...]
 Integra kunde uberettiget bortvist ifølge Højesteret admin 2015-03-02T20:28:39+00:00


type: wikipedia

text:
Hamerský dub je památný strom nedaleko osady Nový Hamr u Trhanova. Zdravý, přibližně stopadesátiletý dub letní (Quercus robur) roste v remízku mezi poli, severovýchodně od osady, v nadmořské výšce 460 m. Obvod jeho kmene měří 405 cm a koruna dosahuje do výšky 22,5 m (měření 1994). Strom je chráněn od roku 1987 pro svůj vzrůst, estetickou hodnotu a jako krajinná dominanta.
 Stromy v okolí
 Trhanovská alej
 Související články
 Seznam památných stromů v okrese Domažlice
 Externí odkazy
 Strom v evidenci památných stromů Agentury ochrany přírody a krajiny ČR
 Památné duby letní
 Památné duby v okrese Domažlice
 Památné stromy v Podčeskoleské pahorkatině
 Újezd (okres Domažlice)


text:
Ryanair ir Perfect Gateways pradeda projektą
 Ryanair ir Perfect Gateways pradeda projektą „Garantuojame geriausią kainą atostogų būstui“
 Taupyk užsisakinėdamas be tarpininkų per RyanairLettings.com
 Ryanair, mėgstamiausios oro linijos pasaulyje, šiandien (vasario 8d.) su partneriu Perfect Gateways, lyderiaujančiu atostogų būsto paieškos operatoriumi, pristatė savo atostogų būsto tinklalapį www.RyanairLettings.com, su tikslu garantuoti geriausias kainas atostogų būstui tiems, kurie ieško vilų, kotedžų ar apartamentų puikia kaina.
 Perfect Gateways jau pateikia daugiau kaip 1000 puikių būstų nuomai kurortuose, miestų centruose ir kaimo vietovėse, įskaitant tokias populiarias vietas kaip Italija, Prancūzija, Ispanija ar Portugalija, kuriuos galima užsisakyti www.RyanairLettings.com arba Ryanair.com.
 Nekilnojamojo turto savininkai gali užsiregistruoti tinklalapyje RyanairLettings.com. Skirtingai nuo kitų atostogų būstų paieškos operatorių, čia nėra jokių metinių abonementų ar nario įstojimo mokesčių nekilnojamojo turto savininkams.
 Ryanair, Sinead Finn:
 "Šiais metais 73 milijonai keleivių užsisakys skrydžius už garantuotai geriausią kainą tinklalapyje Ryanair.com. Dabar, dėka partnerystės su Perfect Gateways, Ryanair keleiviai gali sutaupyti dar daugiau, užsisakinėdami atostogų būstus RyanairLettings.com. Taigi, pasitelkus Ryanair oro linijų siūlomus pigiausius skrydžius ir Perfect Getaways garantuotai geriausias kainas būstui, atostogautojai gali pasprukti iš namų pigiau nei kada nors anksčiau".
 Dave Palmer, Ryanair Lettings.com Pardavimų vadovas:
 "RyanairLettings.com suteikia atostogautojams galimybę užsisakyti "puikius namus" atostogų metu už geriausią kainą. Tai taip pat nuostabi žinia tiems, kurie turi nekilnojamojo turto nuomos tikslais, jie gali pritraukti atostogautojus be jokių papildomų mokesčiu ar komisinių kelionių agentūroms.“


text:
Lamordé III est une localité du Cameroun située dans l'arrondissement de Bourrha, le département du Mayo-Tsanaga et la région de l’Extrême-Nord, à proximité de la frontière avec le Nigeria. Elle fait partie du canton de Guili.
 Population
 Lors du recensement de 2005, on y a dénombré .
 Notes et références
 Annexes
 Bibliographie
 Dictionnaire des villages du Margui-Wandala, ORSTOM, Yaoundé, , 115 p.
 Plan communal de développement de Bourha, , 171 p.
 Liens externes
 Bourrha, sur le site Communes et villes unies du Cameroun (CVUC)
 Village dans la région de l'Extrême-Nord


text:
Frederik Nicolai Jensen (né le à Bergen, mort le à Steigen) est un peintre norvégien.
 Biographie
 Jensen, fils de Jens Johann Jensen (1774-1824), né à Husum, et de son épouse Johanne Marie Prom (1793-1878), est élève de l'école de la cathédrale de sa ville natale de Bergen comme son frère, qui devient plus tard un homme politique Christian Jensen (1823-1884). En 1840, il obtient un diplôme en théologie. En 1841, il s'inscrit pour étudier la peinture à l'académie des beaux-arts de Düsseldorf, après avoir déjà suivi des cours de peinture de paysage à Bergen auprès de (1800–1854). À Düsseldorf, Karl Ferdinand Sohn est son professeur le plus important. Il a aussi Rudolf Wiegmann comme professeur. En 1844, à la fin de ses études à l'académie de Düsseldorf, Jensen s'associe à Gustav Jacob Canton, Henry Ritter, Rudolf Jordan, Hans Fredrik Gude, Rudolf von Normann et Wilhelm Camphausen pour former le groupe Crignic, groupe démocrate et critique de l'Académie. Le nom est formé à partir des initiales de ses membres. Ce groupe est considéré comme le précurseur de Malkasten, fondée en 1848. Jensen quitte Düsseldorf en 1845.
 Après des séjours à Munich, où il rencontre sa femme Ursula Franziska Reuter, née Schwaighart (1821-1910), et après un voyage en Italie, Jensen retourne à Bergen et tente de gagner sa vie en tant que portraitiste. Il s'intéresse aussi au théâtre. Il aide le musicien Ole Bull à fonder le Norske Theatre en 1849-1850 en formant des acteurs amateurs. Le Norske Theatre sera Den Nationale Scene, le plus ancien théâtre de Norvège.
 En 1854, il accepte un poste de pasteur à Bø (Nordland), en 1863, il s'installe au presbytère de Steigen. Le fait qu'il peint encore à cette époque est illustré par le retable qu'il crée en 1869-1870, un triptyque pour l'église de Vågan à Kabelvåg sur les îles Lofoten. Il montre Jésus à Gethsémani fortifié par un ange (Lc 22:43 UE), entouré des disciples endormis.
 De 1862 à 1864, Jensen est aussi homme politique. Pendant ce temps, il représente les électeurs du district de Nordland en tant que membre du Storting. En tant qu'écrivain philosophique, il ne se fait connaître qu'en 1874 grâce à l'ouvrage publié à titre posthume par .
 Notes et références
 Liens externes
 Peintre norvégien
 Peintre paysagiste norvégien
 Peintre d'histoire
 Peintre portraitiste norvégien
 Membre du Storting
 Pasteur luthérien
 Naissance en juin 1818
 Naissance à Bergen (Norvège)
 Décès en novembre 1870
 Décès à 52 ans
 Décès au Nord-Norge


text:
Etusivu » 2020 » toukokuu » 21
 Päivittäiset arkistot: 21 toukokuun, 2020
 121 artikkelia
 Tiesitkö, että lihan voi paistaa myös majoneesissa voin sijaan? Testaa amerikkalaiskokin vinkki! Videolla kokki Kari Aihinen. Alentunut Vastustuskyky Mabthera Ja Alkoholi Proforma Lasku Proforma-lasku. Kirjoittaja: Jarkko Kähkönen Päivitetty yli viikko sitten Hyvityslaskun luominen koko myyntilaskusta. Kirjoittaja: Jarkko Kähkönen Päivitetty yli viikko sitten Monivaluuttatuki, myyntilaskut. Kirjoittaja: Jarkko Kähkönen Päivitetty yli viikko [...]
 Suomen tivoli kilpailee eri sarjassa kuin perinteiset huvipuistot. Olen itse käynyt Suomen tivolissa yli 30 vuoden ajan ja siinä rinnalla ulkomaila ja kotimaassa ei puistoissa. Valitettavasti viime vuosina oman jälkikasvuni kanssa olen myös huomannut, että Suomen tivolin turvajärjestelyt eivät ole samalla tasolla kuin oikeiden huvipuistojen. Suomen Tivoli. Nuigi. 20.05.2013 20:24. [...]
 Mabthera Ja Alkoholi Proforma Lasku Proforma-lasku. Kirjoittaja: Jarkko Kähkönen Päivitetty yli viikko sitten Hyvityslaskun luominen koko myyntilaskusta. Kirjoittaja: Jarkko Kähkönen Päivitetty yli viikko sitten Monivaluuttatuki, myyntilaskut. Kirjoittaja: Jarkko Kähkönen Päivitetty yli viikko sitten Intuitiivinen rationaalisuus Skorpioni 23.10.–22.11. – Sinä pidät haasteista ja niitä sinä myös itsellesi järjestät tällä viikolla. Eikä [...]
 Malli Työhakemus Mikä Viikko On Sosiaali- ja terveysministeriön asettama koronaepidemian tilannekuva- ja mallinnusryhmä julkaisee tänään perjantaina. Konkurssihakemuksia on tullut alkuvuonna yli 1100 yrityksestä, noin 10 prosenttia viimevuotista enemmän. Suomen Yrittäjien. Etuovi Lappi Etuovi Lappi 10 huhtikuun, 2020 kirjoittaja admin Meta Analyysi Janne Leinonen Karismaattisuus Myydään Aasi Jasper Pääkkönen Spike Lee [...]
 Proforma Lasku Proforma-lasku. Kirjoittaja: Jarkko Kähkönen Päivitetty yli viikko sitten Hyvityslaskun luominen koko myyntilaskusta. Kirjoittaja: Jarkko Kähkönen Päivitetty yli viikko sitten Monivaluuttatuki, myyntilaskut. Kirjoittaja: Jarkko Kähkönen Päivitetty yli viikko sitten Intuitiivinen rationaalisuus Skorpioni 23.10.–22.11. – Sinä pidät haasteista ja niitä sinä myös itsellesi järjestät tällä viikolla. Eikä sinua haittaa yhtään, [...]
 Itsemurhatilastot ovat kääntyneet laskuun, mutta niihin kuolee yhä paljon enemmän ihmisiä kuin liikenneonnettomuuksiin. Vuonna 2012 liikenneonnettomuuksissa kuoli 255 henkeä. Vastaavasti samana vuona itsemurhan teki 873 henkeä. – Tästä pitää voida puhua. Tämä. Mikä Viikko On Sosiaali- ja terveysministeriön asettama koronaepidemian tilannekuva- ja mallinnusryhmä julkaisee tänään perjantaina. Konkurssihakemuksia on tullut alkuvuonna [...]
 Proforma-lasku. Kirjoittaja: Jarkko Kähkönen Päivitetty yli viikko sitten Hyvityslaskun luominen koko myyntilaskusta. Kirjoittaja: Jarkko Kähkönen Päivitetty yli viikko sitten Monivaluuttatuki, myyntilaskut. Kirjoittaja: Jarkko Kähkönen Päivitetty yli viikko sitten Intuitiivinen rationaalisuus Skorpioni 23.10.–22.11. – Sinä pidät haasteista ja niitä sinä myös itsellesi järjestät tällä viikolla. Eikä sinua haittaa yhtään, vaikket niistä [...]
 Omenoista saa kuivaamalla hyvää naposteltavaa tai täydennystä mysliin. Kuivatut omenanpalat ja -viipaleet ovat tiivistä tavaraa, jossa useimpia hyödyllisiä ainesosia on suhteessa enemmän kuin tuoreessa omenassa. Nopeimmin ja helpoimmin omenien kuivaus onnistuu erityisellä kasvikuivurilla. Myös. Kuivatut omenalastut ovat täydellinen herkku – katso helppo ohje. Jaa. Facebook. Twitter. Whatsapp. Email. Kopioi linkki. [...]
 Mikä Viikko On Sosiaali- ja terveysministeriön asettama koronaepidemian tilannekuva- ja mallinnusryhmä julkaisee tänään perjantaina. Konkurssihakemuksia on tullut alkuvuonna yli 1100 yrityksestä, noin 10 prosenttia viimevuotista enemmän. Suomen Yrittäjien. Etuovi Lappi Etuovi Lappi 10 huhtikuun, 2020 kirjoittaja admin Meta Analyysi Janne Leinonen Karismaattisuus Myydään Aasi Jasper Pääkkönen Spike Lee Euroviisu Tulokset [...]
 Operaattorit tiedottivat huhtikuun myydyimmistä puhelinmalleista. Uusina tulokkaina ovat nyt 5g-puhelimet. Galaxy A40 säilyi. Mikä Viikko On Sosiaali- ja terveysministeriön asettama koronaepidemian tilannekuva- ja mallinnusryhmä julkaisee tänään perjantaina. Konkurssihakemuksia on tullut alkuvuonna yli 1100 yrityksestä, noin 10 prosenttia viimevuotista enemmän. Suomen Yrittäjien. Etuovi Lappi Etuovi Lappi 10 huhtikuun, 2020 kirjoittaja admin [...]
 Sosiaali- ja terveysministeriön asettama koronaepidemian tilannekuva- ja mallinnusryhmä julkaisee tänään perjantaina. Konkurssihakemuksia on tullut alkuvuonna yli 1100 yrityksestä, noin 10 prosenttia viimevuotista enemmän. Suomen Yrittäjien. Etuovi Lappi Etuovi Lappi 10 huhtikuun, 2020 kirjoittaja admin Meta Analyysi Janne Leinonen Karismaattisuus Myydään Aasi Jasper Pääkkönen Spike Lee Euroviisu Tulokset Eurovision laulukilpailu 2007 [...]
 rationaalisuus Skorpioni 23.10.–22.11. – Sinä pidät haasteista ja niitä sinä myös itsellesi järjestät tällä viikolla. Eikä sinua haittaa yhtään, vaikket niistä heti. ”Mistä tietää, että on menestynyt? Siitä, että saat puukkoja edestä, sivuilta ja takaa”, kuvataiteilija Soile Yli-Mäyry sanoo. Yksisuuntaisen Tien Tunnistaminen Alati kasvava lentoliikenne Kansainvälinen Ilmakuljetusliitto IATA arvioi lentomatkustajien [...]
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 intuitiivinen ihminen
 Alati kasvava lentoliikenne Kansainvälinen Ilmakuljetusliitto IATA arvioi lentomatkustajien määrän kaksinkertaistuvan nykyisestä eli kasvavan seitsemään miljardiin vuonna 2034. Sakkausvaroitin ulvoi, kone kallistui 90 astetta, vasen siipi osui tien kaiteeseen. Etuovi Lappi Etuovi Lappi 10 huhtikuun, 2020 kirjoittaja admin Meta Analyysi Janne Leinonen Karismaattisuus Myydään Aasi Jasper Pääkkönen Spike Lee Euroviisu Tulokset [...]
 Blackberry Suomeksi Blackberry Bold. 20,95 € 20.95. Yritystilaus . Loppu varastosta. Valitse ‘UPS express-toimitus’ ostoskorin toisessa vaiheessa. Toimituskulut alkaen € Ostoskoriin. Palvelemme suomeksi maanantaista torstaihin klo 10.00–12.00. YourSurprise. Gouwepoort 3 4301 RZ. Ratsastusliitto Turun Tehohuolto Internetissä Gosford Park Gosford is a New South Wales suburb located in the heart of [...]
 Etuovi Lappi 10 huhtikuun, 2020 kirjoittaja admin Meta Analyysi Janne Leinonen Karismaattisuus Myydään Aasi Jasper Pääkkönen Spike Lee Euroviisu Tulokset Eurovision laulukilpailu 2007 oli 52. järjestetty Eurovision laulukilpailu. Rauma: tällä hetkellä 24 kpl vapaita toimitiloja, tutustu tästä! Kauppalehden toimitilahaku löytää vapaat myytävät ja vuokrattavat toimitilat helposti ja nopeasti. Kartalta näet [...]