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FILE - In this Wednesday, Nov. 23, 2016, file photo, players of Brazil's Chapecoense celebrate at the end of a Copa Sudamericana semifinal soccer match against Argentina's San Lorenzo in Chapeco, Brazil.... (Associated Press)

 FILE - In this Wednesday, Nov. 23, 2016, file photo, players of Brazil's Chapecoense celebrate at the end of a Copa Sudamericana semifinal soccer match against Argentina's San Lorenzo in Chapeco, Brazil. A chartered aircraft with 81 people on board, including the Brazilian first division Chapecoense... (Associated Press)

 MEDELLIN, Colombia (AP) — A chartered plane with a Brazilian first division soccer team crashed near Medellin while on its way to the finals of a regional tournament, killing 76 people, Colombian officials said Tuesday. Five people survived.

 The British Aerospace 146 short-haul plane, operated by a charter airline named LaMia, declared an emergency at 10 p.m. Monday (0300 GMT) because of an electrical failure, aviation authorities said.

 The aircraft, which had departed from Santa Cruz, Bolivia, was transporting the Chapecoense soccer team to Medellin's Jose Maria Cordova airport.

 The team, from southern Brazil and which had started its journey in Sao Paulo, was scheduled to play Wednesday in the first of a two-game Copa Sudamericana final against Atletico Nacional of Medellin.

 It wasn't immediately clear if the team switched planes in Bolivia or just made a stopover with the same plane.

 "What was supposed to be a celebration has turned into a tragedy," Medellin Mayor Federico Gutierrez said from the search and rescue command center.

 The club said in a brief statement on its Facebook page that "may God accompany our athletes, officials, journalists and other guests traveling with our delegation."

 Brazil as well as South America's soccer federation extended its condolences to the entire Chapecoense community and said its president, Luis Dominguez, was on his way to Medellin. All soccer activities were suspended until further notice, the organization said in a statement.

 Elkin Ospina, mayor of La Ceja, near where the crash took place, said rescuers working through the night had been heartened after pulling three passengers alive from the wreckage.

 Authorities and rescuers were immediately activated but an air force helicopter had to turn back because of low visibility. Heavy rainfall complicated the nighttime search, and authorities urged journalists to stay off the roads so ambulances and other rescuers could reach the site.

 Images broadcast on local television showed three male passengers arriving to a local hospital in ambulances on stretchers and covered in blankets connected to an IV. All were apparently alive and one of them was reportedly a Chapecoense defender named Alan Ruschel.

 The plane was carrying 72 passengers and nine crew members, aviation authorities said in a statement. Local radio said the same aircraft transported Argentina's national squad for a match earlier this month in Brazil, and previously had transported Venezuela's national team.

 British Aerospace, which is now known as BAE Systems, says that the first 146-model plane took off in 1981 and that just under 400 — including the successor Avro RJ — were built in total in the U.K. through 2003. It says around 220 of are still in service in a variety of roles, including aerial firefighting and overnight freight services.

 A video published on the team's Facebook page showed the team readying for the flight earlier Monday in Sao Paulo's Guarulhos international airport.

 The team, from the small city of Chapeco, was in the middle of a fairy tale season. It joined Brazil's first division in 2014 for the first time since the 1970s and made it last week to the Copa Sudamericana finals — the equivalent of the UEFA Europa League tournament — after defeating two of Argentina's fiercest squads, San Lorenzo and Independiente, as well as Colombia's Junior.

 The team is so modest that its 22,000-seat arena was ruled by tournament organizers too small to host the final match, which was instead moved to a stadium 300 miles (480 kilometers) to the north in the city of Curitiba.

 "Chapecoense was the biggest source of happiness in the town," the club's vice-president, Ivan Tozzo, told Brazil's SporTV. "Many in the town are crying."

 ___

 Joshua Goodman reported from Bogota. Associated Press writer Mauricio Savarese contributed to this report from Rio de Janeiro. ||||| LA UNION, Colombia/CHAPECO, Brazil (Reuters) - The pilot of a LAMIA Airlines plane that crashed in Colombia, virtually wiping out a Brazilian soccer team, had radioed that he was running out of fuel and needed to make an emergency landing, according to the co-pilot of another plane in the area.

 The crash on Monday night killed 71 people. Six survived, including just three members of the Chapecoense soccer squad en route to the biggest game in their history, the Copa Sudamericana final.

 Avianca co-pilot Juan Sebastian Upegui said in a chat message with friends that the LAMIA pilot told the control tower at the airport in Medellin that he was in trouble.

 Priority had already been given to a plane from airline VivaColombia, which had also reported problems, Upegui said. Reuters confirmed the audio message, which local media played on Wednesday, was from Upegui.

 After reporting being low on fuel, the LAMIA pilot then said he was experiencing electrical difficulties before the radio went silent.

 “Mayday mayday ... Help us get to the runway ... Help, help,” Upegui described the pilot as saying. “Then it ended ... We all started to cry.”

 The BAe 146, made by BAE Systems Plc, slammed into a mountainside. Besides the three players, a journalist and two crew members survived.

 One survivor, Bolivian flight technician Erwin Tumiri, said he only saved himself by strict adherence to security procedure, while others panicked.

 “Many passengers got up from their seats and started yelling,” he told Colombia’s Radio Caracol. “I put the bag between my legs and went into the fetal position as recommended.”

 Bolivian flight attendant Ximena Suarez, another survivor, said the lights went out less than a minute before the plane slammed into the mountain, according to Colombian officials in Medellin.

 Of the players, goalkeeper Jackson Follmann was recovering from the amputation of his right leg, doctors said.

 Another player, defender Helio Neto, remained in intensive care with severe trauma to his skull, thorax and lungs.

 Fellow defender Alan Ruschel had spine surgery.

 Suarez and Tumiri were shaken and bruised but not in critical condition, medical staff said, while journalist Rafael Valmorbida was in intensive care for multiple rib fractures that partly collapsed a lung.

 Investigators from Brazil have joined Colombian counterparts to check two black boxes from the crash site on a muddy hillside in wooded highlands near the town of La Union.

 Bolivia, where LAMIA is based, and the United Kingdom also sent experts to help the probe.

 HOMAGES PLANNED

 The plane “came over my house, but there was no noise,” said Nancy Munoz, 35, who grows strawberries in the area. “The engine must have gone.”

 Wreckage from a plane that crashed into Colombian jungle with Brazilian soccer team Chapecoense, is seen near Medellin, Colombia, November 29, 2016. REUTERS/Fredy Builes

 By Wednesday morning, rescuers had recovered all of the bodies, which were to be sent to Brazil and Bolivia. All of the crew members were Bolivian.

 Forty-five of the bodies have been identified, Colombian officials said.

 Soccer-mad Brazil declared three days of mourning.

 It was a bitter twist to a fairy-tale story for Chapecoense. Since 2009, the team rose from Brazil’s fourth to top division and was about to play the biggest match in its history in the first leg of the regional cup final in Medellin.

 Global soccer greats from Lionel Messi to Pele sent condolences.

 In the small city of Chapecó in remote southern Brazil, black and green ribbons were draped on fences, balconies and restaurant tables. Schools canceled classes, and businesses closed.

 “It’s a miracle,” Flavio Ruschel, the father of Alan Ruschel, told Globo News as he prepared to fly to Colombia. “I don’t think I’ll be able to speak, just hug him and cry a lot.”

 Black banners hung from a cathedral downtown and wrapped around a 14-meter statue of one of the town’s founding explorers.

 Outside the team’s Conda stadium, a group of hardcore fans put up a tent and promised to keep vigil until the bodies of their idols returned to the city.

 “We were there for them in victory, and we’re here for them in tragedy, rain or shine,” said fan Caua Regis. “Like family.”

 Slideshow (10 Images)

 The club is planning an open wake at their stadium, a city official said.

 A homage was also planned for later on Wednesday at the stadium in Medellin of Atletico Nacional, which had been due to play Chapecoense in the regional final in the evening.

 The Colombian team wants the trophy to be given to Chapecoense in honor of the dead.

 “As far as we are concerned,” the team said, “Chapecoense will forever be the champions of the Copa Sudamericana Cup 2016.” ||||| 05:28

 Raimundo Colombo, the governor of Santa Catarina, where the Chapecoense team is based, has issued a statement expressing his profound regret.

 Colombo noted that Chapecoense were not only representing the city of Chapecó and the state of Santa Catarina, but were also making history as the first club from the region to reach the final of an international competition.

 He said he was in “state of shock” and expressed his solidarity with the families of the players, club officials and journalists who formed the delegation “at what is a time of great pain for the sporting community in Santa Catarina and in Brazil”.

 Nivaldo, a Brazilian goalkeeper who has been at the club since 2006 but did not travel to Colombia, told the UOL Esporte website that he was woken at 5am this morning by a phonecall from a worried friend who wanted to know if he was on the flight.

 Nivaldo said he had tried to call his teammates and other club staff who were on the plane but that nobody picked up the phone.

 The wife of one Brazilian survivor has used Instagram to express her relief. Amanda Ruschel, who is married to Alan Ruschel, the first player to be taken to hospital, posted an image of the player alongside the message:

 “Thank God Alan is in the hospital, stable. We are praying for all of those who were not yet rescued and offer our support to all their relatives. This is a complicated, difficult situation. Only God himself can give us strength. 🏻 Thank you God.” |||||
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– A chartered plane with a Brazilian first division soccer team on board crashed in a mountainous area near Medellin while on its way to the finals of a regional tournament, killing 76 people, Colombian officials say. Five people survived, including three players, reports Reuters. Aviation authorities say the British Aerospace 146 short-haul plane, operated by a charter airline named LaMia, declared an emergency at 10pm because of an electrical failure, the AP reports. The aircraft, which had departed from Santa Cruz, Bolivia, was transporting the Chapecoense soccer team to Medellin's Jose Maria Cordova International Airport. The team started the journey in Sao Paulo. A Reuters photographer described the tail section as having been severed from the plane and totally destroyed. The team, from the small city of Chapeco, was in the middle of a fairy-tale season. It joined Brazil's first division in 2014 for the first time since the 1970s and made it last week to the Copa Sudamericana finals after defeating two of Argentina's fiercest squads, San Lorenzo and Independiente, as well as Colombia's Junior. "What was supposed to be a celebration has turned into a tragedy," Medellin Mayor Federico Gutierrez said from the search-and-rescue command center. "May God accompany our athletes, officials, journalists, and other guests traveling with our delegation," the club said in a brief statement on its Facebook page. The Guardian reports Brazilian President Michel Temer has declared three days of mourning.


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(CNN) The Senate Judiciary Committee will vote on whether to favorably recommend Brett Kavanaugh's nomination to the Supreme Court as previously scheduled Friday morning, though top GOP senators did not know as of Thursday night whether enough key Republican votes had been convinced to confirm President Donald Trump's nominee.

 Kavanaugh's supporters and critics are now closely watching a handful of key Republican senators as they decide whether to support the nominee, following a day-long, blockbuster hearing that featured both Kavanaugh and the woman who accused him of sexual assault.

 The vote scheduled for Friday morning means undecided GOP members of the committee -- including Arizona Republican Sen. Jeff Flake -- have just hours to publicly choose a side in a deeply polarizing political fight.

 As of Thursday night, Flake -- who also met earlier with fellow key votes Republican Sens. Susan Collins and Lisa Murkowski and Democratic Sen. Joe Manchin -- told reporters, "There's more doubt than certainty moving ahead."

 "This isn't easy for anybody," Flake told reporters. "Some of us have been talking for a while -- similar questions I guess."

 When asked if he thought more time before the deadline would help with his decision, Flake said he didn't know.

 "When you have more time, you look at what more time has done in the past couple of days in term of ludicrous allegations, some of which have been recanted. Others just were anonymous to begin with, and what does that do to the accused. Just to give it more time. I don't know. You have to weigh those things, You have to weigh all those things."

 GOP senators told reporters that members meeting behind closed doors said the committee vote would happen as previously scheduled Friday morning and that the first procedural vote will take place on the Senate floor Saturday. GOP leaders had pushed for a full Senate vote on Tuesday, October 2.

 Senate Majority Leader Mitch McConnnell would not confirm if he had the votes following a conference wide meeting Thursday night.

 When asked if he was confident the nomination would advance out of committee, he replied: "well the next step is the committee will be voting in the morning."

 He added, "We're optimistic, basically."

 'We're meeting at 9:30'

 Senate Judiciary Committee chairman Chuck Grassley declined to answer questions Thursday night from reporters as he repeatedly said, "we're meeting at 9:30" -- a reference to the committee meeting where the panel is scheduled to vote on whether to give Kavanaugh a favorable recommendation.

 When asked by the media if the nomination will come to the full Senate floor for a vote, Grassley responded "Depends on what happens tomorrow."

 Republicans can advance Kavanaugh's without any support from Democrats, but given their 51-49 seat majority in the chamber, Kavanaugh's supporters can only lose one vote and still advance his nomination.

 Sen. John Cornyn, who as majority whip is the second-ranking GOP member in the chamber, expressed optimism following a Republican meeting Thursday night that Kavanaugh's nomination will be favorably reported out of the committee on schedule.

 Asked if he is confident that Kavanaugh can advance out of the committee, he said, "I am optimistic, yes."

 At least one long-undecided Republican senator, Bob Corker of Tennessee, announced his support for Kavanaugh just before 9 p.m. ET on Thursday night.

 "While both individuals provided compelling testimony, nothing that has been presented corroborates the allegation," Corker said in his announcement. "There is no question that Judge Kavanaugh is qualified to serve on the Supreme Court, and in a different political environment, he would be confirmed overwhelmingly."

 Four key senators meet

 The meeting of Flake, Collins, Manchin and Collins occurred less than hour after Kavanaugh finished his testimony before the Judiciary Committee , where he forcefully and passionately maintained his innocence and defiantly challenged Democratic senators who grilled him on multiple allegations of inappropriate behavior.

 On Thursday morning, that same committee heard from Ford, who she said was "100%" certain Kavanaugh sexually assaulted her when they were teenagers in the 1980s. In Kavanaugh's testimony, he also said he was "100%" sure he did not sexual assault anyone.

 Collins and Murkowski have appeared to be the most outspoken Republican senators in seeking additional investigation into the allegations of inappropriate behavior that have surfaced against Kavanaugh in recent days.

 Multiple sources familiar with a private Wednesday meeting -- the night before the hearing -- told CNN that Collins appeared unnerved by the latest allegations, citing in particular that a sworn statement from accuser Julie Swetnick sent to the panel, which carries with it the possibility of perjury for lying to Congress. At that Wednesday meeting of Republican chairmen, GOP leaders tried to reassure Collins, keenly aware of the critical role she plays.

 When asked by reporters earlier this week whether there should be a full FBI investigation into the allegations, Murkowski responded, "It would sure clear up all the questions, wouldn't it?"

 On Thursday night, Murkowski said she was leaving to think over the nomination at home.

 "I'm going to go home, have dinner and have a chance to think about all that's gone on today," Murkowski told reporters.

 Manchin is up for re-election this fall in a state Donald Trump won overwhelmingly and supported Trump's last Supreme Court nominee Neil Gorsuch. Manchin was among a handful of Democrats from red and purple states that Kavanaugh supporters were targeting as possible votes.

 "We are still talking," Manchin told CNN leaving that meeting. "There are no decisions on anything. There are some concerns that people have and we're going to try to close the loop." ||||| "His testimony was powerful, honest, and riveting," President Donald Trump wrote on Twitter of his Supreme Court nominee Brett Kavanaugh's testimony. | Saul Loeb/AFP/Getty Images White House Trump thrilled at Kavanaugh defiance The president applauds a Trumpian defense from his nominee — but some White House allies are concerned by his accuser's 'credible' performance.

 President Donald Trump and his aides were ebullient Thursday as Supreme Court nominee Brett Kavanaugh defiantly rejected charges of sexual misconduct — a mood that reflected some relief after Trump officials conceded that his accuser, Christine Blasey Ford, offered a compelling performance in the first half of the day.

 Trump and senior officials were impressed by Kavanaugh’s combative defense before the Senate Judiciary Committee, in which the Trump nominee, alternating between fury and tears, called several misconduct charges against him a “calculated and orchestrated political hit” and “national disgrace” that had devastated his life and family.

 Story Continued Below

 Minutes after the committee adjourned Thursday evening, Trump tweeted that his nominee "showed America exactly why I nominated him."

 "His testimony was powerful, honest, and riveting," Trump wrote. "Democrats' search and destroy strategy is disgraceful and this process has been a total sham and effort to delay, obstruct, and resist. The Senate must vote!"

 Playbook PM Sign up for our must-read newsletter on what's driving the afternoon in Washington. Email Sign Up By signing up you agree to receive email newsletters or alerts from POLITICO. You can unsubscribe at any time.

 That capped something of a roller-coaster day for a White House that had watched in the morning as Ford gave a powerful and disturbing account of what she said was a sexual assault by Kavanaugh when the two were high school students at a party in the 1980s.

 "She seems sincere, kind, thoughtful and credible," a former Trump White House official said. "Hard to suggest she is politically motivated."

 Trump, who watched the hearing aboard Air Force One on his flight back to Washington from New York City early in the day, refrained from tweeting until the day’s proceedings had ended shortly before 7:00 p.m. Some of his aides fretted early in the day as Trump watched CNN and Fox News commentary suggesting that Ford’s testimony — and what officials called a disappointing performance by a female prosecutor hired by Judiciary Committee Republicans to question her — might tip the balance against Kavanaugh’s troubled nomination.

 Kavanaugh said he did not share his fiery opening remarks with anyone except a law clerk, and a White House official said his defiant tone when he initially addressed the committee after lunch caught many in the building by surprise.

 But Trump was elated when Kavanaugh, whom he previously complained was not defending himself with enough force, lashed out at Democrats and the media for what Kavanaugh called casual character assassination.

 One senior White House official said Kavanaugh seemed to have tapped into a key element of Trump’s own personal style: hit back hard and without apology.

 “What do you like to drink, Senator?” Kavanaugh angrily asked one questioner, Sen. Sheldon Whitehouse (D-R.I.).

 “I think he’s studied the way people around Donald Trump have been treated and he figured out a way to prevail,” said the official. The official confirmed that Trump had watched and relished Kavanaugh’s combative opening statement, which the official called “superb.”

 poster="http://v.politico.com/images/1155968404/201809/770/1155968404_5841121077001_5841119722001-vs.jpg?pubId=1155968404" true

 Some of Kavanaugh’s rhetoric also echoed comments of the president at a news conference the day earlier, in which Trump lambasted Democrats for allegedly manufacturing false allegations in what Trump called a “con job.” Both Trump and Kavanaugh also suggested that men accused of sexual misconduct had lost the presumption of innocence, and that higher principles of due process and public service were at stake.

 The senior White House official added that Kavanaugh’s approach also echoed the defiant response of Supreme Court Justice Clarence Thomas, who survived public charges of sexual harassment that played out during his nationally televised 1991 confirmation hearings.

 It remained unclear by evening whether Kavanaugh’s nomination would survive an astonishing day that covered everything from alleged rape to drinking games, the geography of Bethesda, Maryland, and crass high school yearbook jokes. But the day’s end, the mood in the White House was considerably brighter than it had been earlier, when some officials cringed at the role of Arizona prosecutor Rachel Mitchell, who led the GOP side’s questioning of Ford.

 “That’s a disaster,” said one administration official. The official argued that Republican lawmakers had erred by caving to the pressures of identity politics and hiring a woman to quiz Ford to avoid having an all-white male lineup of Republicans question her.

 Trump allies also recognized the bad optics of a prosecutor seeming to interrogate a victim who even some committee Republicans later acknowledged had come across as sympathetic. Mitchell approached Ford with a patient tone, but seemed to be searching for holes in Ford’s story as she asked about her air travel — Ford has said the alleged assault left her claustrophobic and uncomfortable in airplanes — and who paid for and advised her to take a polygraph test.

 Trump allies who want to see Kavanaugh confirmed also were concerned that Mitchell failed to poke any substantial holes in Ford's account or character that would make her story less believable. During her questioning, Mitchell herself acknowledged that the day's format — in which she was able to question Ford in five-minute intervals — was not an ideal way to assess an alleged victim's story.

 But not all White House aides and officials were so unhappy about Ford’s testimony in the first half of the day. One White House official and another person close to the confirmation process noted that, despite emotional responses on TV and via social media to the day's hearing, the key audience is a limited number of Republican senators. They include Jeff Flake, Susan Collins and Lisa Murkowski. Those senators have expressed a desire for a no-drama, fair hearing, and the sources said they felt Mitchell was delivering that.

 The two sources also noted that the hearing had failed to produce any new facts that might incriminate Kavanaugh. And midway through the 53-year-old judge’s testimony, he had made no obvious stumbles or admissions of wrongdoing.

 Trump aides were “particularly impressed,” said one of the White House officials, when Kavanaugh told senators that his 10-year-old daughter had recently said at bedtime that she and her sister should pray for Ford.

 poster="http://v.politico.com/images/1155968404/201809/3042/1155968404_5841153123001_5841150714001-vs.jpg?pubId=1155968404"

 And after Sen. Lindsey Graham launched a dramatic tirade against committee Democrats who he said “want … to destroy this guy’s life,” White House press secretary Sarah Huckabee Sanders cheered him on via Twitter. White House aides said they felt Graham had articulated their own anger over the personal charges against Kavanaugh, including Graham’s charge, delivered at a near-shout, that “What you want to do is destroy this guy's life, hold this seat open, and hope you win in 2020.”

 At least one conservative legal activist distributed talking points early in the day defending Mitchell and noting Ford conceded to her that she must have been given a ride to and from the party where she says Kavanaugh assaulted her but could not remember who might have done so. “Whoever drove [Ford] home doesn't exist," the activist argued. The talking points also noted that a polygraph test Ford took and passed could be invalid because it was administered around the time of her grandmother’s funeral. The talking points also noted that Mitchell had managed to prove that "there was no witness to support what she's alleging happened.”

 At the day’s outset, Republicans expressed resignation that Kavanaugh had mishandled the situation from the beginning, by trying to portray himself as a choir boy instead of admitting that he drank heavily in high school, college and law school, as multiple classmates and yearbook entries have shown. A better strategy, White House officials conceded, would have been to admit he didn’t remember the assault described by Ford, but that he believed her story and issue her an apology.

 White House officials said they saw his decision to sit for an interview with Fox News on Monday as a mistake. And that a better way to have handled the accusations would have been as Trump did after the release of the "Access Hollywood" tape in October 2016: a quick apology and then a forceful forging ahead.

 “He feels for Brett, the person,” one person familiar with Trump’s thinking said early in the day, noting that Trump sees it as Kavanaugh’s job to defend his own name.

 “When he’s accused, he punches back,” the person said.

 By the day’s end, Kavanaugh had done the same — winning the president’s support, even if his nomination remained in the balance.

 Christopher Cadelago contributed to this report.

 CORRECTION: This article has been updated to correct the spelling of Sen. Whitehouse's name. |||||

– President Trump was pleased with his Supreme Court nominee's performance before the Senate Judiciary Committee on Thursday, tweeting that Brett Kavanaugh "showed America exactly why I nominated him." Politico described the mood of Trump and his aides as "ebullient." Trump watched Kavanaugh's opening statement (which Politico calls "combative") and was pleased, an official said. "I think [Kavanaugh] studied the way people around Donald Trump have been treated, and he figured out a way to prevail," the official said. A source speaking to CNN during the hearing summed it up: "The only way to earn respect in Trumpworld is to brawl. And [Kavanaugh] is brawling." Following the hearing, three Republican senators (Susan Collins, Lisa Murkowski, and Jeff Flake) and a Democratic one (Joe Manchin) met privately in an office at the Capitol, CNN reports, noting that the three Republicans are the wildcards for whether Kavanaugh will be confirmed.


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The Solar Impulse 2 plane took off Monday from Nagoya, ending a frustrating four-week hiatus during its unprecedented bid to circle the world without fuel.

 Flight engineers spotted a possible cloudless stretch over the Pacific and in a pre-dawn scramble got the solar-powered plane airborne from Nagoya Airport, where it has been grounded since June 1.

 “We are very, very happy,” project spokeswoman Elke Neumann said by phone from the airport. “We have now packed the hangar up. We are just doing the last logistical operations.”

 She said a cargo plane will ferry the inflatable hangar together with the support crew to Kalaeloa Airport near Honolulu, where Solar Impulse 2 is expected to land after a nonstop flight of roughly five days and nights.

 Solar Impulse 2 is a lightweight aircraft driven by four electric propellers and banks of solar panels atop its fuselage and wings. It took shelter at the Nagoya city airport, also known as Komaki Airport, part way through a flight from Nanjing, China, to Hawaii.

 A previous effort to resume the flight last Wednesday was canceled at the last minute as ranks of journalists looked on. This time, the project team announced plans to take off only an hour or so before departure.

 “We just wanted to make sure that we are really safely on the way to Hawaii,” explained Neumann. “It created a lot of disappointment.”

 The team issued a statement thanking their Japanese hosts for helping accommodate the aircraft and support staff during the unplanned visit.

 “Solar Impulse extends its gratitude to all those in Japan who have worked very hard to accommodate us,” the statement said.

 It said those who had helped during this “challenging” phase included Aichi Gov. Hideaki Omura, the Swiss Embassy and project sponsors Schindler Holding AB and ABB Ltd.

 From Hawaii, the plane aims to reach the United States mainland and to cross the Atlantic while calm summer conditions persist. Its round-the-world voyage will end at its starting point, Abu Dhabi.

 Swiss pilot Andre Borschberg said June 17 that the unplanned grounding in Nagoya was eating away at the time margin and that “question marks” hung over the project’s completion this year.

 He said with every day of delay the effort comes closer to having to pause and resume next year. ||||| Image copyright Solar impulse Image caption The plane has a bigger wingspan than a jumbo jet but is incredibly light

 A solar-powered plane has passed the "point of no return" in its second bid at making a record-breaking flight across the Pacific Ocean.

 Solar Impulse took off from Japan's Nagoya Airfield at 18:03 GMT on Sunday.

 The journey to Hawaii is expected to take approximately 120 hours.

 The team spent nearly two months waiting for clear weather to cross the Pacific, and a developing cold front forced the plane to make an unscheduled landing in Japan earlier this month.

 "Andre Borschberg has passed the point of no return and must now see this 5 days 5 nights flight through to the end," Solar Impulse said on its website.

 The pilot now no longer has the option to turn around and return to Japan, if the weather forecast changes.

 Weeks of delay

 The first attempt to fly over the ocean was cut short after a change in the forecast forced an unscheduled landing.

 And another attempt to take off last Tuesday was cancelled at the last moment because of concerns about the conditions.

 If the pilot succeeds, it will be the longest-duration solo flight in aviation history, as well as the furthest distance flown by a craft that is powered only by the Sun.

 The Pacific crossing is the eighth leg of Solar Impulse's journey around the world.

 But this stage has proven to be the most difficult, and has been hit by weeks of delays.

 Image copyright Reuters Image caption The plane had to make an unscheduled landing in Japan after its first attempt to cross the ocean

 Swiss pilot and Solar Impulse co-founder Andre Borschberg, who is flying the experimental single-seater craft, was initially supposed to begin his journey to Hawaii from Nanjing in China.

 But he spent weeks there, with his ground-support team, waiting for the right flying conditions to present themselves.

 He finally took off on the 31 May, but a deterioration in the forecast a few hours into the mission meant that he had to divert to Japan.

 The rainy season in Nagoya has meant another long wait there - but after the false start last week, meteorologists are now confident they have found a weather window to make the five-day, five-night crossing to Hawaii.

 A spokesperson said that the plane would be heading straight out across the Pacific.

 LEG 1: 9 March. Abu Dhabi (UAE) to Muscat (Oman) - 772km; in 13 hours and 1 minute

 LEG 2: 10 March. Muscat (Oman) to Ahmedabad (India) - 1,593km; in 15 hours and 20 minutes

 LEG 3: 18 March. Ahmedabad (India) to Varanasi (India) - 1,170km; in 13 hours and 15 minutes

 LEG 4: 18 March. Varanasi (India) to Mandalay (Myanmar) - 1,536km; in 13 hours and 29 minutes

 LEG 5: 29 March. Mandalay (Myanmar) to Chongqing (China) - 1,450km; in 20 hours and 29 minutes

 LEG 6: 21 April. Chongqing (China) to Nanjing (China) - 1,241km; in 17 hours and 22 minutes

 LEG 7: 30 May. Nanjing (China) to Nagoya (Japan) - 2,852km; in 44 hours and 9 minutes

 Leg 8: 28 June. Nagoya (Japan) to Kalaeloa, Hawaii (USA) - 8,000km; 120 hours (estimated)

 The experimental craft - which has 17,000 solar cells - is powered only by the Sun.

 Once over the ocean, if it fails to soak up enough rays to fully charge its batteries and make it through the night, the pilot could be forced to bail out.

 Mr Borschberg has been trained for that eventuality.

 He has a dinghy and enough supplies for several days while he waits for the team to identify a vessel to go pick him up.

 But, of course, the team hopes none of this will be necessary.

 Mr Borschberg's will spend the duration of the flight strapped into his seat in a cockpit that is about the same size as a telephone booth.

 He will only be allowed to take 20-minute cat-naps, but says he will use yoga and meditation to make his journey more comfortable.

 If this flight succeeds, the plane will continue its journey around the world, with Bertrand Piccard taking the controls for the next Pacific crossing from Hawaii to the US mainland.

 The plane will then continue across North America, before attempting to fly over the Atlantic.

 However, the build-up of delays could impact on the later stages. Ideally, the plane needs to cross the Atlantic before August, when the hurricane season reaches its peak.

 Follow Rebecca on Twitter. |||||

– Round two of the Solar Impulse's toughest leg is under way. After the solar plane's first attempt to cross the Pacific was interrupted a month ago, flight engineers spotted what the Japan Times calls a "possible cloudless stretch." That allowed pilot Andre Borschberg to take off from Japan's Nagoya Airfield at 3:04am local time bound for Kalaeloa, Hawaii. The team announced the plane was to depart only an hour before it did so. Borschberg has since "passed the point of no return," meaning he can't return to Japan if he encounters bad weather, according to the project's website, per the BBC. If successful, the leg will be the longest-duration solo flight in aviation history at 120 hours and the furthest distance flown by a strictly-solar aircraft at 4,900 miles. Prior to starting this leg on a trip around the world, the Impulse 2 had flown about 5,000 miles. Co-pilot Bertrand Piccard is next set to fly the plane from Hawaii to Phoenix before the plane eventually arrives on the eastern seaboard. The Impulse 2 will then attempt an Atlantic crossing, though any further delays could seriously hamper the trip. The team optimally needs to traverse that ocean before the peak of hurricane season in August. The plane had been scheduled to take off from Japan last week, but had to cancel at the last moment due to weather. (Discover how Borschberg will cope during the lengthy Pacific flight.)


Summarize this article:

LAGUNA BEACH – Jonas Bevacqua, co-founder and creative director of the Irvine-based clothing company LRG, was found dead in his home on Bern Drive in Laguna Beach on Monday morning, the Orange County Coroner's Office confirmed. He was 34.

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 The cause of death for the well-known urban-style clothing designer has not yet been determined, Supervising Deputy Coroner Kelly Keyes said. The Laguna Beach Police Department did not provide details but said that the death does not appear to be suspicious.

 LRG – short for Lifted Research Group – both supports and is supported by a community of musicians, artists and athletes who have donned the company's clothing. According to LRG, the company's clothes have been worn by celebrities from Kobe Bryant and Reggie Bush to Kanye West and John Legend to Quentin Tarantino and Tom Arnold.

 Entrepreneur magazine reported the company had sales of $5 million in 2002 and $150 million in 2006, earning it the No. 5 spot on the publication's 500 fastest growing companies.

 LRG co-founders Robert Wright and Charlie Moothart in a statement posted on the company's website Tuesday night described Bevacqua as a "visionary" who served as a "friend, partner, father, mentor and very caring person."

 "Jonas was a star who burned brightly in the sky and who is gone too soon," the statement read. "There is a hole in our hearts that will never be filled. He will always be loved and missed by his friends, family and those he inspired."

 Those sentiments were shared among online followers as news spread of Bevacqua's death.

 "A true fashion pioneer,'' wrote an admirer on Twitter.

 "RIP Jonas Bevacqua. Your accomplishments and trend setting ways inspired many,'' wrote another.

 The early years of Bevacqua's life were spent in Long Beach, but when he got into high school, his family moved to Laguna Beach. These two cultures were very different to him – the streets of Long Beach and the beaches of Laguna – and it helped shape him. He took to skating and surfing rather than team sports.

 His family is a veritable melting pot. Bevacqua, who is U.S-born Vietnamese, was adopted along with six others by Helen and Joe Bevacqua, who also have one biological son. He has a black brother and sister, Filipino brother and sister, half-white-half black sister, half Jamaican-half-Spanish brother and a white brother.

 "I grew up in a pretty unique environment and was exposed to a lot of different things," Bevacqua told the Register in 2009. "I didn't feel there was a clothing company to bridge the gap among all these different things that we were into – that spoke for that melting pot of what was going on. That's what LRG was all about."

 After high school, he tried out college.

 "I did two semesters but probably showed up like three times," Bevacqua said.

 He drifted around California for a couple of years and spent time in San Diego, Los Angeles and San Francisco. In 1999, he decided he wanted to start a clothing company.

 Bevacqua moved back in with his parents in Laguna Beach to start LRG. He worked as a valet during the day and at night he was a DJ at local clubs. His parents helped him get a computer for work.

 He met Robert Wright while working as a DJ. Wright had a college education and experience working for O'Neill, a surf clothing brand, and he delivered all that knowledge to Bevacqua. They received some investor funding from Charlie Moothart and Ronnie Ghenender and LRG was born.

 They started out with some sketches and ideas working out of Bevacqua's bedroom as he learned how to design and get clothes made.

 "I had no idea what I was doing. I knew I definitely needed to get stuff made. We put together this game plan. I had to get some hats embroidered. So, I found some place local to us in Santa Ana," Bevacqua said.

 Design at LRG is all about the message. Sometimes the message is about wit or humor and other times it's about a state of mind. The "Lifted" in Lifted Research Group, for example, can reference an elevated state of mind. Some of the messages LRG delivered over the years include: Make Jeans, Not War; Underground Inventive, Overground Effective; Equipment For Life's Journey; The Underachievers.

 One message LRG revisits from time to time holds particular personal meaning to Bevacqua. Adopt Children, Not Style.

 "That's my life story," Bevacqua said.

 Bevacqua is survived by his fiancé, son, seven siblings and his mother and father, LRG officials said. ||||| Jonas Bevacqua, who co-founded the popular street clothing brand LRG in 1999 and presided over its rapid rise as a major fashion force among young people, was found dead Tuesday. He was 34.

 Orange County sheriff's officials said Bevacqua's body was found in his Laguna Beach home.

 "There were no obvious signs of the cause of death," sheriff's spokesman Jim Amormino told The Associated Press. He added that the county coroner would conduct an autopsy Wednesday.

 A statement on Irvine-based LRG's website describes Bevacqua as a friend, partner, father and mentor.

 "We ask that everyone keep his family in their hearts and prayers and respect their privacy in this time of incredible grief," the statement reads in part.

 According to the company's Facebook page, Bevacqua and his business partner, Robert Wright, founded Lifted Research Group, known to patrons as LRG, with start-up capital raised in part from friends of Bevacqua's adoptive father.

 Bevacqua had dropped out of college and moved back home with his parents when he met Wright while working as a DJ at Southern California clubs. The two sketched out some of their earliest fashion ideas in his bedroom.

 Deeply influenced by Southern California's skateboard, surfing and hip hop culture, he said he and Wright began making clothes that reflected their interests but that no one else seemed to be providing.

 "I grew up in a pretty unique environment and was exposed to a lot of different things," he said in a 2009 interview with the Orange County Register. "I didn't feel there was a clothing company to bridge the gap between all these different things that we were into _ that spoke for that melting pot of what was going on. That's what LRG was all about."

 By 2006, LRG had annual sales of $150 million and was named by Entrepreneur magazine as No. 5 on its list of that year's 500 fastest growing companies. Among its popular clothing lines are Luxirie, which targets 18- to 30-year-old women, offering clothing with Western and military themes, and items such as crystal-covered jeans.

 Initially a clothing company, LRG has since branched out to include sales of electronic devices, music and other items. It described itself as a "creative lifestyle" company that attempts to reflect its founders' interests, not only in fashion but also environmental causes and other activities.

 "The company is also involved in the promotion of underground recording artists and sponsors a skateboarding team," according to its website.

 In the 2009 Register interview, Bevacqua described a passionate but casual work ethic that he said drives LRG, whose headquarters includes a basketball court and skateboard half-bowl and ramp.

 "No one is really a suit-and-tie-guy," he said of LRG's employees. "If anybody wears a suit, it's because he wants to, not because he has to."

 Bevacqua is survived by his mother, father, son, fiancee and seven siblings, according to the company's website. |||||

– The co-founder of the hugely popular hip-hop and skateboarding clothing brand LRG has been found dead in his Laguna Beach home. Jonas Bevacqua was 34. There was no obvious cause of death, and an autopsy will be conducted, AP reports. LRG, which the designer founded when he was barely out of his teens, branched out from clothing into music and other items, which supported up-and-coming recording artists. Bevacqua, who grew up in a multi-racial California family, said he founded LRG because no other company was creating clothing that reflected his and co-founder Robert Wright's interest in surfing, skateboarding, and hip-hop. "I grew up in a pretty unique environment and was exposed to a lot of different things," Bevacqua told the Orange County Register in 2009. "I didn't feel there was a clothing company to bridge the gap among all these different things that we were into—that spoke for that melting pot of what was going on. That's what LRG was all about."


Article:
Background The natural progression of chronic disease involves periods of apparent remission interspersed by exacerbations and, in the year leading to death, multiple hospitalisations.1 Some indicators of poor prognosis can suggest a patient is nearing the end of life,2 and have been found useful for initiating discussions with families regarding pre-emptive care planning.1 Yet there is uncertainty of the time, frequency and duration of the next episode of decompensation as well as the ultimate prognosis causing doubts about whether to continue active management. Further, while the majority of people want to die at home, most will die in hospital.3–8 Patients nearing the end of life are high-level users of ambulance services,9 emergency services,2 ,10 hospital wards11 or intensive care units and many die in hospital.12 Significant numbers of patients with cancer or other terminal illnesses are suitable for palliative care but often are readmitted to acute hospitals multiple times with lengths of stay of just under a week.10 ,13 ,14 While there are accepted policies for de-escalating treatment in terminally ill patients,2 ,15–17 there are also inherent and societal pressures on medicine to continue utilising technological advances to prolong life even in plainly futile situations.15 The implications of a decision to administer or withhold aggressive treatment for terminal patients are enormous for clinicians, patients and their families, for the health system and for society as a whole. It can be difficult to reach a decision that balances the rights of patients to die with dignity18 ,19 and the expectations of families about satisfactory end-of-life care,20 ,21 while considering the limitations of health resources where opportunity costs cannot be disregarded.22–24 Delaying unavoidable death contributes to unsustainable and escalating healthcare costs, despite aggressive and expensive interventions. These interventions may not influence patient outcome; often do not improve the patient's quality of life; may compromise bereavement outcomes for families; and cause frustration for health professionals.20 ,25–29 This highlights the importance of developing more accurate ways of identifying patients near the end of life, involving both the patients and their carers in those discussions and then making more appropriate management plans. For about two decades many acute hospitals have adopted rapid response systems to identify and manage seriously ill patients.25 ,30–32 They were initially developed to recognise at-risk patients early as a basis for triggering a rapid response to improve patient outcomes. In doing so, the system also identifies patients at the end of life who are predictably deteriorating. Up to one-third of all of rapid response team (RRT) calls have been related to end-of-life issues.33 ,34 This emphasises the failure of current hospital systems to recognise patients at the end of life. Often it is the patient and carers who initiate this conversation.25 ,35 Clinical decision aids are widely used to involve patients in informed treatment decisions that incorporate their personal preferences and values.36 Sensitive clinical decision rules have been used to discontinue futile resuscitation on patients who experience a cardiac arrest.37 However, we have not found a fit-for-purpose screening checklist or clinical decision tool for objective identification of end of life within days, weeks or months to minimise inappropriate treatment at hospital admission.29 There is a need to recognise patients at the end of life while at the same time acknowledging uncertainty around the exact time and circumstances when death will occur.38 The aims of the CrisTAL checklist are to assist clinicians to recognise these patients and to change the culture of the hospital to one where end of life is openly discussed and dealt with more appropriately.39

 Rationale Accordingly, there is a need to collate evidence to assist clinicians, carers and families in decision-making about the most sustainable model for appropriate and best quality care in the last few months of life. The specific objectives of this research are to: review literature to obtain definitions for dying patient and end of life; review existing literature regarding screening tools for the prediction of death in hospitalised patients; propose a checklist for screening of hospitalised patients at-risk of dying in the short to medium term. Two common and important situations where patients at the end of life can potentially be identified are on admission to the emergency department (ED); and when a patient deteriorates and becomes the subject of a RRT call. This paper reports on the development of a clinical decision aid for use in both circumstances: CrisTAL (Criteria for Screening and Triaging to Appropriate aLternative care). It summarises the information available in the literature to construct the domains for such a screening instrument based on patient data items routinely available at the point of care. The tool is intended to offer a starting point to begin discussions with the patient and relatives about priorities and preferences on type and place for end-of-life care.39 ,40 It also may identify elderly who will benefit from alternative care pathways instead of hospitalisation.5 ,41 The routine use of such a tool may also change the culture of the organisation to one which is more aware of patients who may be at the end of life and one where different management pathways are considered earlier. The tool is not meant to dictate whether or not a patient receives life sustaining therapy or is the subject or a do-not-resuscitate order. However, it may provide an objective assessment to inform and support that decision, made jointly by patients, their family and the treating team.

 Methods We undertook a narrative literature search in PubMed, Cochrane Library and Google Scholar for published and unpublished papers about explicit and practical definitions of ‘end of life’ and for tools or screening instruments to predict death. The search strategy included the following terms: (End of life, terminal, dying, inappropriate resuscitation, do-not-resuscitate, cardiopulmonary resuscitation order, limitations of treatment, discontinuation of care, futility, advanced directive) and (hospital, acute care facility, palliative care, ED) and (Screening tool, decision aid, algorithm, predictive, predictor of death). This was supplemented with manual searches through the reference lists of eligible papers. The variables and thresholds explored for the screening tool were adopted from existing scales and published findings that demonstrated their association with either in-hospital or 30-day mortality or survival to 12 weeks.42–47 Based on the practicalities of applying the tool as decision-making support at the point of care, we used four criteria to decide whether the existing instrument was helpful for the purpose of objectively diagnosing dying and whether to discard items: ready availability in medical records,42 ,43 need for clinical judgement, use of value judgment and self-sufficiency of indicators. This review was followed by consultation with two doctors and three ICU nurses with intensive care qualifications and experience in end-of-life care, about the feasibility of acquiring or documenting these data items in routine care.

 Results We found 112 relevant articles dealing with the definition of dying, determination of severity of deterioration, prediction of in-hospital death, preferred place of death and options for alternative end-of-life care. Among these, we identified 18 instruments and their variants validated in different settings. Below is a summary of the operational definitions and commonly used or cited tools to predict death in hospital. Operational definitions Nine working definitions of end of life were found to assist in limiting the number of items for a screening tool to a manageable set (table 1). These were mostly impractical in their requirement of clinicians’ subjective assessment; or confined to patients imminently dying within hours; and of limited use for elderly patients with chronic disease, nearing end of life within days or weeks. Table 1 Definitions of end of life and their suitability for routine use in screening We defined inappropriateness of admission to hospital for patients at the end of life as those ‘admissions when the resources of the hospital will not have any significant impact on the clinical prognosis of the elderly patient with multiple life-threatening comorbidities’. As pragmatic definitions of ‘dying patients’ were not prevalent in the literature, we searched for a suitable proxy measure that could be drawn from studies examining predictors of poor survival. These are abundant and cover both subjective and objective parameters anticipating death. Subjective variables and their utility in predicting short-term to medium-term mortality Of the instruments developed in the past 30 years for prognostication of death after admission, many still require value judgements and unstructured subjective assessments, which renders them less reassuring and hence less useful as a tool for deciding at the time whether to admit a patient. Performance Status Scales designed as early as 1949 by Karnofsky53 ,54 and The World Health Organisation (ECOG PS) in 1982 are simple and popular instruments for determining appropriate intensity of care for patients. They have undergone adaptations over time55 where completion still involved major value judgements, which makes them impractical and unreliable for a standardised prognosis (table 2). Table 2 Existing scales or screening tools to predict risk of death and their domains Various indices have been designed to identify illness severity and risk of death after admission (table 2). Some reliably capture the level of quality of life in terminal patients but do not focus on objective signs;54 some use nursing assessment of organic and psychosocial aspects;56 others suggest a checklist that combines objective (eg, semiconsciousness) and subjective items (eg, ‘irreversible deterioration’).51 Some emphasise application of survival prediction for in hospital-based palliative care services with high prognostic accuracy (85.6%) in estimating death within 3 days of admission to a palliative care facility, but only 54% and 57.6% accuracy in predicting death within 4–30 days and by 6 months.57 A global assessment of frailty using a subjective score between 1 (very fit) and 7 (severely frail) had good predictive validity for death within 18 months58 but required clinical and value judgements, and did not incorporate the impact of underlying conditions, hence reducing its ease of use for routine care by less experienced personnel. Clinician perception about risk of death has been found to be reasonably accurate in particular for patients with advanced chronic heart failure or chronic obstructive pulmonary disease as an adjuvant in the decision to more efficiently target palliative services and end-of-life care planning.59 Finally, the global self-rated question designed to assess patient perception of their own health in comparison with other people their age, not intended as a prognostic tool but since the early 1980s has been associated with predicting long-term mortality in the elderly,60 independently of ‘objective health status’ and across ethnic groups. The self-rated health question is now better understood,60–62 and has been validated as a screening tool for vulnerable people at higher risk of death in community.63 Its influence on imminent risk of death at hospital admission is not known and we will include it in our screening tool. Objective variables and their utility in predicting short-term mortality Several factors have been found to have an impact on the risk of death after hospital admission, including age 65 years and above,42 ,63 ,85 ,86 multiple comorbidities,18 multiorgan failure,44 physiological data from laboratory test results64 ,76 and type of service and urgency of admission.43 We propose a combined algorithm quantifying the aggregate risk estimation of some previously developed instruments to take us closer to a more accurate definition of dying. An historical exploration of 18 of these estimates has shed more light on the influence of these factors. The diagnosis of advanced cancer has probably attracted the most attention for predicting prognosis and appropriate care. From a review of 24 studies and 18 prognostic indicators, there was general agreement that anorexia and weight loss showed the most significant association with poor survival, followed by cognitive impairment, dyspnoea and dysphagia.83 While several of these studies were conducted in small convenience samples, some with doubtful statistical methods,42 clinicians would agree that these are largely symptoms of imminent death. Uncertainty of what constitutes dying in the short term has led to the development of practical prediction tools to assist in treatment decision-making, guide family consultations, and minimise unnecessary expense to the health system (table 2). Prognostic scales and indices Performance Status Tools have been well received and modifications tested in various settings. Table 2 summarises scales found a predicting outcome and time to death/discharge, some of which have been validated in similar or divergent populations and others have led to refinements and developments of further tools.72 many are cancer-specific scales, thus have limited value for wider use in ED.82 For instance the PaP score is good at reducing the prognostic uncertainty of death within 1 month of admission to palliative care services.76 However, it is only validated for patients with cancer and it can yield significant differences between the prediction of registered nurses and doctors.76 ,77 ,87 The Charlson Comorbidity Index (CCI), was designed to estimate 1–10-year mortality in longitudinal studies and is not validated as prognostic indicator for short-term outcomes in cancer or other conditions.88 The Elixhauser Comorbidity Index is a complex tool74 which uses administrative databases to estimate increased risk of in-hospital death or prolonged hospital stay.68 but clinicians may not find it user-friendly because it relies on administrative data and requires calculations. Further, the authors recommended a combination with other influential factors for a more accurate prediction of death in hospital.18 The Acute Physiology and Chronic Disease Evaluation (APACHE II) tool and its variants APACHE-L, APACHE III and APACHE IV and the Simplified Acute Physiology Score, SAPS II were designed to measure the severity of disease for adult patients and are all used to predict in-hospital death and risk-adjusted length of stay in intensive care units.65–67 ,70 ,89 The scores indicate the risk of death in patient groups rather than individual prognosis.90 Moreover, the APACHE instruments are heavily dependent on laboratory-based data not generally available in all EDs in Australia. Multiple attempts have been made to enhance objective early warning scores (EWS) for identification of critical illness and deterioration on admission and in intensive care. Improvement in serial EWS within 4 h of presentation to hospital predicts improved clinical outcomes75 ,79 ,84 ,91 ,92 hence EWS has been deemed as a potential triage tool in the ED for acute medical patients.75 ,79 ,81 ,84 ,93 While the developers of some EWS have emphasised that they did not intend them as predictors of patient outcome,94 experience has shown that these scores are being used in practice to predict death. Accordingly, we chose to include these in the construction of algorithms defining the diagnosis of dying. In 2012, the Rothman Index was found to be a strong predictor of both in-hospital mortality, hospital readmission and post-discharge mortality at 2 days, 30 days and 1 year.44 ,56 Unfortunately the Rothman Index relies on comprehensive collection of nursing or doctors’ assessments, not part of routine care in outpatients or ED in most hospitals.

 Development of CriSTAL To be considered useful on admission at ED or during an RRT attendance, the screening tool items should meet the following criteria: easily collected in routine practice,42 or readily available in electronic or paper medical records; does not require specialist clinical judgement; is sufficient to independently predict death in specific conditions; and with two exceptions, does not employ a value judgment. None of the 18 published predictive tools met the four criteria; five met three criteria but four of these instruments involved clinical judgements and one involved value judgment; nine tools met two criteria and four tools only met one criterion. Figure 1 shows the distribution of criteria to justify the need for a fresh tool that met the four criteria. Figure 1 Outcome of the literature review. In the absence of a comprehensive instrument combining acute and chronic predictors to increase certainty of diagnosis of imminent death or death within weeks or months, this review gathered recognised predictors of death for elderly patients with complex health profiles from existing prognostic tools to create a new screening instrument. We anticipated that incorporating objective variables would enhance certainty of the screening tool and could assist in the decision to appropriately generate do-not-resuscitate orders25 and consider alternative end-of-life care orders. The variables and values proposed for the CriSTAL screening tool were adopted from existing scales and from published research findings demonstrating their association with either in-hospital or 30-day mortality or survival to 12 weeks.42–45 ,56 ,76 Old age and RRT criteria are priorities on the checklist. Supplementation with a quantifiable level of severity based on EWS75 ,79 ,84 ,91; history of repeat hospitalisations with or without admissions to ICU95; emergency admission96; at least one of the predefined advanced comorbidities from the evidence-based list;35 an objective measurement of frailty;85 documentation of nursing home placement;33 ,46 evidence of cognitive impairment;25 ,42 ,63 ,73 ,83 and readily available test results: proteinuria and if ECG confirms abnormalities.97 Table 3 shows our resulting 29-item screening tool, named CriSTAL, to denote our intention to introduce transparency in the identification of the dying patient and enable objective clinician decisions about prognosis and justification for administering or de-escalating aggressive treatments. Table 3 Proposed components of the Criteria for Screening and Triaging to Appropriate aLternative care tool to identify end-of-life status before hospital admission A slight modification is proposed for the use of the tool following a RRT attendance (table 4). This might encourage reassessment of the need for continuing hospitalisation in an acute care facility and discussion about the need for limitations of treatment if death is imminent. Table 4 Proposed components of the Criteria for Screening and Triaging to Appropriate aLternative care tool to identify end-of-life status after a rapid response call where a do-not-resuscitate order is not in place

 Discussion How would CriSTAL be used in practice? It may characterise ‘appropriateness of admission’ and appropriateness of subsequent treatment for patients at the end of life in a way that can be applicable to a wide variety of terminal health conditions. It could be used as a platform for beginning discussions with patients and their carers. It may also add more certainty identifying the irrevocably dying patient with chronic comorbidities and prevent further futile treatments to prolong life. We have omitted indicators of system failures or nursing staff workloads such as TISS or NEMS90 that may potentially influence risk of death, as these did not fulfil our inclusion criteria of being routinely available The Scottish health system implemented a national action plan for care at the end of life deriving from the realisation that 30% of all hospital bed-days were accounted for by multiple admissions of people in the final year of life.41 The ‘Dying well’ premise in Scotland is that alternative care is integral to continuity of care outside the hospital. The strategy includes among others, early identification of care needs for any terminal illness, holistic assessment and involvement of patients and families in the coordination of alternative care.2 Inspired by this development, our definition of inappropriate hospital admission is linked to the more objective scoring factors of the CriSTAL tool, whose accuracy is to be validated to more precisely establish the main determinants of death in the short term. Our review indicated that old age42 ,63 ,85 ,86 and concurrent illnesses18 ,25 ,42 ,46 ,63 ,101 were the strongest predictors of death in and outside intensive care.45 ,104 Strengths of this developmental work are the evidence-base source of variables in the tool and the extensive range of predictors covering demographic, physiological and diagnostic prediction measures. A limitation of this research is that the item selection was based on a narrative review with focused set of search terms. This may have led to overlook of some articles that would have been captured in a systematic and broader search strategy. However, the comprehensive search for tools and the breadth of instruments found using this approach provided a sufficiently large number of items to start the discussion on possible amalgamation of variables from existing instruments to meet our targeted need. Other researchers among the readership may choose to expand the search or enhance the tool. In fact, a limitation of CriSTAL's development at this stage is its length for routine administration, and the number of potential predictors which may lead to model ‘overfitting’. The testing of too many variables is known to reduce the generalisability of the predictive model.105 By retrospective testing and future prospective validation we hope to reduce the total number of items without sacrificing predictive accuracy or generalisability. Initially, CriSTAL's 29 subitems will be tested in a retrospective data review using a case–control study design where cases are all deaths reported from the RRT attendances system in a teaching hospital during 2012–2013. Controls will be age-sex-ward matched records of patients admitted in the same period with an RRT call but did not die before or within 3 months of discharge. Sensitivity, specificity and positive and negative predictive values will be calculated from logistic regression models of matched cases and controls. This retrospective validation has been endorsed by the South Western Sydney Local Health District Ethics Committee. The next step after retrospective testing will be the prospective administration of the validated tool as part of the admissions procedure in emergency and after the RRT calls on general wards. The accuracy of models with different number of variables will be determined using the area under the receiver-operating characteristics (AUROC) curve.106 Minimum accuracy will be defined as area under the ROC curve >80%, and variables not contributing significantly to the model will be dropped from the instrument. Survival analysis and Cox proportional hazards regression will investigate the most significant predictors of imminent death. A 5% chance of survival to hospital discharge among those predicted to die will be chosen as the maximum error allowed for the tool to be considered useful. While it is acknowledged that predictions based on population subgroups are not meant to be used for individuals,107 the calculated risk can be used as a reference to inform the decision by the individual under the clinician's guidance, on whether or not to continue aggressive treatment, given the odds of dying based on the well-established predictors. Careful use of the CriSTAL tool care for decision-making would involve alignment with quality of care principles and patient values and preferences, and should not be driven by hospital financial pressures or need to meet health system performance indicators.24 Finally, it is important to recognise that the use of a screening tool for identifying patients who have a high probability of dying within 3 months can only provide an indication of those who with a low probability of survival and will not be a signal of absolute certainty.50 Testing its appropriateness, reliability and predictive value in different patient subpopulations will help reduce this uncertainty but its predictive value may vary in different settings and for different timeframes and this needs to be ascertained. Further, its values after an RRT response will need to be assessed in relation to its value at the time of admission for patients when trialled. As emphasised before, testing in different settings could yield different predictive performance depending on the patient profile and possibly the influence of factors not accounted for in the tool. Readers and researchers are encouraged to train and validate the CriSTAL tool in their facility to generate the most valid and relevant set of variables for their subpopulations.

 Conclusions and recommendations This tool does not intend to preclude access to healthcare for the terminal elderly, but to provide an objective assessment and definition of the dying patient as a starting point for honest communication with patients and families,3 about recognising that dying is part of the life cycle. Dignified withdrawal of intensive and inappropriate treatment29 ,52 and triage into alternative care in non-acute facilities10 ,38 is an area where there is still ample room for improvement.1 ,29 ,39 Standard guidelines for alternative end-of-life care are not yet broadly adopted in Australia and discussions with policy-makers need to continue.2 However, increasing evidence of alternative out-of-hospital care acceptable to clinicians108 and others are known to include sedation to minimise distress, pain management,109 spiritual support,41 music therapy and home-based palliative care.110 If proven accurate in the prediction of short-term death, a reduced version of CriSTAL could be proposed for routine use at hospital admission. We acknowledge that the Australian health system may not yet be equipped to respond to the demand for alternative healthcare facilities for the dying.111 However, it is hoped that using such predictive tools may encourage more appropriate services for managing patients at the end of life. Training for nurses and doctors in the use of the screening tool and in approaching patients and families with concrete information about inevitability of death and lack of benefit of further intensive treatment are paramount.27 ,112 They will be better equipped to communicate the responsible decision to suspend efforts and handle potential requests for futile treatment.41 ,49 Automation of CriSTAL and its scoring would facilitate use at time of admission and production of instant or retrospective locally relevant profiles of patients imminently dying. Potential uses include as a clinical support tool for decision-making on triage to appropriate end–of-life care facilities; to prevent death in some cases; and to examine variation in risk-of-death levels, differences in admission practices, and inform triage policies across hospitals,43 as a first step into cost-effectiveness and patient satisfaction studies. ||||| Researchers at the University of New South Wales, in Sydney, Australia, insist that the checklist does not intend to withhold treatment but said it intends to stop “intrusive, expensive and ultimately pointless medical procedures”.

 The programme, dubbed CriSTAL (Criteria for Screening and Triaging to Appropriate alternative care), will be trialled in Sydney A&Es later this year to identify patients deemed likely to die within three months of going into hospital.

 Among the points listed as risk factors is low blood pressure, a weak pulse, history of disease, dementia, repeat hospitalisation, weakness, heart failures and sudden weight loss.

 Dr Magnolia Cardona-Morrell, who led the research at the university’s Simpson Centre for Health Services Research, said: “Most terminally ill people want to die at home, but in fact three quarters end up dying in acute hospitals, often after intrusive, expensive and ultimately pointless medical procedures.

 The study's authors claim the list would improve care by enabling doctors to be honest about patients' chances with families and giving them greater choice “Current acute hospital systems often fail to recognise or cater to the needs of people for whom death is imminent and unavoidable. They are geared for aggressive treatment and emergency resuscitation, not peaceful, harm-free transitions.

 “Elderly people who are dying need to be protected from heroic but intrusive live-saving hospital interventions that often only prolong suffering rather than enhance quality of remaining life.”

 The checklist is only meant to be used for patients aged 65 or over and a number of factors must combine for death to be considered “unavoidable”.

 A spokesperson for the University of New South Wales said CriSTAL had been compiled using an “extensive review of the strengths and weaknesses of medical literature that attempts to diagnose dying”. Most of the existing tools were found to rely on clinical judgment, subjective assessments and value judgments.

 A paper describing the assessment procedure has been published in the BMJ Supportive and Palliative Care journal.

 In it, Dr Cardona-Morrell and Ken Hillman, a professor of intensive care, argue that a balance must be struck between limited health resources, families’ expectations and the dignity of the patient.

 CrisTAL is being trialled in selected hospital emergency departments in Sydney this year. The programme includes communication training for medical staff, so they can sensitively discuss with dying patients and their carers the limitations of medical treatment and their choices.

 Dr Cardona-Morrell said medicine “cannot work miracles” against old age and multiple chronic conditions in elderly patients.

 Her co-author Professor Hillman believes the management of elderly patients at the end of their lives is “one of the greatest challenges facing health care”.

 “Most patients and their carers do not wish to be admitted to a hospital at the end of their life and this is a major contributor to the unsustainable costs of health care,” he said.

 No such list exists in Britain but the director of Age UK said the move would be welcomed on the condition that discussions with relatives were handled “compassionately”.

 “The best time to begin discussing end of life issues and an older person’s wishes is well in advance, when they are fit and well, but we acknowledge that this isn't always possible,” Caroline Abrahams added.

 “The ability to accurately identify people entering hospital who are nearing the end of their lives ought to help ensure they receive high quality care, appropriate to their needs, so we welcome this development.

 "However, in practice, access to good end of life care services remains extremely variable and discussions with older people and their families about this most difficult of subjects are not always handled sensitively and well.” ||||| □ Being admitted via emergency this hospitalisation 96 (associated with 25% mortality within 1 year)

 □ OR Meets 2 or more of the following deterioration criteria on admission 30 32 98

 □ 1. Decreased LOC: Glasgow Coma Score change >2 or AVPU=P or U

 □ 2. Systolic blood pressure <90 mm Hg

 □ 3. Respiratory rate <5 or >30

 □ 4. Pulse rate <40 or >140

 □ 5. Need for oxygen therapy or known oxygen saturation <90% 33

 □ 6. Hypoglycaemia: BGL 99

 □ 7. Repeat or prolonged seizures 99

 □ 8. Low urinary output (<15 mL/h or <0.5 mL/kg/h) 100

 □ OR MEW or SEWS score >4 46 79

 AND OTHER RISK FACTORS /PREDICTORS OF SHORT-MEDIUM-TERM DEATH

 □ Personal history of active disease (at least one of): 18 25 42 46 63 101 102

 □ Advanced malignancy

 □ Chronic kidney disease

 □ Chronic heart failure

 □ Chronic obstructive pulmonary disease

 □ New cerebrovascular disease

 □ Myocardial infarction

 □ Moderate/severe liver disease

 □ Evidence of cognitive impairment (eg, long term mental disorders, dementia, behavioural alterations or disability from stroke) 25 42 63 73 83

 □ Previous hospitalisation in past year 10

 □ Repeat ICU admission at previous hospitalisation 95 (associated with a fourfold increase in mortality)

 □ Evidence of frailty: 2 or more of these: 42 46 63 85 89 98

 □ Unintentional or unexplained weight loss (10 lbs in past year) 18 83 85

 □ Self-reported exhaustion (felt that everything was an effort or felt could not get going at least 3 days in the past week) 85

 □ Weakness (low grip strength for writing or handling small objects, difficulty or inability to lift heavy objects >=4.5Kg) 63

 □ Slow walking speed (walks 4.5 m in > 7 s)

 □ Inability for physical activity or new inability to stand 46 98

 □ Nursing home resident/in supported accommodation 33 46

 □ Proteinuria on a spot urine sample: positive marker for chronic kidney disease & predictor of mortality: >30 mg albumin/g creatinine 56 103 ||||| A test to determine if elderly patients will die within 30 days of being admitted to hospital has been developed by doctors to give them the chance to go home or say goodbye to loved ones.

 Health experts say the checklist will prevent futile and expensive medical treatments which merely prolong suffering.

 The screening test looks at 29 indicators of health, including age, frailty, illness, mental impairment, previous emergency admissions and heart rate and produces a percentage chance of death within one month and 12 weeks.

 Researchers say the aim of Critera for Screening and Triaging to Appropriate aLternative care, or CriSTAL for short, is to kick-start frank discussions about end of life care, and minimise the risk of invasive ineffective treatment.

 “Delaying unavoidable death contributes to unsustainable and escalating healthcare costs, despite aggressive and expensive interventions,” said lead author Dr Magnolia Cardona-Morrel, a researcher at the University of New South Wales.

 “These interventions may not influence patient outcome; often do not improve the patient’s quality of life; may compromise bereavement outcomes for families; and cause frustration for health professionals.”

 Earlier this week Professor Sir Mike Richards, the Chief Inspector of Hospitals for the Care Quality Commission, warned that dying patients are receiving wide variations in care because of hospital failure to replace the Liverpool Care Pathway.

 The controversial end-of-life plan was scrapped after a review of the regime found that hospital staff wrongly interpreted its guidance for care of the dying, leading to patients being drugged and deprived of fluids in their last weeks of life.

 The Health Select Committee is currently examining palliative and end of life care in the wake of the LCP controversy.

 However the new test aims to provide a ‘starting point’ for ‘honest communication with patients and families about recognising that dying is part of the life cycle’

 Researchers looked at 112 peer-reviewed studies to find out which tests and questions were the best predictors of death.

 They claim the test will help doctors and nurses who are often under great pressure from family members and society to prolong the life of patients at all costs.

 “While there are accepted policies for de-escalating treatment in terminally ill patients, there are also inherent and societal pressures on medicine to continue utilising technological advances to prolong life even in plainly futile situations,” said Dr Cardona-Morrel.

 “Training for nurses and doctors in the use of the screening tool and in approaching patients and families with concrete information about inevitability of death and lack of benefit of further intensive treatment are paramount.”

 Most patients end up dying in hospital, even though that is not their stated preference, when asked.

 Caroline Abrahams, Charity Director at Age UK, said:“The best time to begin discussing end of life issues and an older person’s wishes, is well in advance, when they are fit and well, but we acknowledge that this isn’t always possible.

 “The ability to accurately identify people entering hospital who are nearing the end of their lives ought to help ensure they receive high quality care, appropriate to their needs, so we welcome this development. However, in practice, access to good end of life care services remains extremely variable and discussions with older people and their families about this most difficult of subjects are not always handled sensitively and well.

 “So as well as improved analysis and triage of people’s needs, better training and support for medical staff in speaking compassionately with older people and their families about end of life care is also required. “

 By giving families and patients some options about the preferred place of death, the test could also help terminally ill elderly people choose to go home, the authors said.

 The checklist is yet to be tested but the researchers hope it will eventually be used for all hospital admissions.

 The research was published in the BMJ Open publication Supportive & Palliative Care. ||||| A test devised by Sydney researchers to determine the likelihood of a patient's death within the next 30 days will be trialled in local hospitals from March.

 The Criteria for Screening and Triaging to Appropriate aLternative care, or CriSTAL, developed by University of New South Wales researcher Magnolia Cardona-Morrel, would take into account 29 different criteria to assess whether it was worthwhile carrying out life-saving treatments and procedures.

 Careful criteria: The CriSTAL test is designed to help terminally ill and elderly patients choose whether to undergo further treatment. Photo: Greg Newington

 Dr Cardona-Morrel said the test was designed to help doctors begin a conversation with terminally ill patients, particularly elderly patients, as to whether they would like to continue to receive treatment and where they would prefer to die.

 "The test is easy to administer and the [answers] are readily available in the patient's clinical records and it can be completed in five or 10 minutes," she said. "The score by no means decides the treatment."

 She said the aim of CriSTAL was to stop the common practice of terminally ill patients being put through unnecessary treatments and surgery in an attempt to save their lives.

 "Doctors are keeping people alive because they can," Dr Cardona-Morrel said. "Hospitals are full of elderly people living longer because technology allows it. A lot of them would like to die at home."

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 Dr Cardona-Morrel said the results of the test were designed as a tool for doctors to use in discussing the available options with patients.

 "When a patient is diagnosed with a terminal illness their first question is always, 'Doctor, how long do I have left?," she said.

 "Doctors see their role as to protect their patients so they don't like to give them sad or bad news."

 The test, which was presented at a medical conference in the US recently, has been welcomed by medical professionals around the world.

 "I had lots of nurses and doctors standing there saying, 'We have been waiting for a tool like this for years, when can we start using it?'" she said.

 "To me that is an indication there is a need out there."

 Once the score is determined the doctor could have a transparent conversation with the patient about their wishes.

 She said once the score is determined the doctor could have a "transparent conversation" with the patient about their wishes and give them all the options available, including palliative care at home, or in a hospice.

 The test is undergoing retrospective testing, looking at patients who have died and seeing if it would have been able to calculate the time they had left, before it is introduced into hospitals.

 Dr Cardona-Morrel said the test was already being used in some Irish and US hospitals, and she hoped it would be in use in Australian hospitals by the end of the year.

 Even though the test has not been designed for general practitioners to use, Dr Cardona-Morrel said she hoped it would encourage them to keep an eye out for the signs of a terminally ill patient and begin discussions about advanced care directives before the patient became too unwell.

 The full list of criteria can be found in the paper by Dr Cardona-Morrell and Ken Hillman in the British Medical Journal. |||||Summary:

– Seniors had better brace themselves: Some US hospitals are now administering the "death test," which estimates an elderly patient's chance of dying over the next 30 days. Invented in Australia, the test weighs 29 different criteria—including blood pressure, respiratory rate, and medical history—to determine whether hospitalization is worthwhile or the patient should return home or go to a hospice, the Sydney Morning Herald reports. The idea is to prevent needless and expensive procedures while allowing patients to spend their last days with loved ones. "Most terminally ill people want to die at home, but in fact three quarters end up dying in acute hospitals, often after intrusive, expensive, and ultimately pointless medical procedures," says study author Magnolia Cardona-Morrell, the Independent reports. The test also aims to take pressure off doctors and nurses to prolong patients' lives "at all costs," the Telegraph reports. "I had lots of nurses and doctors standing there saying, 'We have been waiting for a tool like this for years, when can we start using it?'" says Cardona-Morrell, whose work was presented recently at a US medical conference. "To me that is an indication there is a need out there." She says the test takes just five or 10 minutes, and helps doctors have a more "transparent" conversation with patients. Called CriSTAL, it's now being tested to see if it would have predicted the future of patients who have since died. Then it may be used in more hospitals. (In related news, a study says those who feel younger than their age will live longer.)