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Palliative sedation

In medicine, specifically in end-of-life care, palliative sedation (also known as terminal sedation, continuous deep sedation, or sedation for intractable distress of a dying patient) is the palliative practice of relieving distress in a terminally ill person in the last hours or days of a dying person's life, usually by means of a continuous intravenous or subcutaneous infusion of a sedative drug, or by means of a specialized catheter designed to provide comfortable and discreet administration of ongoing medications via the rectal route.

As of 2013, approximately tens of millions of people a year were unable to resolve their needs of physical, psychological, or spiritual suffering at their time of death. Due to the amount of pain a dying person may face, palliative care is considered important. Proponents claim palliative sedation can provide a more peaceful and ethical solution for such people.

Palliative sedation is an option of last resort for the people whose symptoms cannot be controlled by any other means. It is not considered a form of euthanasia or physician-assisted suicide, as the goal of palliative sedation is to control symptoms, rather than to shorten or end the person's life.

Palliative sedation is legal everywhere and has been administered since the hospice care movement began in the 1960s. The practice of palliative sedation has been a topic of debate and controversy as many view it as a form of slow euthanasia or mercy killing, associated with many ethical questions. Discussion of this practice occurs in medical literature, but there is no consensus because of unclear definitions and guidelines, with many differences in practice across the world.

Definition
Palliative sedation is the use of sedative medications to relieve refractory symptoms when all other interventions have failed. The phrase "terminal sedation" was initially used to describe the practice of sedation at end of life, but was changed due to ambiguity as to what the word 'terminal' meant. The term "palliative sedation" was then used to emphasize palliative care. The level of sedation via palliative sedation may be mild, intermediate or deep and the medications may be administered intermittently or continuously.

The term "refractory symptoms" is defined as symptoms that cannot be controlled despite the use of extensive therapeutic resources, with such symptoms having an intolerable effect on the patient's well-being in the final stages of life. The symptoms may be physical, psychological, or both.

Palliative care
Palliative care is aimed to relieve suffering and improve the quality of life for people with serious and/or life-threatening illness in all stages of disease, as well as for their families. It can be provided either as an add-on therapy to the primary curative treatment or as a monotherapy for people who are on end-of-life care. In general, palliative care focuses on managing symptoms, including but not limited to pain, insomnia, mental alterations, fatigue, difficulty breathing, and eating disorders. In order to initiate the care, self-reported information is considered the primary data to assess the symptoms along with other physical examinations and laboratory tests. However, in people at the advanced stage of the disease with potential experience of physical fatigue, mental confusion or delirium which prevent them from fully cooperating with the care team, a comprehensive symptom assessment can be utilized to fully capture all symptoms as well as their severity.

There are multiple interventions that can be used to manage the conditions depending on the frequency and severity of the symptoms, including using medications (i.e. opioid in cancer-related pain), physical therapy/modification (i.e. frequent oral hygiene for xerostomia/dry mouth treatment), or reversal of precipitating causes (i.e. low fiber diet or dehydration in constipation management).

Palliative sedation
Palliative sedation is often the last resort if the person is resistant to other managing therapies or if the therapies fail to provide sufficient relief for their refractory symptoms, including pain, delirium, dyspnea, and severe psychological distress.

In terms of the initiation of palliative sedation, it should be a shared clinical decision initiated preferably between the person receiving treatment and the care team. If severe mental alterations or delirium is the concern for the person to make an informed decision, consent can be obtained in the early stage of the disease or upon the admission to the hospice facility. Family members can only participate in the decision-making process if explicitly requested by the person in care.

Palliative sedation can be used for short periods with the plan to awaken the person after a given time period, making terminal sedation a less correct term. The person is sedated while symptom control is attempted, then the person is awakened to see if symptom control is achieved. In some extreme cases (i.e. for those whose life expectancy is hours or days at the most), palliative sedation is begun with the plan to not attempt to reawaken the person.

Assessment and obtaining consent
Though people may receive palliative care, pharmacologically decreasing one's consciousness may be the only remaining option to help alleviate intolerable disease symptoms and suffering. Prior to receiving palliative sedation, persons should undergo careful consideration along with their health care team to make sure all other resources and treatment strategies have been exhausted. In the case the person is uncommunicable due to severe suffering, the individual's family member should be consulted, as decreasing the distress of family members is also a key component and goal of palliative care and palliative sedation.

The first step in consideration of palliative sedation is assessment of the person seeking the treatment.

There are several states that one may be in that can make palliative sedation the preferred treatment, including but not limited to physical and psychological pain and severe emotional distress. More often than not, refractory or intolerable symptoms give a more sound reason to pursue palliative sedation. Though the interdisciplinary health care team is there to help each person make the most sound medical decision, the individual's judgement is considered to be the most accurate in deciding whether or not their suffering is manageable.

According to a systematic review encompassing over thirty peer-reviewed research studies, 68% of the studies used stated physical symptoms as the primary reason for palliative sedation. The individuals involved in the included studies were terminally ill or suffering from refractory and intolerable symptoms. Medical conditions that had the most compelling reasons for palliative sedation were not only limited to intolerable pain, but include psychological symptoms such as delirium accompanied by uncontrollable psychomotor agitation. Severe trouble breathing (dyspnea) or respiratory distress were also considered a more urgent reason for pursuing palliative sedation. Other symptoms such as fatigue, nausea, and vomiting were also reasons for palliative sedation.

Once assessment is completed and palliative sedation has been decided for the person, a written consent for administration to proceed must be given by the individual. The consent must state their agreement for sedation and lowering their consciousness, regardless of each individual's stage in illness or the treatment period of palliative sedation. In order to make a decision, one must be sufficiently informed of their disease state, the specificities and implications of treatment, and potential risks they may face during the treatment. At the time of consent, the person should fully be aware of and understand all necessary legal and medical consequences of palliative sedation. It is also critical that the individual is making the decision upon their own free will, and not under coercion of any sort. The only exception where the individual's consent is not obtained would be in emergency medical situations where one is incapable of making a decision, in which the individual's family or caregiver must give the consent after adequate education, as one would have been given.

Continuous vs. intermittent sedation
Palliative sedation can be administered continuously, until the person's death, or intermittently, with the intention to discontinue the sedation at an agreed upon time. Although not as common, intermittent sedation allows family members of the person to gradually come to terms with their grief and while still relieving the individual of their distress. During intermittent palliative sedation, the person is still able to communicate with their family members. Intermittent sedation is recommended by some authorities for use prior to continuous infusion to provide the person with some relief from distress while still maintaining interactive function.

Sedating agents
Benzodiazepines: These are a drug class that works on the central nervous system to tackle a variety of medical conditions, such as seizures, anxiety, and depression. As benzodiazepines suppress the activities of nerves in the brain, they also create a sedating effect which is utilized for multiple medical procedures and purposes. Among all benzodiazepine agents, midazolam (Versed) is the most frequently used medication for palliative sedation for its rapid onset and short duration of action. The main indications for midazolam in palliative sedation are to control delirium and alleviate breathing difficulties so as to minimize distress and prevent exacerbation of these symptoms.

Opioids: Opioid agents —which relieve pain primarily via modulation of receptor activity in the central nervous system —also commonly induce sedation or drowsiness. However, they are more frequently used for analgesia than sedation.

Even though opioids tend to provide a comforting effect for recipients, there exists the risk of drug dependence and —to a lesser extent —substance use disorder and diversion of medications. Therefore, the Clinical Practice Guidelines for Quality Palliative Care from the National Consensus Project recommends a comprehensive assessment of symptoms prior to initiating pharmacological therapy, ongoing monitoring to determine efficacy and any adverse effects, and educating the patient and family.

Administration and monitoring
Palliative sedation is administered commonly in hospital or inpatient settings, but also reported to be performed in home care settings. The medication prescribed for palliation will need dose titration to initially manage the refractory symptoms and relieve suffering, and therapy will continue to maintain adequate effect. Prescribed sedatives can be administered intravenously, rectally, etc. on a continuous and/or intermittent basis. When breakthrough symptoms occur, emergency bolus therapy will be needed to maintain symptom management. Both mild and deep levels of sedation may be used to provide relief from suffering, with deeper levels used when death is imminent and a catastrophic event has occurred.

The person being treated will be monitored during palliative sedation to maintain adequate symptom relief, but the following clinical situations will determine a need for dose titration:

 * Person is at end-of-life: Vitals are not monitored except for respiratory rate to assess respiratory distress and tachypnea. The goal is to achieve comfort, so downward titration of sedation is not recommended due to risk of recurrent distress.
 * Person is nearing end-of-life: Vitals such as heart rate, blood pressure, and oxygen saturation, are monitored to maintain physiological stability through sedation. Depending on the risk of a person to have respiratory depression or become unstable, the treatment dose may need to be adjusted or a benzodiazepine antagonist may be administered.
 * Suffering managed and symptom controlled: Sedation may be carefully lowered for lucidity. This would provide possibility of reevaluating the person's preferences for care or allow family communication.

Nutrition and fluids
As people undergoing terminal sedation are typically in the last hours or days of their lives, they are not usually eating or drinking significant amounts. There have not been any conclusive studies to demonstrate benefit to initiating artificial nutrition (TPN, tube feedings, etc.) or artificial hydration (subcutaneous or intravenous fluids). There is also a risk that IV fluids or feedings can worsen symptoms, especially respiratory secretions and pulmonary congestion. If the goal of palliative sedation is comfort, IV fluids and feedings are often not consistent with this goal.

A specialized rectal catheter can provide an immediate way to administer small volumes of liquids for people in the home setting when the oral route is compromised. Unlike intravenous lines, which usually need to be placed in a hospital environment, the rectal catheter can be placed by a clinician, such as a hospice nurse or home health nurse, in the home. This is useful for people who cannot swallow, including those near the end of life.

Before initiating terminal sedation, a discussion about the risks, benefits and goals of nutrition and fluids is encouraged, and is mandatory in the United Kingdom.

Sedation vs. euthanasia
Titrated sedation might speed up death, although death is considered a side effect and sedation does not equate with euthanasia. A survey of 663 physicians in the United States, found half had an experience of their treatment being characterised as murder, euthanasia, or killing in the preceding five years with palliative sedation (along with stopping of hydration and nutrition) being the most common act in palliative care interpreted as killing.

The primary difference between palliative sedation, relief of severe pain and symptoms, and euthanasia (the intentional ending of a person's life) is both their intent and their outcome. At the end of life sedation is only used if the individuals perceives their distress to be unbearable, and there are no other means of relieving that distress. The intended goal is to provide them some relief of their suffering through the use of benzodiazepines and other agents which inadvertently may increase the risk of death. Studies have been conducted however, showing that the risk of death through palliative sedation is much lower than earlier perceived. This has raised the argument that palliative sedation does not cause or hasten death and that an individual's death following palliative sedation is more likely to be due to their disease —the measure of success of palliative sedation remains relief of a person's symptoms until their end of life. On the other hand, euthanasia is performed with the intent to permanently relieve the person of their pain through death —the measure of success being their death.

In palliative care, the doses of sedatives are titrated (i.e., varied) to keep the individual comfortable without compromising respiration or hastening death. Death typically results from the underlying medical condition.

People (or their legal representatives) only have the right to refuse treatments in living wills; however the demand of life saving treatments, or any treatments at all is controversial among states and heavily depends on each specific situation. However, once unconsciousness begins, as the person is no longer able to decide to stop the sedation or to request food or water, the clinical team can make decisions for the individual. A living will made when competent, can, under UK law, give a directive that the person refuses "Palliative Care" or "Terminal Sedation", or "any drug likely to suppress my respiration."

The use of sedation for palliative care in the UK was considered as part of an independent review of the Liverpool Care Pathway for the Dying Patient. Families of patients in some instances said that they thought the doses of sedatives prevented patients from asking for water leading to death from dehydration, there were many accounts of subcutaneous infusions being started as a matter of course rather than to control a specific symptom,  there were many reports of patients being left alone for a short-period of time by their families only to find that sedation had been administered leaving them unable to speak to their relatives;  relatives and carers reported instances where they felt that the administration of morphine had directly lead to the death of a patient.

Physician-assisted Suicide
As of 2022, assisted suicide in the United States, otherwise known as medical aid in dying, is legal in ten jurisdictions (California, Colorado, District of Columbia, Hawaii, Maine, Montana, New Jersey, Oregon, Vermont, and Washington).

Prevalence
In a review of research articles on various aspects of palliative care, the prevalence of palliative sedation was reported as highly varied. In palliative care units or hospice, the prevalence ranged between 3.1–51%. In the home care setting, two Italian studies reported a prevalence of 25% and 52.5%. Hospital-based palliative support teams vary in prevalence, with reports of 1.33% and also 26%. Different countries also report large differences in prevalence of palliative sedation: A 2009 survey of almost 4000 U.K. people whose care had followed the Liverpool Care Pathway for the Dying Patient found that while 31% had received low doses of medication to control distress from agitation or restlessness, only 4% had required higher doses.

Almost half of the studies reviewed differentiated intermittent versus continuous palliative sedation. The prevalence of intermittent sedation was 30–67% of cases and continuous sedation was 14–68% of cases. People starting intermittent sedation may progress to use of continuous sedation in 10–27% of cases. The prevalence of mild versus deep sedation was also reported: one study reported 51% of cases used mild sedation and 49% deep sedation; a second study reported 80% of cases used mild sedation and 20% deep sedation.

Survival
There are reports that after initiation of palliative sedation, 38% of people died within 24 hours and 96% of people died within one week. Other studies report a survival time of < 3 weeks in 94% of people after starting palliative sedation. Some physicians estimate that this practice shortens life by ≤24 hours for 40% of people and > 1 week for 27% of people. Another study reported people receiving sedation in their last week of life survived longer than those who did not receive sedation, or only received sedation during last 48 hours of life.

According to 2009 research, 16.5% of all deaths in the United Kingdom during 2007–2008 took place after continuous deep sedation.

U.S. hospice care movement
Hospice care emphasizes palliative, rather than curative, treatment to support individuals during end-of-life care when all other alternatives have been exhausted. It differs vastly from other forms of healthcare because both the person and the family are included in all decision-making and aims to treat the individual, not the disease. The Hospice Care Movement began in the United States during the 1960s and was influenced heavily on the model published by St. Christopher's Hospice of London located in Great Britain. Despite differing setting, services, and staffing, the U.S. hospice care movement still sought to maintain the goals and philosophy of St. Christopher's model which centered on symptom control to allow the person to die with freedom, rather than attempting curative treatment.

The first Hospice in the United States, Connecticut Hospice, was founded by Florence Wald and opened in 1974. Supporters of the movement faced many challenges early on, the biggest being the lack of insurance coverage for hospice care services. Initiatives to increase public awareness of the movement were created to combat this obstacle and supply the movement with public funding in order to maintain their services. One of the greatest accomplishments made by the movement was in the inclusion of hospice care in services covered under Medicare in 1982. This victory prompted the creation of National Hospice Week by President Reagan to take place from November 7–14 as a form of recognition to the vital impact nurses and caregivers have on these individuals and their families. Less than five decades after the first hospice program began, there are now over 4,000 programs in place under the umbrella of a multi-billion dollar industry. The cumulative budget for hospice programs nationwide increased from 10 million in the late 1970s, to 2.8 billion dollars in 1995, and 10 billion in 2008.

United States
In 2008, the American Medical Association Council on Ethical and Judicial Affairs approved an ethical policy regarding the practice of palliative sedation. There is no specific law in barring the practice of palliative sedation, and the U.S. Conference of Catholic Bishops is reported to accept the practice of keeping people pain-free at end of life.

Sweden
In October 2010 Svenska Läkaresällskapet, the Swedish medical association, published guidelines which allowed for palliative sedation to be administered even with the intent of the terminally ill person not to reawaken.

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RAF Bruggen

Royal Air Force Brüggen, more commonly known as RAF Brüggen,  in Germany was a Royal Air Force station until 15 June 2001. It was situated next to the village of Elmpt, approximately 43 km west of Düsseldorf on the Dutch–German border. The base was named after the village of Brüggen, the nearest rail depot. Construction began in mid-1952, which involved the clearing of forest and draining of marshland. The station became active in 1953 during the rapid expansion of NATO forces in Europe. The main paint shop situated next to the main runway was responsible for the surface finishing of all aircraft, ground equipment and RAF Regiment Rapier missile systems. In 2002, it was handed over to the British Army and renamed Javelin Barracks.

317 Supply and Transport Column
In 1953, the 317 Supply and Transport Column arrived at RAF Brüggen from Uetersen. This followed the decision to supply all RAF stations in Germany through the port of Antwerp. In 1954 the unit was redesignated as a Mechanical Transport Squadron and was responsible for equipping and supplying all RAF stations in Germany and The Netherlands. The unit remained at Brüggen until 1963, when it was amalgamated into the No. 431 Maintenance Unit RAF which continued to operate until 1993. The demise of 317 MT Squadron marked the end of an era, as it had been on the continent shortly after D-Day under its previous title of 317 Supply & Transport Column. It had built itself an enviable reputation and following the cessation of hostilities carried out convoys to Prague, Warsaw and Moscow. In the 1950 Review of the Royal Air Force, the unit was described as the Carter Paterson of the autobahns.

Throughout its life, 317 carried out a number of humanitarian operations; the first being medical supplies to Bergen-Belsen. This was followed in 1947 by Operation Woodpecker in which timber and peat were supplied to the civilian population of northern Germany in one of the coldest winters on record. This was followed by the return of displaced persons and POWs to their home towns and cities within the British Zone. They were called upon again at the start of the Berlin Airlift (Operation Plain Fare), and lastly, in the winter of 1962/3, the Squadron took a convoy of fuel trucks to the oil refineries in Rotterdam for heating oil which was delivered to hospitals in Germany during the great freeze when the canals were inoperable.

1954–1998 – Strike/attack role
From 1954–1957 the fighter squadrons at Bruggen were 67, 71E, 112 & 130, equipped initially with Canadair Sabre F.4s, later re-equipped with the Hawker Hunter F.4s. These squadrons were either redeployed or disbanded in 1957 with the arrival of 87 Squadron, equipped with Gloster Javelin FAW.1s. The initial strike capability at RAF Brüggen was provided by the English Electric Canberra from the summer of 1957. From 1969 to 1975 the Phantom FGR.2 operated in the strike/attack role and was replaced by the SEPECAT Jaguar GR.1 from 9 April 1975. The Jaguars were replaced by the Panavia Tornado GR.1 beginning on 13 June 1984. With a total of four Tornado GR.1 squadrons at Brüggen and four more at its nearby sister airbase RAF Laarbruch, Brüggen and Laarbruch formed the largest Tornado force in NATO. Hardened Aircraft Shelters were equipped with the U.S. Weapon Storage Security System (WS3), each able to store up to 4 WE.177 tactical nuclear bombs, for delivery by Tornado aircraft.

1984 – Nuclear incident
On 4 September 2007, the British military admitted that there had been an accident with a nuclear weapon at RAF Brüggen on 2 May 1984. The nuclear weapon fell from a transport truck, as the missile wasn't securely attached to the truck. The weapon was eight times more powerful than the bomb that was dropped on Hiroshima in 1945. The casing was X-rayed after the incident, and found to have been undamaged. The six people who were responsible for the accident received a reprimand for their actions in the incident.

1998–2001 – Attack role
Following reunification of Germany, the RAF announced plans to reduce its presence in the country by half. One major part of this was the reduction of Tornado squadrons in Germany from seven to four, No.9, No.14, No.17 and No.31 squadrons. No.9, No.14 and No.31 squadrons took part in the Gulf War, and later operated from Bruggen during NATO's air operations in the Kosovo War, supported by Vickers VC10 tankers.

The decision to remove all RAF assets from Germany was taken in 1996. As a result of the Strategic Defence Review No. 17 Squadron disbanded on 31 March 1999 and began the gradual drawdown of the base. No. 14 Sqn relocated to RAF Lossiemouth in January 2001. A formal ceremony on 15 June officially ended a continuous Royal Air Force presence in Germany since World War II and all of the remaining Tornados had left for RAF Marham by 4 September 2001.

Brüggen squadrons

 * No. 9 Squadron RAF from 1 October 1986 until July 2001) – operating Panavia Tornado GR.1, GR.4.
 * No. 14 Squadron RAF – operating:
 * Phantom FGR.2 between 1 July 1970 and 30 November 1975
 * SEPECAT Jaguar GR.1 between 1 December 1975 and 1 November 1985
 * Panavia Tornado GR.4 from 1 November 1985
 * No. 17 Squadron RAF – operating:
 * Phantom FGR.2 between 1 September 1970 and 30 January 1976
 * SEPECAT Jaguar GR.1 between 1 February 1976 and 1 March 1985
 * Panavia Tornado GR.1 from 1 March 1985–99)
 * No. 20 Squadron RAF – operating SEPECAT Jaguar GR.1 between 1 March 1977 and 30 June 1984
 * No. 25 Squadron RAF – operating Bristol Bloodhound missiles
 * No. 31 Squadron RAF – operating:
 * Phantom FGR.2 between 20 July 1971 and 30 June 1976
 * SEPECAT Jaguar GR.1 between 30 June 1976 and 1 November 1984
 * Panavia Tornado GR.1 from November 1984
 * No. 67 Squadron RAF – operating:
 * Canadair Sabre F.4s between 5 July 1955 and March 1956
 * Hawker Hunter F.4s between January 1956 and 31 May 1957
 * No. 71 Squadron RAF – operating:
 * Canadair Sabre F.4s between 7 July 1955 and May 1956
 * Hawker Hunter F.4s between April 1956 and 31 May 1957
 * No. 80 Squadron RAF – operating English Electric Canberra PR.7 until 30 September 1969
 * No. 87 Squadron RAF – operating:
 * Gloster Javelin FAW.1 between August 1957 and January 1961
 * Gloster Javelin FAW.5 between September 1958 and October 1960
 * Gloster Javelin FAW.4 between November 1959 and January 1961
 * No. 112 Squadron RAF – operating:
 * de Havilland Vampire FB.5 between July 1953 and February 1954
 * Canadair Sabre F.4s between January 1954 and April 1956
 * Hawker Hunter F.4s between April 1956 and May 1957
 * No. 130 Squadron RAF – operating:
 * Canadair Sabre F.4s between August 1953 and May 1956
 * Hawker Hunter F.4s between April 1956 and May 1957
 * No. 213 Squadron RAF operating English Electric Canberra B(I).6 between 22 August 1957 and 31 December 1969
 * No. 37 Squadron RAF Regiment – operating BAC Rapier.
 * No. 431 Maintenance Unit RAF.

Handover to Army
With the Royal Air Force having no use for site of the former RAF Brüggen, the base was handed over to the British Army on 28 February 2002 to become Elmpt Station, Javelin Barracks. The 18-hole RAF Brüggen Golf Club became West Rhine Golf Club.

Former units
 * 7th Signal Regiment
 * 16th Signal Regiment
 * Support Squadron
 * 207 Signal Squadron
 * 230 Signal Squadron
 * 255 Signal Squadron
 * 628 Signal Troop
 * 1st Military Intelligence Battalion
 * HQ Company
 * Operations Support Company
 * 15 Military Intelligence Company
 * 16 Military Intelligence Company

Final closure
The barracks was closed in November 2015 and the site returned to German authorities. Since December 2015 the accommodation units have been used by the German government to house refugees.

The 882 ha area is currently owned by the Bundesanstalt für Immobilienaufgaben (BImA). In 2020 negotiations are under way to sell it to Entwicklungsgesellschaft "Energie- und Gewerbepark Elmpt" mbH (EGE), a company founded in 2016 with the objective of converting 150 ha of the area into an energy and industry park.

license: Creative Commons - Attribution Share-Alike - https://creativecommons.org/licenses/by-sa/4.0/

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Willie Tee

Wilson Turbinton (February 6, 1944 – September 11, 2007), professionally known as Willie Tee, was an American keyboardist, songwriter, singer, producer and notable early architect of New Orleans funk and soul, who helped shape the sound of New Orleans for more than four decades.

Career
Tee arranged, co-wrote and led the band on the Wild Magnolias' self-titled 1974 debut album. The popularity of that recording, and the subsequent They Call Us Wild, introduced the Mardi Gras Indians' street-beat funk to the world.

Tee grew up in the Calliope Projects in New Orleans. His earliest influences ranged from the rhythm and blues of Professor Longhair to the jazz of John Coltrane.

He made his first recordings for the local AFO Records in 1962 while still a teenager. Three years later, he cut "Teasin' You", a soulful, mid-tempo composition for Atlantic Records. His "Walking Up a One-Way Street" and "Thank You John" were also popular hits.

In the late 1960s, Willie Tee & the Souls played venues from the Apollo Theater in Harlem to the Ivanhoe on Bourbon Street. After hearing the band at the Ivanhoe in 1968, jazz musician Cannonball Adderley encouraged Tee to record an instrumental album. The album was never released, but the master tapes were recently rediscovered in the vaults of Capitol Records. Tee's pop was called expressive, his funk ferocious and his jazz "like mirrors in a prism" by longtime producer Leo Sacks, who called Willie Tee "a monster on the B-3 organ" in a Times-Picayune article.

Tee's early recordings, many of which were reissued by New York's Tuff City Records, were employed as source material for rappers. Houston's Geto Boys sampled "Smoke My Peace Pipe", a song Tee had written for the Wild Magnolias. Sean Combs borrowed riffs and grooves from the Gaturs' "Concentrate" for the 1997 album No Way Out. Alex Chilton also recorded a version of "Thank You John" in the 1980s, and Russell Minus completed a suite of elegies in 1996.

More recently, New Orleans rapper Lil Wayne sampled "Moment of Truth", a song from Turbinton's 1976 album, Anticipation for "Tha Mobb", the opening track on Tha Carter II.

Tee remained active in his career as a producer, songwriter, performer and session musician. His collaborations with his brother Earl included 1988's Brothers for Life. He contributed to Dr. John's 2004 album, N'Awlinz: Dis Dat or D'Udda, and appeared briefly in the Oscar-winning Jamie Foxx film about Ray Charles, Ray.

In October 2005, after Hurricane Katrina devastated New Orleans, Turbinton accepted a job as a visiting lecturer in the music department at Princeton University, and spent the next four months working with music students there. In January 2006, he returned to Louisiana and settled in Baton Rouge.

In April 2007, the Louisiana Music Hall of Fame honored Tee for his contributions to Louisiana music with an induction.

Tee died on September 11, 2007, aged 63, four weeks after being diagnosed with colon cancer.

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Shoe-last celt

A shoe-last celt (German: Schuhleistenkeil) is a long thin polished stone tool for felling trees and woodworking, characteristic of the early Neolithic Linearbandkeramik and Hinkelstein cultures, also called Danubian I in the older literature.

Appearance
The tools are square in profile with a rounded top, which is why they are compared with shoe makers' lasts. The preferred material is amphibolite; basalt is also used.

Typology
In regards to the typology of neolithic adzes, initially two types were distinguished,

When width exceeds thickness they were named flat adzes (Flachhacke), when thickness exceeds width shoe-last adzes (Schuhleistenkeile), or high adzes. Within the latter group a distinction is sometimes made between intermediate Flomborn adzes and the higher Hinkelstein adzes (Buttler 1938; Bakels 1987; Merkel 1999). Later, subdivisions were made on the basis of metric characteristics into two groups (Schietzel 1965), six groups (Modderman 1970, 184) and finally two groups again (Dohrn-Ihmig 1983). All typologies were based on the width-height ratio, while Modderman added the absolute dimension. The wide variation, from small to large and from flat to high adzes, certainly reflects a functional differentiation, but the various types do not appear to be of chronological significance.

Use

The polished stone axe or adze introduced a new way of life to Central Europe in mid-sixth millennium BC. It was a tool that was necessary for the clearing of the land to create fields and to build houses. These adzes were also used for the manufacture of agricultural tools, and any other wooden objects.

Shape and wear show that the celts were used as adzes to fell trees and to work wood. Some blades have traces of hafting as well. The finds from the wells of Kückhoven and Eythra in Germany demonstrate a high standard of carpentry. Shoe-last celts have also been used as weapons, as attested by smashed skulls from Schletz (Austria) and Talheim, Neckar (Germany). An older theory suggests their use as hoes, but there are no wear traces to support this.

Towards the end of the Linear Pottery Culture, around 5000 BC, the first perforated tools appear.

title: Shoe-last celt


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User:Santeri~enwiki

hello.

title: User:Santeri~enwiki


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Talk:Sixth Crusade

Legacy and Precedent
I don't think this section is particularly useful and should be absorbed into the main article. It also does not come across as balanced enough, as it hinges on the perception of Frederick's crusade as a success, which some historians would argue is flagrantly untrue. Gh0ti-2 22:13, 7 August 2007 (UTC)

 * How was it not a success? It achieved its goal - the restoration of Jerusalem to Crusader control, not to mention a fair amount of additional territory. All that without fighting a single battle. Pretty successful, especially when compared to the other 13th Century Crusades to the Holy Land, all of which ended pretty horribly. —Preceding unsigned comment added by 76.251.184.121 (talk) 07:09, 13 December 2010 (UTC)

Numbering the Crusades
Can anyone explain to me why the Sixth Crusade is, in German, the de:Fünfter Kreuzzug, that is to say the Fifth? The articles clearly refer to the same event, I'm just wondering why the discrepancy in numbering; it might be worth explaining in the article, since it can be very confusing when trying to do research. -- Jmabel 21:12, Sep 19, 2004 (UTC)

 * Well, both the fifth and the sixth were led by Frederick II, and sometimes they are considered to be one giant crusade. Sometimes nothing after the fourth is numbered, because there are just too many of them to divide into numbered and unnumbered. I have also seen these referred to as "Frederick II's first crusade" and his "second crusade," and also "Louis IX's first crusade" (and his second, to refer to what we have as the eighth and ninth here). However, on de:, they also have de:(Fünfter) Kreuzzug, and a note on the un-bracketed Fünfter saying "Dieser Kreuzzug wird manchmal als Sechtster Kreuzzug gezählt" ("sometimes also considered the Sixth Crusade"). So, after all this, I don't really know why they do that :) Adam Bishop 04:46, 20 Sep 2004 (UTC)

 * I think the non-numbering system works best. Calling Frederick II's crusades 5th and 6th is very much a French tradition and isn't really reflected in most historical studies. Going back to the German numbering that was traditionally used in English language works would obviously cause confusion since the popularisation of the French numbering but it doesn't agree with most of the more in depth books people might go to(people like Riely-Smith, Smail, Kedar, Mayer, Ellenbaum). Naming by leaders is the clearest way to define them in my opinion. 147.10.143.23 06:58, 11 November 2006 (UTC)

 * I think naming by leaders only functions from the 'Fifth Crusade' onwards. The preceding expeditions all had numerous leaders, or at least a clear hierarchy was not really established. Gh0ti-2 22:15, 7 August 2007 (UTC)

Probably typo, certainly confusing
"…and his wife, late Mary I, Queen of Jerusalem." I'm guessing that "late" is a typo for "later", but it can (very obscurely) mean "previously". Could someone who knows the facts here please turn it into "later" or "previously", whichever is correct? -- Jmabel | Talk 01:15, Jun 7, 2005 (UTC)

Decisive Saracen Victory?
The content of this article suggests the opposite of the stated result. 143.167.78.182 (talk) 12:21, 9 April 2013 (UTC)

the leader
hello! on this site its not very clear about who the leader was, so if you can, please help me and edit this talk and tell me who the leader ! thanks!! 86.155.49.250 (talk) 17:30, 3 February 2016 (UTC)

No other commanders, no flags nor coats of arms
Why were the coats of arms and flags in the article removed? There is no rule that forbids their use, nor do they make the article confusing, but vice versa. Why were the other crusade leaders deleted? The military campaign couldm't be the work of one man, it's absurd. The coats of arms and flags depicted who they fought for, or to which faction or family belonged to, this is meaningless, the infobox does not contain any extra information, only basic things, low informational value like learning in elementary school. Preventing the article from being expanded means keeping it at a low informational value and no benefit to the article. This cannot be justified by the pursuit of brevity, clarity etc., when it is against the encyclopedic style. If you want short articles with a minimum of information, then create another Wikipedia for kids. -- Dragovit (talk) 18:46, March 25, 2021 (UTC)
 * Your comments make no sense unless we pretend that the infobox is the entire article. An infobox is an extremely condensed medium for conveying a few key facts from an article; it cannot be comprehensive. These coats of arms appear in a microscopic size, and are extremely obscure. They're not there to "inform"; they're there for the delectation of people who already know and can picture them. There's nothing wrong with being passionate about heraldry, but you're pushing it into the wrong place. Why not work on adding properly-sourced coats of arms to the articles of the people who bore them, where they can be seen in enough resolution to appreciate them, rather than trying to jam miniscule ones into the infoboxes here? Choess (talk) 05:37, 26 March 2021 (UTC)
 * No, your comment make no sense. You don't understand at all that without flags it isn't at all clear who fought against whom. For example, in the Kingdom of Sicily several dynasties exchanged and without a flag or banner or coat of arms it isn't clear whether the kingdom was at that time under the dynasty of Staufen or Anjou or Trastamara etc. Some kingdoms and empires have existed for a thousand years and without a flag or symbol it isn't at all clear what the period is. That's why there are pictures and templates to use, but you're just repeating someone's favorite opinion about aesthetics and don't respect that their creation took someone's time and energy, that's all. -- Dragovit (talk) 17:11, March 26, 2021 (UTC)

Needless duplication of discussion Already told that duplicate discussion is not helpful. Please go to the thread at WT:MILHIST instead of repeating the same points at pages where no one will see them. RandomCanadian (talk / contribs) 16:55, 26 March 2021 (UTC)
 * You're just censoring right now. There isn't repetition of the same points, but the answer to someone's question which you deleted with my answer. User Choess can also participate at WT:MILHIST discussion, but cannot if doesn't know about it. -- Dragovit (talk) 19:02, March 26, 2021 (UTC)
 * I did not delete any of your comments. I just left a note pointing to the discussion at a centralised location, exactly so they can know about it... RandomCanadian (talk / contribs) 18:10, 26 March 2021 (UTC)
 * I didn't see the comments here, so I considered it deleted. And what about comment in the Aragonese Crusade, it was deleted by you, it's true that there were similar points, but they were related to the article. -- Dragovit (talk) 20:53, March 26, 2021 (UTC)

title: Talk:Sixth Crusade


text:
Rǫgnvaldr Óláfsson (fl. 1164)

Rǫgnvaldr Óláfsson (fl. 1164) was a twelfth-century King of the Isles, succeeding the warrior Somerled. He was a son of Óláfr Guðrøðarson, King of the Isles and a member of the Crovan dynasty. In the 1153, Óláfr was assassinated by three nephews, before his son, Guðrøðr, was able to overcome them and succeed his father as king. By 1158, Guðrøðr was forced from power by his brother-in-law, Somairle mac Gilla Brigte, who was married to Óláfr's daughter Ragnhildr. In 1164, when Somairle was killed in an invasion of Scotland, and while Guðrøðr was away in exile overseas, Rǫgnvaldr briefly seized the kingship for himself, before being overcome by Guðrøðr, who had him blinded and mutilated.

Background
Rǫgnvaldr was a son of Óláfr Guðrøðarson, King of the Isles. The men were members of the Crovan dynasty. According to the thirteenth- to fourteenth-century Chronicle of Mann, Óláfr was married to Affraic, daughter of Fergus, Lord of Galloway. According to this source, Óláfr and Affraic had a son, Guðrøðr. Óláfr is further stated to have had many concubines by whom he had several daughters and three sons: Rǫgnvaldr himself, Lǫgmaðr, and Haraldr. One of Óláfr's daughters is stated by the chronicle to have married Somairle mac Gilla Brigte, Lord of Argyll. Although this daughter is not named by the chronicle, she is identified as Ragnhildr by the thirteenth-century Orkneyinga saga.

In 1153, the thirteenth- to fourteenth-century Chronicle of Mann reports that Óláfr was assassinated by three nephews whilst Guðrøðr was absent in Norway. Within months of his father's assassination, Guðrøðr executed his vengeance. According to the chronicle, he journeyed from Norway to Orkney, enstrengthened by Norwegian military support, and was unanimously acclaimed as king by the leading Islesmen. He is then stated to have continued on to Mann, where he overcame his father's three killers, putting one to death whilst blinding the other two, and successfully secured the kingship for himself.

In 1155 or 1156, the chronicle reveals that Somairle conducted a coup against Guðrøðr, specifying that Somairle's son, Dubgall, was produced as a replacement to Guðrøðr's rule. Late in 1156, Somairle and Guðrøðr finally clashed in a bloody but inconclusive sea-battle. According to the chronicle, when the clash finally concluded the feuding brothers-in-law divided the Kingdom of the Isles between themselves. Two years later, the chronicle reveals that Somairle invaded Mann and drove Guðrøðr from the kingship into exile. With Guðrøðr gone, it appears that either Dubgall or Somairle became King of the Isles. Although the young Dubgall may well have been the nominal monarch, the chronicle makes it clear that it was Somairle who possessed the real power. Certainly, Irish sources regard Somairle as a king by the end of his career.

Reign
Somairle lost his life in a failed invasion of Scotland in 1164. Although it is possible that Dubgall was able to secure power following his father's demise, it is evident that the kingship was seized by Rǫgnvaldr within the year. According to the chronicle, his reign began after he defeated a force of Manxmen at Ramsey. Almost immediately afterwards, Guðrøðr made his return, with the chronicle reporting that Guðrøðr arrived on Mann with a large body of men, overpowered Rǫgnvaldr, having him mutilated and blinded. Guðrøðr thereafter regained the kingship, and the realm was divided between him and Somairle' descendants, in a partitioning that stemmed from Somairle's coup in 1156.

title: Rǫgnvaldr Óláfsson (fl. 1164)


text:
User talk:Akehurst

Hello and welcome to Wikipedia!

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Proposed deletion of J. Michael Davis

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title: User talk:Akehurst


text:
Stroke-ornamented ware culture

The Stroke-ornamented ware (culture) or (German) Stichbandkeramik (abbr. STK or STbK), Stroked Pottery culture, Danubian Ib culture of V. Gordon Childe, or Middle Danubian culture is the successor of the Linear Pottery culture, a major archaeological horizon of the European Neolithic in Central Europe. The STK flourishes during approximately 4900-4400 BC. Centered on Silesia in Poland, eastern Germany, and the northern Czech Republic, it overlaps with the Lengyel horizon to the south and the Rössen culture to the west.

Description
The STbK and the Notenkopfkeramik are a development of the LBK. Much of the Musical Note pottery features incised zig-zag bands going around the pot, with punctures at the line segment junctions. The STK abandons incision in favor bands of small punctures, also in zig-zag patterns, with a vertical band dividing each angle. The effect is a band pattern of contiguous A-frames.

Where the Musical Note pottery expanded east over the Bug River, the STK moved down the Vistula and Elbe. The spread of this style must have been basically the transmission of cultural objects. The homes of the STK people show a slight modification that became a major feature of later cultures: one end of the long house was made shorter than the other to achieve a trapezoidal shape. The reason for this modification remains obscure. Also, the STK people developed a preference for cremation rather than burial. The preceding early LBK had used both methods.

Goseck circle
An unusual structure associated with STK has been found at Goseck, southwest of Berlin in Saxony-Anhalt : a large, double concentric ring of post holes pierced by gates and surrounded by a circular ditch. The placement of the gates and some of the posts lead some investigators to hypothesize an observatory similar to Stonehenge, but in wood rather than stone; i.e., the posts mark some positions of celestial bodies.

title: Stroke-ornamented ware culture


text:
Rights of the Terminally Ill Act

Rights of the Terminally Ill Act may refer to:
 * Rights of the Terminally Ill Act 1995, briefly legalising euthanasia in Australia's Northern Territory
 * Uniform Rights of the Terminally Ill Act, dealing with withholding of life support in the United States

title: Rights of the Terminally Ill Act


text:
Jim Courier

James Spencer Courier (born August 17, 1970) is an American former world No. 1 tennis player. Courier won four major singles titles, two at the French Open and two at the Australian Open, and was the youngest man to reach the singles finals of all four majors, at the age of 22 years and 11 months. He also won five Masters titles and was part of the victorious United States Davis Cup teams in 1992 and 1995. Since 2005 he has worked as a tennis commentator, notably for Nine (and previously Seven), the host broadcaster of the Australian Open. He is also an analyst for Tennis Channel and Prime Video Sport.

Tennis career
Courier was raised in Dade City, Florida, and though he excelled at youth sports in general, after a certain point it became clear that tennis was where his true talent lay. As a junior player in the 1980s, Courier attended the Nick Bollettieri Tennis Academy and won the prestigious Orange Bowl in 1986 and 1987 (the first to win back-to-back titles since Ivan Lendl), as well as the French Open junior doubles title in 1987.

Courier turned professional in 1988 and made his Grand Slam breakthrough at the 1991 French Open when he defeated Stefan Edberg and Michael Stich to reach his first Grand Slam final. In the final he defeated his former Bollettieri Academy roommate Andre Agassi in five sets to win his first Slam. He made the quarterfinals of Wimbledon before losing to eventual champion Stich. At the US Open he defeated defending champion Pete Sampras in the quarterfinals and then Jimmy Connors in the semifinals, before losing the final to Edberg.

1992 saw Courier defeat Edberg to win the Australian Open, and he celebrated by jumping into the nearby Yarra River. He then followed this result by defeating future Grand Slam champions Thomas Muster, Goran Ivanišević, Agassi and Petr Korda to successfully defend his French Open title. Afterward, Courier charmed the Parisian crowd by delivering a victory speech in French. Courier also enjoyed a 25-match winning streak during the season. In February of that year, following the San Francisco tournament, he became the tenth player to reach the world no. 1 ranking since the ranking system was implemented in 1973, and the first American since John McEnroe; he finished 1992 as the world no. 1 ranked player. Courier also was a member of the US team that won the 1992 Davis Cup. In 1992 he was the top-seeded player at the Olympics in Barcelona, where he lost in the third round to eventual gold medalist Marc Rosset from Switzerland.

In 1993, Courier again won the Australian Open, defeating Edberg in the final for the second consecutive year, and jumped into the Yarra a second time, but it was to be his last such celebration after contracting a stomach bug from the muddy and polluted river. He reached his third consecutive French Open final, which he lost to Sergi Bruguera in five sets. He also reached the 1993 Wimbledon final, defeating Edberg in the semifinals, and lost to Sampras in four sets. By reaching the Wimbledon final, Courier had reached the finals of all four Grand Slams at the age of 22, a record which still stands in men's singles. Courier also became the first player since Rod Laver to reach the finals of the Australian, French and Wimbledon in the same season; the feat was not matched until 2006 by Roger Federer. Courier again was part of the US team that won the 1995 Davis Cup.

Courier captured a total of 23 singles titles and 6 doubles titles during his career. He spent a total of 58 weeks ranked as the World No. 1 in 1992 and 1993. He reached the finals of all four major championships during his career, a feat accomplished by only seven other male players in the Open Era. Courier retired from the ATP tour in 2000. He was inducted into the International Tennis Hall of Fame in 2005.

Courier returned to the tour at the 2005 U.S. Men's Clay Court Championships when he received a wildcard into the doubles draw partnering Andre Agassi. The pair lost in the first round to eventual finalists Martín García and Luis Horna in three sets. It would be the last match of Courier's career.

After retirement from top-level tennis
Since his retirement as a top-level player, Courier has served as a tennis analyst and commentator for the Tennis Channel, USA Network, NBC Sports, TNT, ITV, Sky Sports and the Seven and Nine Networks. Since 2005, Courier has headed the commentary for the domestic host broadcaster of the Australian Open, which was Seven from 2005 to 2018 and Nine since 2019. Courier calls many centre court men's singles matches for the network and often conducts the post-match on-court interviews with the winning player. He also provided special comments on the Seven Network's Wimbledon coverage between 2013 and 2019. Courier started working with the British channel ITV for the French Open in 2012. In 2015, Courier worked with the British channel Sky Sports for their US Open coverage. The Jim Courier Club House now stands on the grounds of the Dade City Little League complex in John S. Burks Memorial Park in Dade City, Florida. Courier is an alumnus of that Little League program.

In 2004, Courier founded InsideOut Sport & Entertainment, a New York-based event production company that owns and operates the Champions Series, Legendary Nights exhibitions as well as private corporate events.

He also founded Courier's Kids, a non-profit organization that supports tennis programs in the inner city of St. Petersburg, Florida.

Courier currently competes on the Champions Series and in various charity exhibition matches.

Courier married Susanna Lingman in 2010.

On October 27, 2010, Courier was named captain of the United States Davis Cup team, replacing Patrick McEnroe. Courier stepped down from the role after the 2018 semi-final defeat to Croatia. Courier led his country with a 10–8 record and two semi-final appearances during his captaincy.

In August 2019, Courier was working for Prime Video UK, for their exclusive coverage of the US Open.

In 2022, he co-presented popular Australian reality show Ninja Warrior for the Nine Network, whom he also works for on their Australian Open coverage each local summer.

Records

 * These records were attained in Open Era of tennis.

Professional Awards

 * ITF World Champion: 1992.
 * ATP Player of the Year: 1992.

Head-to-head
Courier has the following head-to-head records against the listed opponents (No. 1 ranked players in boldface):

 * Michael Chang (12–12)
 * Wayne Ferreira (9–2)
 * Goran Ivanišević (8–3)
 * Guy Forget (7–1)
 * Richard Krajicek (7–1)
 * Marc Rosset (7–4)
 * Andre Agassi (7–5)
 * Thomas Muster (7–5)
 * Todd Martin (6–1)
 * Thomas Enqvist (6–2)
 * Stefan Edberg (6–4)
 * Sergi Bruguera (5–2)
 * Cédric Pioline (5–4)
 * Michael Stich (5–7)
 * Greg Rusedski (4–0)
 * Andrei Chesnokov (4–6)
 * Pete Sampras (4–16)
 * Jimmy Connors (3–0)
 * Tim Henman (3–1)
 * Petr Korda (3–1)
 * Karol Kučera (3–1)
 * Sjeng Schalken (3–1)
 * David Wheaton (3–3)
 * Carlos Costa (2–1)
 * Andrés Gómez (2–1)
 * John McEnroe (2–1)
 * Carlos Moyá (2–1)
 * Andrei Cherkasov (2–2)
 * Albert Costa (2–2)
 * Brad Gilbert (2–2)
 * Magnus Larsson (2–2)
 * Andrei Medvedev (2–2)
 * Jonathan Stark (2–2)
 * Gustavo Kuerten (1–0)
 * David Nalbandian (1–0)
 * Marat Safin (1–1)
 * Andrei Olhovskiy (1–1)
 * Slava Doseděl (1–4)
 * Yevgeny Kafelnikov (1–5)
 * Boris Becker (1–6)
 * Alberto Berasategui (0–2)
 * Patrick Rafter (0–3)
 * Marcelo Ríos (0–3)
 * Àlex Corretja (0–4)
 * Ivan Lendl (0–4)

Champions Series titles

 * 2005: Stanford Cup Houston – defeated Todd Martin 6–2, 6–3
 * 2006: Champions Cup Naples – defeated Pat Cash 6–4, 7–6(8)
 * 2006: The Championships at the Palisades – defeated Martin 5–7, 7–6(6), [10–4]
 * 2008: The Residences at the Ritz-Carlton Grand Cayman Legends Championship – defeated Wayne Ferreira 7–6(3), 7–6(1)

NOTE: In Champions Series tournaments, there are only two sets. A tiebreaker to ten is held instead of a third set.

title: Jim Courier