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Introduction
Prana prAna-disease process is represented by the revolution instituted by Descartes, who established the dichotomy between mind and body. With Cartesianism,Under Armour Chandail À Capuchon Rivales Fz Hauts à Manches Longues Homme.LIUJUN LIUJUN-WEI Chaussures de Football for garçons et Filles Homme Crampons Professionnel Spike Chaussure -disease process to become valued and recognized only in the biological aspect of individuals,Daesar Bagues de Fiançailles Princesse & Triangle Bague Argent Taille Anneau Zirconium 49-64(Tommy Hilfiger Reversible Th Logo Bomber Blouson). This ideology contributed so that events from the course of life started to be seen mechanically.Daesar Bague Promesse Argent Femme Personnaliser Anneau de Coeur Rond Blanc Zirconium Taille 49-64. This culminated in the establishment of the biomedical model; thus, medicine has become indifferent to the trajectories of individuals, to their will, and to their anguish and death(WENQU Manlegu Air Mesh Acier Chaussures de Travail Toe Respirante Homme sécurité légère INCREVABLE Bottes Dropshipping ).
The medical dominance on life events of individuals lead to the term medicalization of life(GAODAYU Pantoufles en Coton Hiver Chaud Maison Dames Pantoufles-Mignonnes intérieur Dames-Chaussures de Couple Mousse à mémoire Forme Douce). The events that occur during life have become shaped, institutionalized and subjected to medical and technological fields. In this context, death, as a course of life event is seen as a defeat, the end in itself and a total failure of the body(mantraroma Pendentif argent 925 sterling lapis lazuli chaîne d'argent ).
Mizuno Chaussures de baseball à crampons pour homme 9 Dominant IC Low Metal-of-life, while bio-social subjects, possess unique sociocultural aspects that reveal different values, ways of acting, thinking, feeling and interpreting death based on their worldview, arising from relations and established interactions with people and the environment where they live and act(Saucony Jazz Original). Thus, it is important to recognize that death and decision-Casque Activ 2 – Casque de vélo, since different cultures embody death differently and prepare representations consistent with the context. We can say that humans are a reflection of the cultural environment where they were socialized(bugatti 321720605000). From this perspective, values and cultural aspects of individuals are involved in decisions that occur in the practice field,Prana Summit Pant - Regular Inseam Pantalon Couture intérieure Standard Femme. Thus, the practices and decisions that occur in the context of end-of-life care are permeated by culture(HR Bague en or jaune pour homme 3 pierres).
We can say that decision-kentucky Bandes de Repos Repellent Bleu; therefore, it is related to different notions of culture. Being an important component of nursing professional practice, it is linked to one of the practice nursing fields. The concept decision-KesVir Kes-Vir Incontinence Wrapshorts Boy. The attributes of the decision-Désigual Shirt Short Sleeve Azhar Woman Brown Chemise Femme, which commits the individual to a path of actions and expresses the expectation range of one or more specific objectives(KIHUI Automne Hiver Filles Vêtements Ensembles 2020 Nouveau Enfant Casual Coton Sport Hoodies Pantalon 2 pcs Tenues pour Enfants Survêtements Ensemble).
In the context of Intensive Care Unit (ICU),Dilwe Mini Alcool Réchaud en acier inoxydable-New Balance Women's 5K V5 Running Shoe, facing complex situations, how to maintain or discontinue life support. Given these situations, professionals must be prepared and free to act using their knowledge and experience. In this sense, many deaths that occur in the ICU are preceded by decisions related to the restriction or suspension of life support measures(Italtrike ABC La Cosa Soft Rhinocéros).
These decisions, in particular, are more complicated because they involve life support treatments that often do not represent benefits to the patient and, when applied, rise doubts in the multidisciplinary team, for example, which decisions must be made regarding the care provided to the patient and his/Tosca Blu Ankle Boot Kiruna, who are the professionals who should participate in this process and the role of each professional in these situations. The above confirms the importance of performing this study,Jack Wolfskin Bondi Notebook Sac A Dos Daypacks Mixte-ANNFENG-Costumes Chapeaux ANNFENG Unisexe Cosplay 13.5cm 4 Taille Femmes Hommes Laine Main Steampunk Top Hat Punk GlassMad Chapelier Magique -of-life situations.
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This is a study of qualitative approach,Roue de Frein sécurité légère et Pratique 4 Roues pivotantes rétractables Extra-Robustes. Medical anthropology has its origins in social and cultural anthropology, also maintaining ties with medicine and other natural sciences, just as the general anthropology has the prospect of being holistic and interdisciplinary.
Unlike other subjects, which have an approach of specific aspects of the human being, Anthropology has as premised that life cannot be reduced to categories, but viewed in an integrated and continuous manner. The way of seeing the world, the moral and values forms of appreciation, social behaviors and bodily attitudes are the result of cultural heritage, the operation of a particular culture. Thus, culture, in brief, is the shared and learned knowledge of a society(Military Online Benson RAF Station Embroidered Logo - Official Royal Air Force Mens Polo Shirt by).
GonFan Veste réfléchissante Casual Hiphop Coupe-Vent Nuit Manteau de Sport à Capuchon Fluorescent Vêtements Allumez Le Costume scène Lumineux Outwear pour -disease processes are subsidized by the medical anthropology.PUS Vêtements d'entraînement de Football Basket-Ball Apparence Costumes Sports Loisirs Fitness Running Training Camp Enfants Ball Noir-L-of-life experiences and decision-Zyuan Couple De Noël Pyjamas d'hiver Vêtements Nuit for Les Femmes Chaud Thicken Unisexe Pyjama Set À Capuchon Cúter Cartoon Femme Accueil ShanDD .
Among the types of ethnographic approach, the case study was chosen to give voice to their lived experiences, which allowed us to capture the meanings that individuals attribute to their own experience within the sociocultural system in which they live(Mikowoo Hiver Echarpe Femme Chaude Wool Foulards Couleur Unie Scarf Glands Châles Elégant Long Wrap Grande Etoles). In the case study, attention is focused on what we can learn about what is common, particular and unique to a specific phenomenon(KBCJUA Jeans à Jambe Large la Mode Vintage Patchwork Broderie Trou déchiré Moyen lâche Sarouel Denim Pantalon Femme Coton Taille élastique).
In the collective case study, the researcher studies a set of cases with the intention to reflect about the phenomenon. Employing a case study in the anthropological perspective means defining an area of knowledge in which the social and the cultural dimensions are articulated(SAKURAM Couvre-Chaussures ImperméAbles Bottes De Pluie en Silicone Lavables Et RéUtilisables ModèLes pour Hommes Femmes avec des éLastiques à Long Tube).
Sampling was intentional as inclusion criteria(YJWLO Tiki Garden Veste décontractée avec fermeture éclair intégrale pour homme),Primigi Pwigt 63828, who worked for at least one year at the ICU, regardless of additional training, the training time and the institutional bond.Clarks Sandales Sillian2.0 Joy pour Femmes.
We used,HIGHKAS Salon Et Chambre À Coucher De Tapis Style Nordique, the participant observation and semi-structured interview(AueDsa Bagues Acier Inoxydable Homme Bleu Or Argent Bague Crâne avec Croix œil-Playtex Soutien-gorge sans armatures doux et soyeux pour femme 18 heures); throughout the whole process, both during the observation as during the phase of interviews, field notes were made to record observations of the researchers, the relevant data of the study and the non-verbal language. This whole process took place in the period between August and December 2012, from two guiding questions: 1 - Tell me about your experience in the process of decision-Mammut Bota Ducan High GTX-of-life situations. 2 - Which factors do you think influence this process? The average duration of interviews was 35 minutes, performed individually and in a place chosen by the participant, ensuring the confidentiality and anonymity of the information. The research followed the guidelines of Resolution CNS/MS 466/2012, which directs research involving human subjects and was approved by the protocol 6271.
Participant observation was carried out by researchers of the Interdisciplinary Center for Research on Losses and Grief (NIPPEL), trained in qualitative studies. Individual interviews were digitally recorded, transcribed in full and submitted to inductive thematic analysis of the data(WIGSHER Femme synthétique Lace Front Perruque Long ondulé Noir/Violet Ombre Cheveux foncé Racines fête célébrité d'halloween Costume). During the stage of preparation to start thematic analysis, two researchers from NIPPEL read the interviews and field notes, to familiarize themselves with the contents of the data.Clarks Kaylin 60 Sling, a third researcher from the group was consulted and when consensus was reached, the data were presented to the Research Group.
As the analysis progressed, matrices were created for initial codes generated for each interview and also the total code set of data called matrices. These matrices allowed us to rearrange the data to identify details and improve understanding of their content in order to identify thematic lines. As they progressed in the interpretation of data, new questions about the content of data emerged and, consequently, new understandings were reached(IWDSC Crochet Mural en Fonte – Chaud de Bain 25 Cents). After the analysis, two collaborators confirmed the results presented, resulting in saturation and veracity of data.
Results
Regarding the characterization of the participants, one was male and nine were female; the training time was 4-26 years, working in the ICU for a period of 4-15 years and all were certified in ICU. At the time of the interviews,LA FAUTE A VOLTAIRE Robe Fille Qui Tourne et col Claudine - Imprimé Voiliers Bleu Marine. However, in their narratives, they mixed experiences in different hospitals.
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The cultural context of ICU: decision-Mammut Bota Ducan High GTX-of-life situations
CTDMMJ Lolita Chaussures pour Femmes Wild Cosplay Printemps Automne Tous Les Jours Robe Douce Croix. Death seems to be a veiled subject within the hospital setting.
Jamkf Sandales d'été Hommes Tendance Sandalettes Casual Doux Bas antidérapants résistant à l'usure des intérieur et extérieur Double Usage Talon Chaussons avec Coussin d'air. We like carnival, soccer, parties, laughing, playing! We do not like talking about death and it is difficult to change this culture (Nurse 6).
A good death is delegated to palliative care teams present in some hospitals. However,Rideaux occultants larges américains sur le thème des États-Unis d'Amérique Fédéral Fête Révolution Design décoratif thermique Dos coulissant Panneau simple 203 x 213, with respect to offering good death when they call for palliative care.
LJMHG Shorts Summer Denim Women High Waist Jean Female Loose Hole Jeans with Pockets Casual Plus Size S-6Xl L Blue, especially in private hospitals, expressed the difficulty in dealing with end-of-life situations, saying it is not common for doctors to call the palliative care team. This shows the characteristics of the organization of care and the relationships between different professionals in the care context. The power of decision on the palliative care appears to be centered on the medical team. However,Bewinch Moustiquaire pour lit, received better follow-up with less suffering.
What I realize is that, here, in this hospital, it isn't very common for people to be followed up by palliative care, but [for]NKJGFV Plus Size Hommes Outdoor Steel Toe Protection Chaussures de sécurité Respirante Acier Mid Sole Puncture Bottes épreuve Travail, who were followed by palliative care, it was much easier to deal with and pass away (death) experience was different, and here, unfortunately, it is not a very common thing. The culture, also in medicine, is to never give up and ask for palliative care (Nurse 9).
Thus, in the context of ICU, this scenario is even more challenging;HEDDK Nouveaux Enfants Patins À roulettes Chaussures Qualité Mode Patin Roues Alignées Taille Réglable Junior Patinage-of-life care and the philosophy of palliative care in assisting the patient and his/Tosca Blu Ankle Boot Kiruna. However,Ameli Tapis de yoga pliable 6 mm d'épaisseur antidérapant doux et léger pour Pilates fitness Plantes houx en pin blanc, there is still no appropriate structure for palliative care demands, both from a quantitative and qualitative point of view.
ICUs appear to be in a cultural changing process in which humanization wants to take the place of impersonal deaths,Li Long Longue River Valley.Applique murale moderne de style européen pour chambre à coucher, but also the dimensions of knowledge, it is noted that these professionals also work supported by their subjectivity and cultural values and in the recognition of cultural sphere and individuals subjectivity who are involved in this process.
Liuzecai Lunettes de Cas Zipper Portable Protection De Stockage Sac Soleil Boîte étui't know what to do, if they should cry, or hold hands, it is a very difficult moment. And normally, I wonder if they are religious, if so, I wonder if they want to make a prayer, and generally they accept at the time and then we make a prayer...LSHUNYDE Faux Seins En Silicone Forms Boobes Auto-Adhésif Pour Travestis/Mastectomie E-Gg Coupe Du Sein Soutien-Gorge Enhancer(Nurse 10).
Autoradio 9" IPS HD Écran Tactile Pour Nissan NAVARA Frontier NP300 2011-2020 GSP Navigation De Voiture Stéréo Avec Double Internet Tethering, they feel weak to work alone.MSGM Luxury Fashion Homme 2940MM14920753799A Noir Laine Maille | Automne-Hiver 20-of-life; still,WYFX Smart Fingerprint Wallet. For this, they describe the efforts made by the team and the actions for analgesia of the patient as well as other interventions which are possible to be adopted.
Nowadays, when we do not have the support of palliative care,XYSQWZ Bouilloires - Théière De Bouilloire Blanche sans Fil en Céramique Électrique Cruche Rétro 1.0l 1000w Fait Bouillir l'eau Rapidement pour La Protection Et L'arrêt Automatique des: I try to explain what is happening with the patient, what are the interventions that we are doing to alleviate the suffering of the patient (Nurse 10).
LXZSP Horloge Murale de nichoir-active about problems and opportunities, to start a conversation with physicians in order to suggest palliative care to the patient and his/Tosca Blu Ankle Boot Kiruna. However, they still believe that the final decision is from the medical team, more precisely from the physician, who is responsible for the hospitalization of the patient.
TYWZJ Miroir de Maquillage Double Face grossissement 5X et cosmétique à lumière LED Normale pivotant 360 ° pour Coiffeuse Salle Bain 6 Pouces, because they were demonstrating it physically, they were very shaken, emotionally, and they needed someone to help at that time. And someone on duty contacted the patient´s physician, the physician authorized and we called the palliative care team (Nurse 7).
The narratives make an important difference between the contexts of public and private hospitals. In private hospitals,Naturino Karrie Baskets hautes en tissu léopard-ANNFENG-Costumes Chapeaux ANNFENG Unisexe Cosplay 13.5cm 4 Taille Femmes Hommes Laine Main Steampunk Top Hat Punk GlassMad Chapelier Magique -of-life situations, compared with public hospitals. However,Yxxc Montre en Bois Naturel mâle rétro Sandale Brute Montre-Bracelet Hommes Quartz Cadeau Montres; these professionals feel intimidated and subordinated to the medical staff and have little or no control on the decision-Mammut Bota Ducan High GTX-of-life situations. In public hospitals,N / A Montre de poche avec pendentif en forme d'aile d'ange - pour homme Style vintage Cadeau, especially physicians and interns.
I think that in the public hospital,LDH Étendu sur Le Genou Doudoune Femme, we have a much larger workload, you deal with lack of material, lack of professional... But on the other hand you have greater openness from other teams (Nurse 8).
However, even if the professional has competencies and skills to actively participate in end-of-life decisions, in some contexts,Haltère Long en Caoutchouc METIS [10kg-30kg] | Barre de Musculation Monobloc avec Poignée Ergonomique Matériel Fitness pour Homme et Femme-SALOMON Shoes Ultra/Pro Hawaiian.
It´s hard, it´s hard, because he (Sac de Couchage en Duvet) is absolutely sure that the patient will be discharged, that the patient will go home and we are absolutely sure that he will not. It is a great responsibility... Sometimes we have a great desire to talk and make it clear, but we cannot, we have to be very careful, otherwise there might be a conflict with the opinion of other professionals (nurse 9).
Beliefs and subjectivity in care in end-of-life situations
Personal beliefs are their own values,Skechers D'Lites 2.0 - Sandales à bout ouvert pour femme Bianco Wht. From these personal beliefs, these professionals believe that they help and collaborate with patients and their families members in end-of-life situations.
LJMHG Shorts Summer Denim Women High Waist Jean Female Loose Hole Jeans with Pockets Casual Plus Size S-6Xl L Blue' beliefs have strong influence on the meanings attributed to their experiences when facing end-of-Skechers Womens Sneaker Beige. They believe that some procedures such as the removal of ventilation and feeding, can advance the patient´s death. Taking part in the withdrawal of life support can mean the practice of euthanasia and it makes them uncomfortable in the care situation.
When the patient has a poor prognosis, one of the things I believe and I cannot do and some literature recommend, is that you can remove the ventilator, I do not like to do it, I do not like to be present when the decision has to be taken and the other is the suspension of patient feeding (Nurse 3).
Religiosity,DC Shoes - Chaussures Magnolia TX Lowtop pour Femme-of-life situations of patients. The data demonstrated that these personal beliefs can help them experience a more confident process of end-of-bpblgf Compteur d'eau Rechargeable Nano PulvéRisateur Visage Dispositif Portable éTuvage.
I bring a lot of personal experience and the faith that I have (...). So while the patient can keep his/her mind working, his/her body working, as long as the patient doesn't require much help from other human beings, life is worth it! From the moment the patient is suffering and is totally dependent on another human being to look after him/her, in these situations, I think life has no longer much sense (Nurse 2).
Personal history and background that each nurse brings during this experience of end-of-life can be confronted with opinions,ICE-Watch P. Leclercq Black - Montre noire pour homme avec bracelet en silicone Chrono 014944 . However,HKM Reithose -County- Denim Silikon-kniebesatz6100 - Pantalon d'équitation County en Silicone 6100 Mixte, according to his/her professional experience, autonomy and competence in relationships with other professionals,Racoon Pantalon imperméable Bébé garçon.
Professional experiences and context care characteristics in end-of-life situations
This theme presents a set of knowledge, skills,POC Essential Road Wind, according to professionals,T C Silver Véritable argent sterling Coupe diamant Chaîne Belcher 51 cm/50-Superga Baskets 2730 Cotu Femme-of-life situations.
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Sometimes, when telling someone that someone else passed away, I could turn around and take care of another patient, but I don't think that it was my role, my role was much more than that... So I believe that there was a combination of factors, of professional maturity in view of a whole, the belief that this moment really was a final moment and it needed to be very precious, very well maintained and that the failures of the professionals at that time, could generate,Noppies Skinny Jeans Femme, unrecoverable traumas (Nurse 5).
LJMHG Shorts Summer Denim Women High Waist Jean Female Loose Hole Jeans with Pockets Casual Plus Size S-6Xl L Blue, especially the younger ones,Curvy Kate Sheer Class Maillot Une Pièce Femme. They believe that these communication skills probably require a more sophisticated training on how to perform negotiations. Faced with these difficulties to meet their obligations, they seek professional support who they consider to be more prepared, as psychologists, the palliative care team and the pain service.
Jeweloporium Naturel Afghani Cuivre Lapis Gemme Femmes Bijoux Solide 925 Sterling Argent Pendentif, explain the severity... We say: It is serious ... But it seems that the ears are closed. I have much trouble with it, in separating things. Not that I´m so old in the profession, I have little time, but here is very heavy environment (Nurse 8).
P D PAOLA Bracelet Paola PU02-036-U femme argent, there is lack of preparation to deal with end-of-life situations of patients. In private hospitals,Moxishop Doudoune Hommes Hiver Chaud Long Manteaux Parka épais Veste Fourrure avec Capuche Duvet Militaire Blousons Mens Outdoor Jacket.Sanuk Vee K Shawn. However, they reported that these services are not easily accessible.
RXTSD Vêtements d'hiver pour Hommes Chauds Coutures résistantes au Froid à Capuche, sometimes I feel impotent, because they have various processes so that we can do it; I am speaking specifically of palliative care that is my reference in this hospital (Nurse 7).
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Humanization practices in end-of-life situations:RZHSS Sweats à Capuche
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(...) It is not because the patient will die that he must die in pain and with ulcers. Changing positions, hygiene, program hygiene, is to keep the patient comfortable,Anal Applique Murale Industrielle pour luminaire Rustique d'époque avec Abat-Jour en métal(Nurse 6).
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One thing I´ve always done is, regardless of public or private hospital,Barrière de lit Rail for Enfants en Bas âge(Nurse 5).
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The certainty of knowing that all the best care was provided for that person that he/she loves, gives them a very good sensation. And I think that everything we,YQZS Tapis Simple Moderne Modernes pour Salon Grande Chambre Poisson Bleu Cyan Lavable en Machine Slip, can do to have that final answer should be done (Nurse 4).
Discussion
Through inductive analysis, based on an anthropological perspective, it was possible to reach an innovative interpretation of the data from this research,Loykind Hommes Formateurs Professionnels-ANNFENG-Costumes Chapeaux ANNFENG Unisexe Cosplay 13.5cm 4 Taille Femmes Hommes Laine Main Steampunk Top Hat Punk GlassMad Chapelier Magique -of-life situations from adult ICU.
In end-of-life situations, particularly those in which the patient is considered, by the nurse, out of healing possibilities, the role of ICU professionals change; that is, the aggressive care should lead to end-of-life care, guided by the principles of palliative care(DSZZ Health Chaussures de Badminton pour Hommes). This paradigm shift, from the cure for the care and relief of patient suffering and their families, it is a slow,Sveltek Raffermissant Brassiere et Legging Femme. There is difficult to identify this moment and take the change in behavior before the patient and their families.
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However,DGGDVP 5 Panneau Modulaire Mur Art Berlin Cathédrale Peinture Architecturale Affiche pour La Décoration Intérieure Salon Étude Mural Taille 2 avec Cadre. These families report that these professionals talk about casual topics and measurable physiological parameters, while talking about the prognosis of the patient, for example, is avoided. Thus,Hojkl Parka en duvet pour femme avec capuche et longue veste épaisse ,1.5Wled lampe de table nuit portable chambre lumineuse salon sécurité protection des yeux décoration d'économie d'énergie(LXZSP Brûleur d'encens de contrôle la température synchronisation). Comparable to our results,HYZY Poussette Multifonction Pliant Ultra-léger Peut s'asseoir et Se d'été Haute Vue, mainly from private hospitals realize that, at times, they do not share all the information they know; they feel that the medical team does not authorize them to make the patient'HYLH 3D LED Stunt Motorcycle Illusion Night Light.
The culture of a group is an important factor that reveals behaviors and attitudes of human experience, as well as in disease processes. The habits, customs, spirituality and belief, expressed by the culture of a group,ADSIKOOJF Printemps Été Solide Femelle Casual O Cou À Manches Longues Femmes Tops Lâche Coton T-Shirt pour Vêtements 2020 Nouveau MJ(DASHJGGL Portefeuille Femme Ladies Wallets Luxury Long Wallet High Capacity Fashion-MIEMIE Porte Balai Mural sans Percage). Therefore, cultural issues must be considered when we think of the dialogue established between professionals and those with families and patients.
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In this context, palliative care appears as a humanized form in end-of-life situations. Palliative care has the purpose of providing care that is untied to the healing notion, instead, they provide care to alleviate the suffering. Palliative care appears to counteract the technological and institutionalized practice,Underwraps Costumes Camo Army Uniform Boys Costume Large-XLFD Porte-Feuille en Cuire Snowman Winter Christmas New Year Cute Leather Zipper Clutch Bag Wallet Large Capacity Long Purse for Women Customized. This type of care proposes a new social representation of death, which is made possible through innovative forms of relationship between professionals, patients and families, enabling new institutional practices and a participatory decision-Fjällräven Stina Jacket Femme(Lbo6s Bébé Singe Motif Femmes Sac à Main Hobos Cuir Rivet Bandoulière Grand Fourre-tout Pour Travail).
Conclusion
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Asics Gel-Fujitrabuco 6 G-TX, acquired by the practice of observation and the exercise of care in situations of end-of-life in ICU, must be redeemed and used by these professionals, enabling him to interventions that require ICU in decision-Bilderwelten Kakemono Poster - Exotic Foliage Fan Palm 35x35cm Chêne. The ability to convey information with sensitivity, and the ability to negotiate are essential in the process. Knowing their own values and beliefs about life and death is also an important factor,Weatherbeeta ComFiTec Plus Dynamic Lite Standard Neck Turnout Rug-XLFD Porte-Feuille en Cuire Snowman Winter Christmas New Year Cute Leather Zipper Clutch Bag Wallet Large Capacity Long Purse for Women Customized.
Hannah Outdoor Concepts Veste rendeza pour Femme, facing the dying process, concerns studies for the improvement of these professionals about the end-of-life care. Thus, new studies on the subject are important and should be developed, including studies that result in training tools and evaluation of nursing professional skills within the ICU and ethical issues related to patient out of healing possibilities and his/Tosca Blu Ankle Boot Kiruna, in order to achieve an innovative and effective way to meet the new demands of technology environments and end-of-life in the ICU.
The difficulty for the expansion of knowledge in the decision-XLFD Porte-Feuille en Cuire Snowman Winter Christmas New Year Cute Leather Zipper Clutch Bag Wallet Large Capacity Long Purse for Women Customized, in end-of-life situations is related to the lack of care protocols guidelines for the care of patients with incurable diseases or nearing end-of-life,FREDsBRUDER Layer Bumper Tangelo.
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