Objective: The Patient Self-Determination Act of 1990 (PSDA) protects a patient’s right to predetermine the level of life-supporting care they are willing to receive (U.S. Department of Health and Human Services, 1993). In Arizona, the advance directive (AD) complies with the PSDA and is used to guide care in the event of cardiopulmonary failure. The AD may indicate “do not resuscitate” (DNR), which prohibits cardiopulmonary resuscitation in the event of cardiac arrest. In the institution used for this project, a palliative care team assists with identifying goals of care and helps guide interventions consistent with the AD. The purpose of this Doctor of Nursing Practice (DNP) project was to complete a retrospective chart review and identify patients admitted to the medical intensive care unit (ICU) with a DNR as indicated by a copy of the AD in the electronic health record (EHR) and determine if they received a palliative care consultation. This information could support a quality improvement project led by the DNP-prepared AGACNP focused on ensuring a palliative care consultation within 48 hours of admission for patients admitted to the ICU with a DNR. Methods: A search of the EHR identified patients admitted to the medical ICU over a 12-month period. The EHR of patients admitted with a DNR were reviewed to determine if they received a palliative care consultation during the ICU stay and the patient’s final disposition. Findings: A total of 38 patients had an AD indicating DNR status on admission to the medical ICU. Of those patients, 26 (68.4%) received a palliative care consultation. Twelve patients (31.6%) with a DNR status on admission did not receive a palliative care consultation. Additionally, five patients with a DNR (13.16%) died in the ICU without receiving a palliative care consultation. Conclusion: Twelve patients with an AD indicating a DNR did not receive a palliative care consultation, and five of those patients died in the ICU. The findings from this project support a quality improvement project to implement palliative care consults to review goals of care for patients with a pre-existing AD indicating a DNR code status.

Bakgrund: Olika typer av krisplaner, psykiatriska förhandsdirektiv, har använts som ett verktyg för att hjälpa patienter att kommunicera sina behov och önskemål under psykisk kris när de inte förmår göra det själva. Sedan 1980-talet har de psykiatriska förhandsdirektiven använts för att öka patientsäkerheten, personcentrering, minska vårdkonsumtion inklusive ofrivillig behandling. Syfte: Syftet var att beskriva patientens erfarenheter av krisplanering i den psykiatriska vården. Metod: En kvalitativ litteraturöversikt med systematisk ansats. Femton artiklar med kvalitativ eller mixad metod valdes ut och analyserades utifrån Thomas och Hardens metod för tematisk syntes. Resultat: Patienters upplevelse av krisplanering redovisas i sex analytiska teman; stärkt vårdrelation, autonomi och empowerment, en väg till självinsikt, trygghet och säkerhet, involvering av närstående samt svårigheter i samband med krisplanering. Det framkom att patienternas upplevelser var starkt färgade av personalens bemötande. Tidigare erfarenheter var avgörande för patientens förmåga att ingå ett samarbete med personalen i syfte att arbeta proaktivt och förhindra negativa konsekvenser av återfall. Slutsats: Krisplanens skyddande och förebyggande funktion var till nytta för såväl patienter som närstående och personal. Patienter upplevde krisplaneringen som ett verktyg för att stärka vårdrelation samt att genom ökad delaktighet utöka autonomi och empowerment. Processen utvecklade patientens kunskap om sin sårbarhet, sina förmågor och självinsikt. Det är viktigt att vara medveten om att vårdpersonalen har en stor inverkan på patienters upplevelse av krisplaneringen. / Background: Various types of crisis plans, psychiatric advance directives, have been used as a tool to help patients communicate their needs and wishes during psychological crises when they are unable to do so themselves. Since the 1980s, psychiatric advance directives have been used to increase patient safety, person-centeredness, reduce care consumption including involuntary treatment. Aim: The purpose was to describe patients’ experiences of the crisis planning in psychiatric care. Method: A qualitative literature review with a systematic approach. Fifteen articles with a qualitative or mixed method were selected and analyzed based on Thomas and Harden's method for thematic synthesis. Results: Patients' experience of crisis planning is reported in six analytical themes; strengthened care relationship, autonomy and empowerment, a path to self-awareness, safety and security, involvement of relatives and difficulties in crisis planning. It emerged that the patients' experiences were strongly colored by the treatment of the staff. Previous experiences were decisive for the patient's ability to enter into a collaboration with the staff in order to work proactively and prevent negative consequences of relapse. Conclusion: The crisis plan's protective and preventive function was beneficial for patients as well as relatives and staff. Patients experienced the crisis planning as a tool to strengthen the care relationship and to increase autonomy and empowerment through increased participation. The process developed the patient's knowledge of their vulnerability, abilities and self-awareness. It is important to be aware that the staff had a large impact on the patients' experience of crisis planning.

Request for termination of life in Benelux countries from the perspective of civil law The master's thesis is about euthanasia which is known as one of the most controversial and discussed topic in the world of law and medicine, especially termination of life on request. The aim of this work is to innovatively interduce unique legislation of termination of life on request in Benelux countries from the perspective of civil law because I am convinced of its importance despite being overshadowed by the meaning of criminal perspective. In a first chapter the terminology, definition and theory dividing will be explained. The other terms which are connected with the things above are the content of this part as well. The human rights related to euthanasia are discussed in next part of this work. Benelux countries have their own euthanasia enactment - this is what third chapter is about. Next part shows in-depth analysis of due care criteria which are countained in second chapter of Termination of life on request and Assisted Suicide Act. Fulfilment of these is one of criterias needed for impunity of the executor of termination of life on request. Fifth chapter is a key part of this work for civil law perspective because of legal requirements for request itself. It also describes related institutes -...

Durante os anos 90 um aumento dramático no isolamento de VRE foi reportado nos estados Unidos, principalmente em unidades de terapia intensiva, esta tendência continua até hoje. No Brasil o primeiro caso de VRE foi documentado em 1996 e desde então muitos casos têm sido descritos em todo país. Uma variedade de medidas tem sido usada para reduzir taxas de VRE, mas a melhor estratégia para o controle e prevenção deste patógeno ainda não está totalmente definida. O Objetivo deste estudo foi avaliar o impacto de um processo multidisciplinar para monitorar a adesão de profissionais às precauções padrão e de contato e o papel do meio ambiente e de equipamentos na transmissão de VRE. Este estudo consistiu de três períodos: um período basal, um período de intervenção e outro de pós-intervenção. O teste qui-quadrado foi usado para comparar os dados dos períodos pré e pós-intervenção e o teste de qui-quadrado para tendência linear foi usado para avaliar a distribuição de VRE e o uso de glicopeptídeos durante o período de estudo, o nível de p<0.05 foi significante. As amostars foram avaliadas pela técnica de PFGE. PCR para detecção do gene de resistência foi realizada para as amostras clínicas. E. faecium foi a espécie mais freqüente tendo sido responsável por 71% das culturas positivas. Foram documentadas 36 infecções e aquelas da corrente sangüínea foram as mais frequentes 17 (47%) A intervenção educacional foi realizada com 136 profissionais. Foram avaliadas 706 oportunidades de precauções padrão e de contato. A adesão às precauções padrão e de contato não aumentou comparando os períodos pré e pós-intervenção. Entretanto, a proporção de culturas ambientais e de equipamentos diminuiu significativamente comparando os períodos pré (23.2%) and pós-intervenção (2.4%) (p<0.001) e foram associadas a diminuição das Infecções por VRE por 1.000 pacientes-dia (p=0.004). O uso de vancomicina (DDD) não mudou significativamente ao longo do estudo (p=0.97) e o uso de teicoplanina aumentou principalmente nos últimos meses de 2007 (p<0.001). O mesmo clone de E. faecium foi encontrado em 90% das amostras. No presente estudo, redução da proporção de contaminação ambiental e de equipamentos esteve associada com diminuição das taxas de infecção por VRE. / During the 1990s a dramatic increase of VRE isolation was reported mostly in the Intensive Care Units (UCI) in the USA and the trend continues. In Brazil, the first VRE isolated occurred in 1996 and many cases have been described thereafter. A variety of measures have been used to reduce VRE rates, the optimal approach however to control and prevent this pathogen, is not well defined. The aim of this study was to evaluate the impact of a multidisciplinary process to monitor improve healthcare work (HCW) compliance with standard and contact precautions and the role of environment and equipments on the transmission of VRE. This study consisted of three period baseline, intervention and pos-intervention period. Chi-2 test was used to compared data pre and pos intervention and chi-2 test for linear trend was used to evaluate the distribution VRE and use of glycopeptides during the study period, the level of p<0.05 was significant. PFGE was performed. Detection of genes of resistance of VRE isolated from clinical samples was performed by PCR E. faecium was the most frequent species isolated being responsible for 71% of positives cultures. Thirty-six infection were documented, bloodstream infection 17 (47%) was the most frequent site. The educational intervention was given to 136 HCW. 706 opportunities were evaluated, the compliance with standard and contact precautions did not improve comparing pre and pos-intervention period. However, the proportion of environmental and equipments positive cultures decreased significantly comparing pre (23.2%) and pos-intervention (2.4%) period (p<0.001) and was associated with decrease of VRE infection per 1.000 pts-day (p=0.004). The use of vancomycin (DDD) did not change significantly over the study period (p=0.97) and the use of teicoplanin increased (p<0.001). Ninety percent of E. faecium belong to the same type. In the present study, reduction of proportion of positive environmental and equipments cultures was associated with decreased of rates of VRE infections.

Durante os anos 90 um aumento dramático no isolamento de VRE foi reportado nos estados Unidos, principalmente em unidades de terapia intensiva, esta tendência continua até hoje. No Brasil o primeiro caso de VRE foi documentado em 1996 e desde então muitos casos têm sido descritos em todo país. Uma variedade de medidas tem sido usada para reduzir taxas de VRE, mas a melhor estratégia para o controle e prevenção deste patógeno ainda não está totalmente definida. O Objetivo deste estudo foi avaliar o impacto de um processo multidisciplinar para monitorar a adesão de profissionais às precauções padrão e de contato e o papel do meio ambiente e de equipamentos na transmissão de VRE. Este estudo consistiu de três períodos: um período basal, um período de intervenção e outro de pós-intervenção. O teste qui-quadrado foi usado para comparar os dados dos períodos pré e pós-intervenção e o teste de qui-quadrado para tendência linear foi usado para avaliar a distribuição de VRE e o uso de glicopeptídeos durante o período de estudo, o nível de p<0.05 foi significante. As amostars foram avaliadas pela técnica de PFGE. PCR para detecção do gene de resistência foi realizada para as amostras clínicas. E. faecium foi a espécie mais freqüente tendo sido responsável por 71% das culturas positivas. Foram documentadas 36 infecções e aquelas da corrente sangüínea foram as mais frequentes 17 (47%) A intervenção educacional foi realizada com 136 profissionais. Foram avaliadas 706 oportunidades de precauções padrão e de contato. A adesão às precauções padrão e de contato não aumentou comparando os períodos pré e pós-intervenção. Entretanto, a proporção de culturas ambientais e de equipamentos diminuiu significativamente comparando os períodos pré (23.2%) and pós-intervenção (2.4%) (p<0.001) e foram associadas a diminuição das Infecções por VRE por 1.000 pacientes-dia (p=0.004). O uso de vancomicina (DDD) não mudou significativamente ao longo do estudo (p=0.97) e o uso de teicoplanina aumentou principalmente nos últimos meses de 2007 (p<0.001). O mesmo clone de E. faecium foi encontrado em 90% das amostras. No presente estudo, redução da proporção de contaminação ambiental e de equipamentos esteve associada com diminuição das taxas de infecção por VRE. / During the 1990s a dramatic increase of VRE isolation was reported mostly in the Intensive Care Units (UCI) in the USA and the trend continues. In Brazil, the first VRE isolated occurred in 1996 and many cases have been described thereafter. A variety of measures have been used to reduce VRE rates, the optimal approach however to control and prevent this pathogen, is not well defined. The aim of this study was to evaluate the impact of a multidisciplinary process to monitor improve healthcare work (HCW) compliance with standard and contact precautions and the role of environment and equipments on the transmission of VRE. This study consisted of three period baseline, intervention and pos-intervention period. Chi-2 test was used to compared data pre and pos intervention and chi-2 test for linear trend was used to evaluate the distribution VRE and use of glycopeptides during the study period, the level of p<0.05 was significant. PFGE was performed. Detection of genes of resistance of VRE isolated from clinical samples was performed by PCR E. faecium was the most frequent species isolated being responsible for 71% of positives cultures. Thirty-six infection were documented, bloodstream infection 17 (47%) was the most frequent site. The educational intervention was given to 136 HCW. 706 opportunities were evaluated, the compliance with standard and contact precautions did not improve comparing pre and pos-intervention period. However, the proportion of environmental and equipments positive cultures decreased significantly comparing pre (23.2%) and pos-intervention (2.4%) period (p<0.001) and was associated with decrease of VRE infection per 1.000 pts-day (p=0.004). The use of vancomycin (DDD) did not change significantly over the study period (p=0.97) and the use of teicoplanin increased (p<0.001). Ninety percent of E. faecium belong to the same type. In the present study, reduction of proportion of positive environmental and equipments cultures was associated with decreased of rates of VRE infections.

This dissertation aims to examine and analyse the current South African position with regard to voluntary euthanasia. An examination is made from constitutional law, common law, case law and statutory law perspectives, including the legislation proposed by the South African Law Commission (project 86). The writings of prominent authors are considered. Once the South African position is examined, a comparative study is undertaken concerning relevant aspects in the Dutch law. The most important findings are that the South African Constitution may allow, and perhaps even demand, the legalization of voluntary euthanasia in South Africa, provided that sufficient safeguards can be established to effectively and sufficiently minimize the risk of abuse. Should this be impossible, the proscription of euthanasia may be reasonable and justifiable in an open and democratic society based on human dignity, equality and freedom. Finally, some recommendations are made for changes to the South African Law Commission’s Final Draft Bill. / Dissertation (LLM (Medical Law))--University of Pretoria, 2008. / Public Law / unrestricted

Psychiatric advance directives (PADs) are legal documents allowing competent individuals to declare their treatment preferences in advance of a mental health crisis. The objective of this thesis is to examine psychosocial perceptions of legal and mental health professionals in Ontario and Quebec regarding their knowledge and willingness to implement PADs. Two hundred professionals---psychiatrists, psychologists, lawyers and administrative tribunal members---participated in an Web-survey measuring psychosocial perceptions of clinical, ethical, legal and implementation factors of PADs. Results indicate Quebec professionals are more willing to begin using PADs than Ontario professionals. Mental health professionals reported more concern than legal professionals for medical malpractice lawsuits for overriding PADs. Advantages of PADs most commonly reported are patients' ability to declare their clear wishes ahead of time, respect for autonomous choice, and establishing a collaborative treatment plan with physicians. Disadvantages included patients' lack of awareness, treatment refusal, and being self-bound to an earlier decision.

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