This thesis investigates the legal validity of living wills (advance directives) in South Africa. The study explores the current status of living wills in South Africa and contains recommendations on how legal enforceability of living wills can be improved in the South African context. The Constitution of the Republic of South Africa, 1996, the common law and the National Health Act, 61 of 2003, serve as basic points of departure for this investigation. Shortcomings in the current South African legislation and proposed draft legislation including the Law Commission’s Draft Bill on End of Life Decisions, 1998, and The National Health Amendment Bill, 2019, as well as shortcomings in the common law, the field of medical ethics and medical practice are indicated and recommendations for an improved framework are made. For purposes of a legal comparative methodology, the legal frameworks of living wills in the Netherlands, England and Canada are investigated. Specific circumstances which could potentially hamper the legal enforcement of living wills are discussed, including: emergency situations, do-not-resuscitate orders, permanent vegetative states, dementia, cessation of artificial hydration and feeding, pregnancy, euthanasia, assisted suicide, palliative care, pain relief and organ donation. It is argued that a living will could be an important tool in enhancing the doctor-patient relationship, not only to the benefit of the autonomous patient whose dignity and other fundamental human rights should be protected, but also to the benefit of the doctor as the medical care provider. / Thesis (LLD)--University of Pretoria, 2019. / Public Law / LLD / Unrestricted

Title: Clinical Decision Making in Paramedicine Author(s) & affiliation(s): Michael Eby – McMaster University, Hamilton, ON, Canada Sandra Monteiro – McMaster University, Hamilton, ON, Canada Geoffrey Norman – McMaster University, Hamilton, ON, Canada Walter Tavares – McMaster University, Hamilton, ON, Canada Background: Paramedics are frequently required to make rapid decisions in an uncontrolled, dynamic environment, often with limited diagnostic information. In Ontario, paramedic practice is based on a set of provincial medical directives that provide diagnostic and treatment criteria. Unsupervised deviation from these directives is classified as a form of error and highly discouraged. To date, there is little known about how years of clinical experience or level of certification affect the way these medical directives are used. The purpose of this study was to examine the relationship between paramedic experience, training and accuracy of treatment decisions when faced with patients who meet and fall outside of the existing medical directives. Methods: Thirty-one participants (16 experienced / 15 novice) were recruited from two paramedic services in Ontario. “Experienced” was defined as in-practice for 5 years or more. Participants were presented with 9 scenarios; in 6 scenarios, the patient presentation fit within the existing directives, while in 3 scenarios, the patient presentation fell outside the medical directives. Multiple-choice responses were used to capture participants’ decisions to treat or not treat the patients. Responses were scored and submitted to a mixed-factorial ANOVA to evaluate differences in accuracy between case types, years of experience and level of training. Results: There was a significant effect of case type (p < 0.004). Accuracy was lower when the patient presentation did not meet the criteria of the medical directive (76.34% (CI = 67.15% to 85.53%) vs. 98.35% (CI = 96.55% to 100%) when they did. There was no effect of years of clinical practice or level of certification. Conclusion: The results suggest both novice and experienced paramedics are able to accurately apply medical directives, however, there is a significant decrease in accuracy when the patient presentation does not fit one. This variation in practice may have a significant impact on patient safety, and further research is required to determine what factors may be causing this decreased accuracy. / Thesis / Master of Science (MSc) / Paramedics work in a fast-paced, dynamic environment. The types of patients, and the situations paramedics encounter are different every day. Paramedic practice is based on a series of provincial medical directives that outline the different proceedures, medications and types of patients that can be treated. While these directives cover many of the cases paramedics encounter, there will always be cases that don’t “fit”. The purose of this study is to see if paramedics approach those types of cases in a different way, and if their years of experience or level of training change how good they are at idenfiying what patients require treatment. As there is very little paramedic specific research on this topic, this study will serve as a starting point for future research and hopefully stimulate discussion about paramedic practice, and how to support paramedics getting better at their jobs.

Objectives: To describe the use of standardized protocols (SPs) in emergency departments (EDs) across Ontario for childhood asthma and analyze the association of SPs with hospital admissions, 7-day ED re-visits, and outpatient follow-up visits. Methods: Population-based retrospective cohort study using health administrative data and survey data. EDs were categorized as having the optimal, other, or no SP for each outcome. Associations were tested with generalized estimating equations. Results: Between 2006/04/14-2009/02/28, 46,510 children with asthma were seen in 146 EDs, with 43 (29.5%) having SPs. Children treated in EDs with the optimal SP compared to no SP had no significant differences in hospital admissions (AOR 1.17; 95% CI 0.91, 1.49) or ED re-visits (AOR 1.09; 95% CI 0.85, 1.40) but were more likely to have follow-up visits (AOR 1.27; 95% CI 1.02, 1.59). Conclusions: SPs for childhood asthma are not common in Ontario EDs and had little impact on outcomes measured.

Objectives: To describe the use of standardized protocols (SPs) in emergency departments (EDs) across Ontario for childhood asthma and analyze the association of SPs with hospital admissions, 7-day ED re-visits, and outpatient follow-up visits. Methods: Population-based retrospective cohort study using health administrative data and survey data. EDs were categorized as having the optimal, other, or no SP for each outcome. Associations were tested with generalized estimating equations. Results: Between 2006/04/14-2009/02/28, 46,510 children with asthma were seen in 146 EDs, with 43 (29.5%) having SPs. Children treated in EDs with the optimal SP compared to no SP had no significant differences in hospital admissions (AOR 1.17; 95% CI 0.91, 1.49) or ED re-visits (AOR 1.09; 95% CI 0.85, 1.40) but were more likely to have follow-up visits (AOR 1.27; 95% CI 1.02, 1.59). Conclusions: SPs for childhood asthma are not common in Ontario EDs and had little impact on outcomes measured.