An Insight Into the Experiences of Malaysian Patients With Advanced Cancer and Their Preferences in End-of-Life Care: A Qualitative Study

BACKGROUND

Preferences of patients with advanced cancer are well studied in Western countries but less so in Asian communities where end-of-life discussions can be seen as taboo. This may lead to patients receiving care that is incongruent with their wishes as their disease progress. It is important for healthcare providers to have a better understanding of patients' experiences and preferences especially in a multicultural country like Malaysia with its diverse beliefs and values to facilitate better planning for future medical care.

OBJECTIVES

To explore the experiences and preferences of Malaysian patients with advanced cancer.

DESIGN

Qualitative study of semi-structured interviews with thematic analysis.

SETTING/SUBJECTS

Purposive sampling of 19 patients with Stage 4 cancer recruited from inpatient and outpatient settings in National Cancer Institute Malaysia.

RESULTS

Three major themes emerged in the exploration of patients' experiences and care preferences in facing advanced cancer namely: 1) Dealing with poor prognosis 2) Spirituality as a source of strength and 3) Enablers of advance care planning.

CONCLUSION

This study highlighted the preference for healthcare providers to be culturally sensitive during end-of-life care discussion and the need for improved spiritual care for Malaysian patients with advanced cancer. Further studies exploring the role of spiritual and cultural factors in advance care planning among Malaysians would be helpful in guiding these efforts.

Convalescent plasma transfusion in severe COVID-19 patients: Clinical and laboratory outcomes

INTRODUCTION

The objective of this study was to investigate the effect of convalescent plasma (CP) transfusion on clinical and serial laboratory parameters in severe COVID-19 patients. The Coronavirus Disease 2019 (COVID-19) pandemic presents a challenge to the healthcare system worldwide due to the limited treatment options available. The body of evidence reported that CP containing anti- COVID-19 antibodies could be effective against the infection.

MATERIALS AND METHODS

This was a cross-sectional study that involved retrospective data collection of severe COVID-19 adult patients who received CP transfusion along with the best-of-care (CP group, n: 53) and best-of-care only (control group, n: 53). An age, gender, and comorbidity were manually matched approximately at a 1:1 ratio.

RESULTS

The prevalence of adverse transfusion reactions was 5.7%. A shorter duration of oxygen support (median: 12 days vs 14 days, P=0.030) and a shorter duration of mechanical ventilation (median: 6 days vs 10 days, P=0.048) were found in the CP group. The laboratory parameters were also improved. However, there was no significant difference in the mechanical ventilation rate, length of hospital stay, length of intensive care unit (ICU) stay, and mortality rate across both groups (P = 0.492, 0.614, 0.793, 0.374).

CONCLUSION

CP transfusion is safe and effective in the treatment of severe COVID-19 patients. However, a revision of our approaches such as early CP transfusion and use of a high-titre anti-COVID-19 neutralising antibody (nAb) unit is necessary to unlock the full potential benefits of CP transfusion among COVID-19 patients.

Social responsibility perspective in public response to the COVID-19 pandemic: a grounded theory approach

Background

Combating viral outbreaks extends beyond biomedical and clinical approaches; thus, public health prevention measures are equally important. Public engagement in preventive efforts can be viewed as the social responsibility of individuals in controlling an infectious disease and are subjected to change due to human behaviour. Understanding individuals’ perception of social responsibility is crucial and is not yet explored extensively in the academic literature. We adopted the grounded theory method to develop an explanatory substantive theory to illustrate the process of how individual responded to the outbreak from a social responsibility perspective.

Methods

In-depth interviews were conducted among 23 Malaysians either through telephone or face-to-face depending on the participant’s preference. Both purposive and theoretical sampling were used. Participants were invited to share their understanding, perceptions and activities during the COVID-19 pandemic. They were further probed about their perceptions on complying with the public health interventions imposed by the authorities. The interviews were audio-recorded and transcribed verbatim. Data was analysed via open coding, focus coding and theoretical coding, facilitated by memoing, sketching and modelling.

Results

Study findings showed that, social responsibility is perceived within its role, the perceived societal role responsibility. In a particular context, an individual assumed only one of the many expected social roles with their perceived circle of responsibility. Individuals negotiated their actions from this perspective, after considering the perceived risk during the outbreak. The four types of behaviour depicted in the matrix diagram facilitate the understanding of the abstract concept of negotiation in the human decision-making process, and provide the spectrum of different behaviour in relation to public response to the COVID-19 pandemic.

Conclusions

Our study adopted the grounded theory approach to develop a theoretical model that illustrates how individual response to COVID-19 preventive measures is determined by the negotiation between perceived societal role responsibility and perceived infection risk. This substantive theoretical model is abstract, thus has relevance for adoption within similar context of an outbreak.

Convalescent plasma as an adjunctive therapy for COVID-19: A single centre experience in Malaysia

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic posed a significant and urgent threat to global health and economy. Currently, there is no effective treatment known to alter the course of COVID-19. Convalescent plasma (CP) has been used previously to treat several types of infections during pandemics. The aim of our study is to evaluate the efficacy of CP in the treatment of severe COVID-19 infections at Hospital Sultanah Bahiyah, Kedah, Malaysia.

MATERIALS AND METHODS

A retrospective cross-sectional study of all severe COVID-19 patients who received CP treatment from 1st August 2020 until 31st December 2020 was conducted. Clinical outcomes were compared before and after CP transfusion.

RESULTS

Thirty-four patients were enrolled and received CP transfusion during the study period. The most common presenting complaints were fever (64.7%) and cough (58.8%). Fourteen patients showed improvement in oxygen support after CP transfusion. Several laboratory parameters also improved such as increased lymphocyte count (1.48 vs 1.98, p=0.008) and decreased C-reactive protein levels (28.1 vs 10.6, p=0.004), and these were statistically significant. Median time from symptoms onset to CP transfusion was 6 days (range 1-11) while median time from PCR diagnosis to CP transfusion was 5 days (range 1-11). One patient developed urticaria after CP transfusion and no severe adverse events were observed. Two of our patients passed away due to secondary causes.

CONCLUSION

This study showed CP treatment was well tolerated and could potentially prevent progression of COVID-19 to a severe disease if administered early during the viraemic phase. Further evaluation with randomized control trial should be conducted to help ascertain the optimal dose and effectiveness of CP treatment, in correlation with the IgG titer of the donated CP.

Addressing Gaps for Health Systems Strengthening: A Public Perspective on Health Systems' Response towards COVID-19

Strengthening the health systems through gaps identification is necessary to ensure sustainable improvements especially in facing a debilitating outbreak such as COVID-19. This study aims to explore public perspective on health systems’ response towards COVID-19, and to identify gaps for health systems strengthening by leveraging on WHO health systems’ building blocks. A qualitative study was conducted using open-ended questions survey among public followed by in-depth interviews with key informants. Opinions on Malaysia’s health systems response towards COVID-19 were gathered. Data were exported to NVIVO version 12 and analysed using content analysis approach. The study identified various issues on health systems’ response towards COVID-19, which were then mapped into health systems’ building blocks. The study showed the gaps were embedded among complex interactions between the health systems building blocks. The leadership and governance building block had cross-cutting effects, and all building blocks influenced service deliveries. Understanding the complexities in fostering whole-systems strengthening through a holistic measure in facing an outbreak was paramount. Applying systems thinking in addressing gaps could help addressing the complexity at a macro level, including consideration of how an action implicates other building blocks and approaching the governance effort in a more adaptive manner to develop resilient systems.

Emergency Laparotomy in a COVID-19 patient with acute abdomen

We describe here the first laparotomy involving a COVID-19 patient in Malaysia. A 60-year-old man screened positive for SARS-CoV-2 in March 2020 and developed acute abdomen in the ward in Hospital Sultanah Bahiyah, Kedah. He underwent laparotomy and cholecystectomy for gangrenous cholecystitis. All personnel adhered to infectious control precautions, donning full personal protective equipment (PPE) throughout the surgery. Post-operatively, due to raised septic parameters, he was carefully diagnosed with and treated empirically for superimposed bacterial sepsis instead of cytokine release syndrome, with confirmed blood culture of Klebsiella pneumoniae. Patient was discharged well later. None of the staff involved in his care developed COVID-19 infection.

Process evaluation of enhancing primary health care for non-communicable disease management in Malaysia: Uncovering the fidelity & feasibility elements

BACKGROUND

In combating the increasing trend of non-communicable diseases (NCDs) over the last two decades in the country, the Ministry of Health Malaysia developed the Enhanced Primary Health Care (EnPHC) initiative to improve care management across different levels of the public service delivery network. An evaluation research component was embedded to explore the implementation issues in terms of fidelity, feasibility, adaptation and benefit of the initiative's components which were triage, care coordination, screening, risk management and referral system.

METHODS

A mixed methods study was conducted at 20 participating EnPHC clinics in Johor and Selangor, two months after the intervention was initiated. Data collected from self-reported forms and a structured observation checklist were descriptively analysed. In-depth interviews were also conducted with 20 participants across the clinics selected to clarify any information gaps observed in each clinic, and data were thematically analysed.

RESULTS

Evaluation showed that all components of EnPHC intervention had been successfully implemented except for the primary triage counter and visit checklist. The challenges were mainly discovered in terms of human resource and physical structure. Although human resource was a common implementation challenge across all interventions, clinic-specific issues could still be identified. Among the adaptive measures taken were task sharing among staff and workflow modification to match the clinic's capacity. Despite the challenges, early benefits of implementation were highlighted especially in terms of service outcomes.

CONCLUSIONS

The evaluation study disclosed issues of human resource and physical infrastructure when a supplementary intervention is implemented. To successfully achieve a scaled-up PHC service delivery model based on comprehensive management of NCDs patient-centred care, the adaptive measures in local clinic context highlight the importance of collaboration between good organisational process and good clinical practice and process.

Collaboration between a tertiary pain centre and community teams during the pandemic

People with chronic pain faced potential treatment disruption during the COVID-19 pandemic in Singapore, as the focus of healthcare shifted. A model of rapid integration of a pain centre with community healthcare teams was implemented to care for vulnerable older patients with chronic pain and multiple comorbidities. Telemedicine and home visits by community nurses were used, with risk-mitigation measures, ensuring comprehensive assessment and treatment compliance. Medications from pain physicians were delivered at home through a hospital pharmacy. A secure national electronic health records system used by all teams ensured seamless access and documentation. Potential emergency department visits, admissions and delayed discharges were thus avoided. Integration of community teams with chronic pain management services can be recommended to ensure pandemic preparedness.

Assessing receptiveness to change among primary healthcare providers by adopting the consolidated framework for implementation research (CFIR)

BACKGROUND

Amid the current burden of non-communicable (NCD) diseases in Malaysia, there is a growing demand for more efficient service delivery of primary healthcare. A complex intervention is proposed to improve NCD management in Malaysia. This exploratory study aimed to assess primary healthcare providers' receptiveness towards change prior to implementation of the proposed complex intervention.

METHOD

This study was conducted using an exploratory qualitative approach on purposely selected healthcare providers at primary healthcare clinics. Twenty focus group discussions and three in-depth interviews were conducted using a semi-structured interview guide. Consent was obtained prior to interviews and for audio-recordings. Interviews were transcribed verbatim and thematically analysed, guided by the Consolidated Framework for Implementation Research (CFIR), a framework comprised of five major domains promoting implementation theory development and verification across multiple contexts.

RESULTS

The study revealed via CFIR that most primary healthcare providers were receptive towards any proposed changes or intervention for the betterment of NCD care management. However, many challenges were outlined across four CFIR domains-intervention characteristics, outer setting, inner setting, and individual characteristics-that included perceived barriers to implementation. Perception of issues that triggered proposed changes reflected the current situation, including existing facilitating aspects that can support the implementation of any future intervention. The importance of strengthening the primary healthcare delivery system was also expressed.

CONCLUSION

Understanding existing situations faced at the primary healthcare setting is imperative prior to implementation of any intervention. Healthcare providers' receptiveness to change was explored, and using CFIR framework, challenges or perceived barriers among healthcare providers were identified. CFIR was able to outline the clinics' setting, individual behaviour and external agency factors that have direct impact to the organisation. These are important indicators in ensuring feasibility, effectiveness and sustainability of any intervention, as well as future scalability considerations.

Research funding impact and priority setting - advancing universal access and quality healthcare research in Malaysia

BACKGROUND

Health Research Priority Setting (HRPS) in the Ministry of Health (MOH) Malaysia was initiated more than a decade ago to drive effort toward research for informed decision and policy-making. This study assessed the impact of funded prioritised research and identified research gaps to inform future priority setting initiatives for universal access and quality healthcare in Malaysia.

METHODS

Research impact of universal access and quality healthcare projects funded by the National Institutes of Health Malaysia were assessed based on the modified Payback Framework, addressing categories of informing policy, knowledge production, and benefits to health and health sector. For the HRPS process, the Child Health and Nutrition Research Initiative methodology was adapted and adopted, with the incorporation of stakeholder values using weights and monetary allocation survey. Workshop discussions and interviews with stakeholders and research groups were conducted to identify research gaps, with the use of conceptual frameworks to guide the search.

RESULTS

Seventeen ongoing and 50 completed projects were identified for research funding impact analysis. Overall, research fund allocation differed from stakeholders' expectation. For research impact, 48 out of 50 completed projects (96.0%) contributed to some form of policy-making efforts. Almost all completed projects resulted in outputs that contributed to knowledge production and were expected to lead to health and health sector benefits. The HRPS process led to the identification of research priority areas that stemmed from ongoing and new issues identified for universal access and quality healthcare.

CONCLUSION

The concerted efforts of evaluation of research funding impact, prioritisation, dissemination and policy-maker involvement were valuable for optimal health research resource utilisation in a resource constrained developing country. Embedding impact evaluation into a priority setting process and funding research based on national needs could facilitate health research investment to reach its potential.

The association between distance to public amenities and cardiovascular risk factors among lower income Singaporeans

Existing evidence on the association between built environment and cardiovascular disease (CVD) risk factors focused on the general population, which may not generalize to higher risk subgroups such as those with lower socio-economic status (SES). We examined the associations between distance to 5 public amenities from residential housing (public polyclinic, subsidized private clinic, healthier eatery, public park and train station) and 12 CVD risk factors (physical inactivity, medical histories and unhealthy dietary habits) among a study sample of low income Singaporeans aged ≥ 40 years (N = 1972). Using data from the Singapore Heart Foundation Health Mapping Exercise 2013–2015, we performed a series of logistic mixed effect regressions, accounting for clustering of respondents in residential blocks and multiple comparisons. Each regression analysis used the minimum distance (in km) between residential housing and each public amenity as an independent continuous variable and a single risk factor as the dependent variable, controlling for demographic characteristics. Increased distance (geographical inaccessibility) to a train station was significantly associated with lower odds of participation in sports whereas greater distance to a subsidized private clinic was associated with lower odds of having high cholesterol diagnosed. Increasing distance to park was positively associated with higher odds of less vegetable and fruits consumption, deep fried food and fast food consumption in the preceding week/month, high BMI at screening and history of diabetes, albeit not achieving statistical significance. Our findings highlighted potential effects of health-promoting amenities on CVD risk factors in urban low-income setting, suggesting gaps for further investigations.

•

We examined associations between access to 5 amenities and 12 CVD risk factors.

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Only 2/60 associations were statistically significant.

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Poorer access to train station was associated with lower odds of sports.

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Poorer access to primary care was associated with lower high cholesterol diagnosis.

Selection of Treatment Strategies among Patients with Type 2 Diabetes Mellitus in Malaysia: A Grounded Theory Approach

Background

Diabetes Mellitus is a multifaceted chronic illness and its life-long treatment process requires patients to continuously engage with the healthcare system. The understanding of how patients manoeuvre through the healthcare system for treatment is crucial in assisting them to optimise their disease management. This study aims to explore issues determining patients’ treatment strategies and the process of patients manoeuvring through the current healthcare system in selecting their choice of treatment for T2DM.

Methods

The Grounded Theory methodology was used. Twelve patients with Type 2 Diabetes Mellitus, nine family members and five healthcare providers from the primary care clinics were interviewed using a semi-structured interview guide. Three focus group discussions were conducted among thirteen healthcare providers from public primary care clinics. Both purposive and theoretical samplings were used for data collection. The interviews were audio-taped and transcribed verbatim, followed by line-by-line coding and constant comparison to identify the categories and core category.

Results

The concept of “experimentation” was observed in patients’ help-seeking behaviour. The “experimentation” process required triggers, followed by information seeking related to treatment characteristics from trusted family members, friends and healthcare providers to enable decisions to be made on the choice of treatment modalities. The whole process was dynamic and iterative through interaction with the healthcare system. The decision-making process in choosing the types of treatment was complex with an element of trial-and-error. The anchor of this process was the desire to fulfil the patient’s expected outcome.

Conclusion

Patients with Type 2 Diabetes Mellitus continuously used “experimentation” in their treatment strategies and help-seeking process. The “experimentation” process was experiential, with continuous evaluation, information seeking and decision-making tinged with the element of trial-and-error. The theoretical model generated from this study is abstract, is believed to have a broad applicability to other diseases, may be applied at varying stages of disease development and is non-context specific.

Social Influences of Help-Seeking Behaviour Among Patients With Type 2 Diabetes Mellitus in Malaysia

This qualitative study aimed to explore the influence of social networks such as family members, friends, peers, and health care providers toward the help-seeking behaviour (HSB) of patients with type 2 diabetes mellitus in the public and private primary care settings. In-depth interviews of 12 patients, 9 family members, and 5 health care providers, as well as 3 focus groups among 13 health care providers were conducted. All interviews were audio-taped and transcribed verbatim for qualitative analysis. Social influences play a significant role in the help-seeking process; once diagnosed, patients source information from people around them to make decisions. This significant influence depends on the relationship between patients and social networks or the level of trust, support, and comforting feeling. Thus, the impacts on patients' help-seeking behavior are varied. However, the help-seeking process is not solely an individual's concern but a dynamic process interacting with the social networks within the health care system.

Computer vision syndrome: a study of knowledge and practices in university students

INTRODUCTION

Computer vision syndrome (CVS) is a condition in which a person experiences one or more of eye symptoms as a result of prolonged working on a computer.

OBJECTIVES

To determine the prevalence of CVS symptoms, knowledge and practices of computer use in students studying in different universities in Malaysia, and to evaluate the association of various factors in computer use with the occurrence of symptoms.

MATERIAL AND METHODS

In a cross sectional, questionnaire survey study, data was collected in college students regarding the demography, use of spectacles, duration of daily continuous use of computer, symptoms of CVS, preventive measures taken to reduce the symptoms, use of radiation filter on the computer screen, and lighting in the room.

RESULTS

A total of 795 students, aged between 18 and 25 years, from five universities in Malaysia were surveyed. The prevalence of symptoms of CVS (one or more) was found to be 89.9%; the most disturbing symptom was headache (19.7%) followed by eye strain (16.4%). Students who used computer for more than 2 hours per day experienced significantly more symptoms of CVS (p=0.0001). Looking at far objects in-between the work was significantly (p=0.0008) associated with less frequency of CVS symptoms. The use of radiation filter on the screen (p=0.6777) did not help in reducing the CVS symptoms.

CONCLUSION

Ninety percent of university students in Malaysia experienced symptoms related to CVS, which was seen more often in those who used computer for more than 2 hours continuously per day.

Mixed feelings about the diagnosis of type 2 diabetes mellitus: a consequence of adjusting to health related quality of life

This study aims to explore patients' reactions to the diagnosis of type 2 diabetes mellitus (T2DM) and their health related quality of life. We adopted a qualitative exploratory study design using a thematic analysis. Twelve patients with T2DM for more than a 2-year duration were interviewed using a semi-structured interview guide. Both purposive and theoretical samplings were used for data collection. The in-depth interviews were audio-taped and transcribed verbatim, followed by line-by-line coding and constant comparison to identify the themes. Data management was facilitated using Nvivo 10. Patients shared their mixed feelings about the diagnosis of T2DM. Six domains of quality of life emerged from these interviews, namely physical and social functioning, work function and social obligations, dietary freedom and conforming to treatment standard. Diabetes management needs to take these themes and patients' feelings associated with their quality of life into consideration.

A forgotten clinical sign making a comeback

We report a case of Staphylococcus aureus infective endocarditis in a patient presenting with fever and rare cutaneous manifestations of Osler Nodes and Janeway Lesions. There had not been any distinct risk factors. His echocardiography subsequently revealed vegetation at the anterior mitral valve leaflet. As Staphylococcus aureus infective endocarditis is of utmost significance in morbidity and mortality, a sharp clinical acumen and follow up investigations is required alongside a prolonged course of antibiotics. Our patient was then started on intravenous cloxacillin for 28 days and gentamicin for 5 days to which he made good progress and recovery.

Desperately seeking dissonance: identifying the disconfirming case in qualitative evidence synthesis

Actively seeking the disconfirming or deviant case is properly regarded as a hallmark of trustworthiness in primary qualitative research. The need to subject emergent theory to such testing is no less important within qualitative systematic reviews. There is, as yet, little available guidance on how to implement such strategies. Few researchers have described the practicalities of seeking the disconfirming case. We survey the methodological literature to gain a better understanding of how systematic reviews of qualitative research handle the disconfirming case. We reflect on our own experience from three recent qualitative evidence syntheses. We describe how reviewers might actively manufacture opportunities to identify discrepant or refutational findings. We conclude by outlining possible methods by which a team might integrate active seeking of a disconfirming case within the overall review process.

Validity and reliability of the SF-36: the Malaysian context

Results of construct validity and reliability of the SF-36 are described, based on data from a multi-centre study on asthmatics and a population based survey. Questionnaire refinement was carried out between the two studies. Quality of data was good, with all items having less than 0.5% missing values. Floor and/or ceiling effects were observed for REE, REP, PF and SF. For scaling assumptions, correlations between each items and its hypothesized scale were all above 0.50, except for one item in PF. and for both items in SF. Item discriminant validity was an issue for items in VT, SF and MH scales. Cronbach's as for all scales exceeded the recommended 0.70 level, except for SF. Only one latent dimension was identified in principal component analysis, and only 52-53% of variance accounted for. As expected, PF shows high correlations with the physical component while MH was highly correlated with the mental component. Contrasting findings in the loadings of other scales were observed in the asthma data. Age, disease severity and presence of self-reported handicap/disability significantly affect PF, while MH demonstrates no obvious pattern with declining age. In essence, the Malay version of SF-36 could be used in Malaysia, with its generally acceptable internal consistency and validity. The caveat is in the call for additional domains of importance to Malaysians that is not covered by the instrument, and in the caution to be employed when using and construing the instrument.

Quality of life of the Malaysian general population: results from a postal survey using the SF-36

Population norms for Health Related Quality of Life using SF-36 are described. A national sample was canvassed in 2000 using a self-administered SF-36 in Bahasa Malaysia and English. Response rate was 30.6%, with 3072 usable data. Male: Female ratio was 1.04 and mean age was 39.8 years. Quality of life was affected by age and sex. Older population and women had a poorer quality of life. Population norms for Malaysia differed from those of US, Canada and Australia. The malaysian general population norm described is useful as reference point for studies in Malaysia. Variability in scores by age and sex emphasize the need to use appropriate age- or sex-specific normative data.

Quality of life--how do Malaysian asthmatics fare?

Asthma can place considerable restrictions on the physical, emotional and social aspects of the lives of patients. The assessment of quality of life aims to provide a means of measuring the impact of this disease on patients' lives, from the patients' perspective. A cross sectional multi-centre study was conducted in six government hospitals throughout the country. Self-administered SF-36 was used, and clinical information obtained through interviews and examination. 1612 asthmatics responded. Females constituted 63% of the respondents; mean age was 40.9 years; Malays were the majority ethnic group, while 70.8% had secondary level education and 53.7% were employed. Half had suffered from asthma for at least 13 years, while 46.8% and 23.6% have moderate and severe disease respectively. Quality of life was affected by severity of disease. Asthmatics, had a significantly poorer quality of life than the general US population. Severe asthma disease was associated with a compromised quality of life, similar to that of COPD.

Medical futility and the critically ill patient

Today, the world of critical care medicine has given us the capabilities to accomplish things that were only dreamed of a few decades ago. When combined with the increasing importance of patient autonomy and economics in healthcare, these new capabilities have caused conflicts about what is too little, and what is too much. Medical futility becomes an issue whenever these conflicts arise. Understanding how to deal with issues surrounding futility begins with defining it. A firm definition is not possible or desirable, but revolves around the probability of being able to achieve a patient's goal with modern medicine. Establishing this understanding between the patient and their family (team), and the healthcare team, is dependent on trust between the two. It must be recognized that there are many reasons for families to not trust healthcare professionals and that these reasons need to be explored and dealt with. Sometimes conflicts regarding predictions and economics need to be addressed. Once trust is established a goal for a course of medical treatment should be discussed from the patient's perspective. This discussion should involve the physician's best judgement as to the chances of achieving this goal, and what type of discomfort or indignity, if any, the patient may experience. Only after these have been clearly discussed can decisions regarding medical futility be made. To date, the U. S. Courts have refused to grant physicians and hospitals the power to override the opinions of family members on matters of futility. However, with time, a consensus of public opinion should influence decisions regarding medical futility.

The effect of arterial lines on blood-drawing practices and costs in intensive care units

STUDY OBJECTIVE

To determine whether the presence of an indwelling arterial access line leads to differences in blood-drawing practices and costs, in patients with similar APACHE II scores, in the ICU.

DESIGN

Prospective, observational.

SETTING

Adult surgical and medical ICUs at a large military tertiary care hospital.

PATIENTS

Twenty-five adult (ie, above 18 years old) patients with arterial access lines and 25 adult patients without arterial access lines. Each had APACHE II of 9 to 20 and none had any central venous access.

MEASUREMENTS AND RESULTS

A survey of the arterial line blood-drawing habits of critical care nurses at our hospital revealed a 2.99-mL mean discard blood volume to clear an arterial line, with only 9.4% not discarding any blood. For each patient enrolled in the study, the number of blood tests and blood draws were recorded during the first two 24-h periods after admission to the ICU. The amount of blood required by the laboratory for each blood test was totalled. In the arterial line group, the mean discard volume was added to the total for each blood-drawing procedure. Increases were found in the number of blood tests (29% increase, p = 0.013), blood-drawing procedures (30% increase, p = 0.014), and the amount of blood volume (44% increase, p < 0.001) sent from patients with arterial lines compared to those without.

CONCLUSION

When APACHE II scores are similar, the presence of an arterial access line may lead to increased blood drawing from patients in ICUs.

Non-operative management of gastric perforation secondary to cardiopulmonary resuscitation

We report the case of a 72-year-old male who suffered a cardiac arrest during an early positive treadmill stress test. After successful resuscitation the patient had evidence of a gastric perforation. Because of his hemodynamic stability, lack of peritoneal signs, and prohibitively high surgical risk, a non-operative management approach was successfully administered. Although not the standard approach to traumatic gastric perforation, this case is not unlike the management of peptic ulcer perforations. A non-operative approach should be considered as an option in selected patients.