RESUMO
PURPOSE: To analyze the characteristics of moribund patients in a surgical intensive care unit (ICU) and highlight the dilemmas inherent in treating such patients. METHODS: Data on all patients admitted to the surgical ICU during the period of three years from July 1999 to June 2002 were collected prospectively. Data were collected on very ill patients who died, in whom it appeared obvious that treatment could not have improved their condition and whose death could have been anticipated. The case notes were subjected to further analysis to determine the difficulties encountered in managing patients whose therapy was considered to be futile. RESULTS: Of 662 admissions, 100 (15.1%) died and 30 (4.5%) patients were treated aggressively, even after a prognosis which reflected futile treatment. The overall mean length of stay for survivors was 7.5 +/- 9.0 [standard deviation (SD)] days and that for the non-survivors was 12.8 +/- 18.1 (SD; P < 0.001). The cost incurred for the treatment of non-survivors was significantly higher than that for the surviving patients. The factors relating to the decisions to continue futile therapy were age of the patient, legal considerations, family wishes and differing opinions between treating physicians. CONCLUSION: Consideration of futility during end-of-life care did not receive adequate attention in this unit which incurred additional human and material resources.
Assuntos
Cuidados Críticos , Países em Desenvolvimento , Futilidade Médica , Ordens quanto à Conduta (Ética Médica) , APACHE , Fatores Etários , Idoso , Barbados , Morte Encefálica , Estado de Consciência , Cuidados Críticos/economia , Cuidados Críticos/legislação & jurisprudência , Família , Feminino , Humanos , Tempo de Internação , Masculino , Futilidade Médica/legislação & jurisprudência , Estado Vegetativo Persistente , Estudos Prospectivos , Diálise Renal , Ordens quanto à Conduta (Ética Médica)/legislação & jurisprudência , Sobrevida , Sobreviventes , Resultado do TratamentoRESUMO
At the beginning of the 20th century, Barbados was described as the most unhealthy place in the British Empire; at the end of the century, it is considered amongst the healthiest of developing countries. At the start of the century the statistics were harsh; for example, there was an infant mortality rate of 400 per 1000 live births. It is now between 10 and 15 per live births. In the last two-thirds of the century, there was a series of ongoing revolutions in Education, Public Health and Hospital Services that affected the health status favourably. The revolution in education was enhanced by the provision of University education starting with Medicine at Mona, Jamaica. Training of doctors expanded to Barbados in 1967 and has been an essential ingredient in the medical care revolution of the last third of the century. In 1953, the first Public Health Centre was opened and Barbados can now boast the most modern public health and primary care facilities. However, modern lifestyles are associated with an epidemic of obesity, diabetes mellitus and hypertension. HIV/AIDS has emerged as a major problem. Health in the 21st century will need to look at lifestyles - the effects of the internal combustion engine, the availability of tools of violence, the lure of `illegal drugs', personal relationships and gender as well as the driving forces behind the associated lifestyles. (AU)
Assuntos
História do Século XX , Humanos , Atenção à Saúde/história , Saúde Pública/história , Barbados , /história , Hospitais/históriaRESUMO
For their own professional health, professionals should demand from administrators that ethical expertise and guidance be available. Otherwise they should set up their own to ensure that this area does not remain a convinient and readily available weapon against health care professionals. (AU)
Assuntos
Humanos , Ética Médica , Região do Caribe , Atenção à Saúde/legislação & jurisprudência , Relações Profissional-Paciente , Pesquisa/legislação & jurisprudênciaRESUMO
The foot complications of diabetic patients are one of the commonest and most devastating of medical problems that occurs in the Caribbean. The scale of the problem is reflected in the fact that, on average, 75 percent of the beds in the general surgical wards of the Queen Elizabeth Hospital in Barbados are occupied with this problem. of the patients admitted, a third lose a limb by amputation and another third lose toes or part of their feet and remain in hospital an average of two months as doctor struggle to prevent them losing their limbs. Half of the patients are in their 70s and when they are admitted to hospital but 4 per cent are as young as thirty to forty years. (AU)
Assuntos
Humanos , Pé Diabético/complicações , Região do Caribe/epidemiologia , Pé Diabético/prevenção & controle , Pé Diabético/terapia , Educação de Pacientes como AssuntoRESUMO
In Barbados diabetics with foot problems account for 80 percent of the patients in the female and 50 percent of those in the male general surgery wards, and many patients have major amputations for preventable problems. A six month prospective study was undertaken of all cases admitted with foot problems to the general surgical wards of the the Queen Elizabeth Hospital (QEH) in order to determine the quality of foot care, particularly among diabetics. 67.5 percent of the 195 patients (55 percent female) admitted to the study were diabetic, most of whom were diagnosed 10 to 19 years previously. Most of the patients were 70 to 80 years old, but significantly more diabetics than non-diabetics were 40 to 70 years old. Foot problems in diabetics were precipitated by events that are considered trivial in non-diabetic patients. 87 (58 percent) of 150 responding patients had their feet inspected by health personnel in the previous year. 47 (63.5 percent) of the 74 who responded about the care of their nails said that they took care of their nails themselves. Nearly 40 percent of diabetic and non-diabetic patients had no reported source of care before their admission. 14 patients (10 diabetic) sought care the same day and 11 (nine diabetics) the day after noticing foot problems. Most patients presented with infection as part of their problem; recognition of the early signs of infection should be an integral part of the education of the diabetic patient. Educational efforts for patients must be continually reinforced because many patients said they had no education about the care of their feet in the previous year.(AU)
Assuntos
Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Idoso , Pé Diabético/epidemiologia , Qualidade da Assistência à Saúde , Barbados , Fatores Etários , Fatores Sexuais , Diabetes Mellitus/complicações , Pé Diabético/etiologia , Fatores DesencadeantesRESUMO
The results of 10 living donor (LRD) renal transplants performed in Barbados during the period 1987 to 1997 are reported. The donors were four mothers, three fathers, two brothers and an uncle. The six female and four male recipients were 14 to 36 years of age. Four recipients displayed delayed graft function (DFG), ie, failure to produce more than 1.0 L of urine in the first 24 hours and/or failure to reduce plasma creatinine by more than 50 percent in the first 48 post-operative hours. Two of these grafts were lost due to thrombosis of the allograft anastomisis; one patient successfully resumed haemodialysis therapy following transplant nephrectomy but the other died from the respiratory distress syndrome three days after transplantation. Of the remaining two patients with DGF, one showed impaired function at one year and subsequently lost the allograft at ten years post-transplantation from chronic rejection, the other has "normal" renal function five year post-transplantation. One other patient died in the early post-operative period, from a cerebral haemorrhage due to uncontrolled hypertension. Five of the allografts were functioning five years after transplantation (mean plasma creatinine = 169.2 umols/l); one has a plasma creatinine of 112 umols/l at one year and another has a plasma creatinine of 300 umols/l eight months after transplantation. This experience shows that the infrastructure to support LRD renal transplants is established in Barbados and can be used to supplement renal replacement initiatives in Barbados and in neighbouring Eastern Caribbean states.(AU)