Moral distress among critical care nurses when excecuting do-not-resuscitate (DNR) orders in a public critical care unit in Gauteng.

Background: A critical care unit admits on a daily basis patients who are critically ill or injured. The condition of these patients' may deteriorate to a point where the medical practitioner may prescribe or decide on a 'do not resuscitate' (DNR) order which must be executed by a professional nurse, leading to moral distress which may manifest as poor teamwork, depression or absenteeism. Objectives: To explore and describe factors contributing to moral distress of critical care nurses executing DNR orders. Design: The explorative descriptive qualitative design was selected to answer the research questions posed. Methods: Critical care nurses of a selected public hospital in Gauteng Province were selected via purposive sampling to participate in the study, and data were collected through semi-structured interviews. Particpants: A shift leader assisted with selection of participants who met the eligibility criteria. The mean age of the participants was 36 years; most of them had more than five years' critical care nursing experience. Twelve critical care nurses were interviewed when data saturation was reached. Thereafter two more interviews were conducted to confirm data saturation. A total of 14 interviews were conducted. Results: Tesch's eight-step method was utilised for data analysis. The findings were classified under three main themes: moral distress, communication of DNR orders and unavailability of psychological support for nurses. Conclusion: The findings revealed that execution of DNR orders is a contributory factor for moral distress in critical care nurses. National guidelines and/or legal frameworks are required to regulate processes pertaining to the execution of DNR orders. The study further demonstrated the need for unit-based ethical platforms and debriefing sessions for critical care nurses. Contribution of the study: The main contribution of this study was to explore and describe the factors contributing to Moral distress when executing a DNR order. This study raised awareness amongst healthcare providers on the factors contributing to moral distress amongst critical care nurses. This study highlighted the importance of developing national guidelines and legal frameworks pertaining to execution of DNR orders. This study alluded to the value of initiating debriefing sessions for critical care nurses involved in the execution of DNR orders.

South African guidelines on the determination of death.

Death is a medical occurrence that has social, legal, religious and cultural consequences requiring common clinical standards for its diagnosis and legal regulation. This document compiled by the Critical Care Society of Southern Africa outlines the core standards for determination of death in the hospital context. It aligns with the latest evidence-based research and international guidelines and is applicable to the South African context and legal system. The aim is to provide clear medical standards for healthcare providers to follow in the determination of death, thereby promoting safe practices and high-quality care through the use of uniform standards. Adherence to such guidelines will provide assurance to medical staff, patients, their families and the South African public that the determination of death is always undertaken with diligence, integrity, respect and compassion, and is in accordance with accepted medical standards and latest scientific evidence. The consensus guidelines were compiled using the AGREE II checklist with an 18-member expert panel participating in a three-round modified Delphi process. Checklists and advice sheets were created to assist with application of these guidelines in the clinical environment (https://criticalcare.org.za/resource/death-determination-checklists/). Key points • Brain death and circulatory death are the accepted terms for defining death in the hospital context. • Death determination is a clinical diagnosis which can be made with complete certainty provided that all preconditions are met. • The determination of death in children is held to the same standard as in adults but cannot be diagnosed in children <36 weeks' corrected gestation. • Brain-death testing while on extra-corporeal membrane oxygenation is outlined. • Recommendations are given on handling family requests for accommodation and on consideration of the potential for organ donation. • The use of a checklist combined with a rigorous testing process, comprehensive documentation and adequate counselling of the family are core tenets of death determination. This is a standard of practice to which all clinicians should adhere in end-of-life care.

South African guidelines on the determination of death.

Summary: Death is a medical occurrence that has social, legal, religious and cultural consequences requiring common clinical standards for its diagnosis and legal regulation. This document compiled by the Critical Care Society of Southern Africa outlines the core standards for determination of death in the hospital context. It aligns with the latest evidence-based research and international guidelines and is applicable to the South African context and legal system. The aim is to provide clear medical standards for healthcare providers to follow in the determination of death, thereby promoting safe practices and high-quality care through the use of uniform standards. Adherence to such guidelines will provide assurance to medical staff, patients, their families and the South African public that the determination of death is always undertaken with diligence, integrity, respect and compassion, and is in accordance with accepted medical standards and latest scientific evidence. The consensus guidelines were compiled using the AGREE II checklist with an 18-member expert panel participating in a three-round modified Delphi process. Checklists and advice sheets were created to assist with application of these guidelines in the clinical environment (https://criticalcare.org.za/resource/death-determination-checklists/). Key points: Brain death and circulatory death are the accepted terms for defining death in the hospital context.Death determination is a clinical diagnosis which can be made with complete certainty provided that all preconditions are met.The determination of death in children is held to the same standard as in adults but cannot be diagnosed in children <36 weeks' corrected gestation.Brain-death testing while on extra-corporeal membrane oxygenation is outlined.Recommendations are given on handling family requests for accommodation and on consideration of the potential for organ donation.The use of a checklist combined with a rigorous testing process, comprehensive documentation and adequate counselling of the family are core tenets of death determination. This is a standard of practice to which all clinicians should adhere in end-of-life care.

The Critical Care Society of Southern Africa guidelines on the allocation of scarce critical care resources during the COVID-19 public health emergency in South Africa.

Letter by Gopalan et al. on article by Singh and Moodley (Singh JA, Moodley K. Critical care triaging in the shadow of COVID-19: Ethics considerations. S Afr Med J 2020;110(5):355-359. https://doi.org/10.7196/SAMJ.2020.v110i5.14778); and response by Singh and Moodley.

Triclosan resistant bacteria in sewage effluent and cross-resistance to antibiotics.

The purpose of this study was to identify triclosan tolerant heterotrophic plate count (HPC) bacteria from sewage effluent and to determine cross-resistance to antibiotics. R2 agar supplemented with triclosan was utilised to isolate triclosan resistant bacteria and 16S rRNA gene sequencing was conducted to identify the isolates. Minimum inhibitory concentrations (MICs) of organisms were determined at selected concentrations of triclosan and cross-resistance to various antibiotics was performed. High-performance liquid chromatography was conducted to quantify levels of triclosan in sewage water. Forty-four HPC were isolated and identified as the five main genera, namely, Bacillus, Pseudomonas, Enterococcus, Brevibacillus and Paenibacillus. MIC values of these isolates ranged from 0.125 mg/L to >1 mg/L of triclosan, while combination of antimicrobials indicated synergism or antagonism. Levels of triclosan within the wastewater treatment plant (WWTP) ranged between 0.026 and 1.488 ppb. Triclosan concentrations were reduced by the WWTP, but small concentrations enter receiving freshwater bodies. Results presented indicate that these levels are sufficient to maintain triclosan resistant bacteria under controlled conditions. Further studies are thus needed into the impact of this scenario on such natural receiving water bodies.

Appreciation of the research supervisory relationship by postgraduate nursing students.

INTRODUCTION: The quality of the relationship between postgraduate students and their supervisors often determines the progress of the students. BACKGROUND: Successful supervision according to students is associated with the expertise of the supervisors and their willingness to share their knowledge with their students. On the other hand, supervisors expect their students to be able to work independently to a large extent. Contradictory expectations of supervisors and postgraduate students can cause delays in the progress of students. AIM: The aim of this study was to explore and describe the aspects of the supervisory relationship that postgraduate students in nursing science at a selected university in South Africa appreciate. METHOD: A qualitative research design with an appreciative inquiry approach was used and 18 students under the guidance of an independent facilitator provided the data during group interviews. FINDINGS AND DISCUSSION: Specific personal and professional qualities of the supervisors contribute to a valued supervisory relationship. Regarding personal qualities, the supervisors should show their understanding of the unique circumstances of the students in challenging times. Supervisors should also be expert researchers. The valued relationship refers to an open and trusting relationship between the students and the supervisors. CONCLUSION: The students' appreciation of the research supervisory relationship contributes to the understanding of the expectations of postgraduate students regarding the support that they need to become scholars in an academic discipline. IMPLICATIONS FOR NURSING AND HEALTH POLICY: There is a need for continuing professional development of supervisors to sensitize them about the expectations of the students.

Hemostatic competency and elastase-alpha 1-proteinase inhibitor levels in surgery, trauma, and sepsis.

Previous studies investigated the effects of neutrophil elastase on isolated factors in the hemostatic process. Some of these reported effects are, however, procoagulative and others anticoagulative. The aim of this study was to ascertain the effect of elastase on the in vivo hemostatic competency. The effect of elastase activity on the hemostatic competency was determined in a group of 50 surgical intensive care unit patients and 23 control subjects. Surgical intensive care unit patients were subgrouped into a surgery, a trauma, and a sepsis-multiple organ failure group. Elastase activity was assessed by elastase-alpha 1-proteinase inhibitor levels and hemostatic competency by thromboelastography. Thromboelastography results showed a relatively normal coagulative ability in the surgery group, a varying degree of thromboelastographic hypocoagulability in the trauma group, and pronounced thromboelastographic instability in the sepsis-multiple organ failure group. Increases in elastase-alpha 1-proteinase inhibitor levels up to 200 micrograms/L were accompanied by a compromised coagulative ability as seen in a prolongation of both the first and second phases of the clotting time, as well as a decrease in the maximal clot elasticity.

Anemia in surgical intensive care patients.

BACKGROUND: The cause of the anemia of patients in surgical intensive care units (SICU) is not completely clear but is likely to be multifactorial. This study investigated a possible role for immune activation in the anemia of SICU patients. METHODS: Neopterin plasma levels, as a measure of T-cell-macrophage-axis activation, RBC-counts, Hb, Hct, MCV, MCH, MCHC, RDW, HDW, red cell morphology and iron status were determined in a group of 47 SICU patients. RESULTS: The study confirms the presence of a moderate anemia (Hb = 10.38 +/- 13 g/dL) in SICU patients. Abnormal red blood cell morphology was observed in 82% of all patients over at least part of their ICU-stay. Markedly enhanced T-cell-macrophage-axis activity was evidenced by a significant increase in the plasma neopterin levels of the patient group (44 +/- 79.6 nmol/L) compared to that of the control group (3.38 +/- 4.9 nmol/L). Iron metabolism was found to be disturbed. CONCLUSIONS: The red cell distribution width, the morphological results, the enhanced macrophage activation state, as well as the results of the iron status, point towards a contribution of an immune-associated functional iron deficiency to the anemia of SICU patients.

Free radical effects on myocardial membrane microviscosity.

Previous studies have shown that myocardial membranes, isolated from ischemic myocardial tissue, showed marked changes in microviscosity. To evaluate the contribution of free radical production and concomitant lipid peroxidation to these changes in microviscosity, the in vitro effects of two radical producing systems (H2O2/FeCl2 and xanthine oxidase/hypoxanthine/FeCl3) were investigated separately on the microviscosity of sarcolemmal, mitochondrial and sarcoplasmic reticulum membranes. In all three membranes both these free radical producing systems caused formation of malondialdehyde as quantitated by the thiobarbituric acid test. The sensitivity of the membranes to free radical damage differed: the sarcolemma was more sensitive to H2O2 damage, while mitochondrial malondialdehyde production was highest with xanthine oxidase. H2O2/FeCl2 caused a reduction in microviscosity (i.e. increased fluidity) of all three membranes, whereas the xanthine oxidase system increased mitochondrial and sarcolemmal microviscosity and reduced that of the sarcoplasmic reticulum. The similarity between ischemia-induced membrane microviscosity changes and those induced in vitro by xanthine oxidase, indicate a possible causal role for superoxide and hydroxyl free radicals produced during ischemia.