How does a doctor declare death? Heuts, Samuel; Wind, Tineke J; Kuiper, Michael A ...
Nederlands tijdschrift voor geneeskunde,
10/2019, Letnik:
163
Journal Article
Ward doctors in regular medical departments have to be competent in declaring the death of a patient. The majority of literature on confirmation of death focuses on special circumstances, including ...intensive care patients and cases involving organ donation. There is no consensus regarding the procedure and criteria for declaration of death in a 'normal' patient on a medical ward. In this article we describe the death criteria, changes that occur in the body following death, and how death can be declared in in a 'normal' patient on a medical ward and in special circumstances.
Abstract
Background: The clinical picture of ventilator-associated pneumonia (VAP) can be mimicked by other infectious and non-infectious diseases. The aim of this study was to determine the ...alternative diagnoses and to develop a diagnostic flow chart for patients suspected of having VAP not meeting the diagnostic broncho-alveolar lavage (BAL) criteria. Methods: Adult intensive care patients with a clinical suspicion of VAP and negative BAL results were included. The clinical suspicion of VAP was based on the combination of clinical, radiological, and microbiological criteria. BAL was considered positive if cell differentiation revealed ≥ 2% cells with intracellular organisms and/or quantitative culture results of ≥ 104 cfu/ml. The most likely alternative diagnosis of fever and pulmonary densities was retrospectively determined by two authors independently. Results: In all, 110 of 207 patients with suspected VAP did not meet the diagnostic BAL criteria and required further diagnostic evaluation. In 67 patients an alternative diagnosis for fever could be found. In 51 patients an alternative diagnosis of both fever and pulmonary densities could be established. In almost 40% of patients no alternative diagnosis could be provided. Non-bacterial pneumonia was diagnosed in 10 patients with Herpes simplex virus 1 (HSV-1) as the most common pathogen. In eight patients non-infectious pneumonitis was diagnosed. Conclusion: Due to the wide range of alternative diagnoses and applied tests the diagnostic work-up proved to be necessarily individualized and guided by repeated clinical assessment. The most frequently found alternative diagnoses were viral pneumonia and non-infectious pneumonitis.
A 49-year-old patient with refractory acute myelogenous leukemia (AML) is described who developed fever and herpes-like skin lesions during treatment with G-CSF. Skin biopsies revealed dermal ...neutrophilic infiltrates compatible with the diagnosis of Sweet's syndrome. The fever and skin lesions disappeared completely after treatment with corticosteroids.
To make an inventory of the number of intensive care (ICU) patients per year in the Netherlands who have been discharged home to die, and the conditions under which this does or should take place.
...Descriptive, survey study.
A survey was conducted across all ICU departments in the Netherlands in the spring of 2012. They were approached in writing and requested to answer a few questions about the possibility of immediate discharge home for ICU patients with a short life expectancy and receiving palliative care.
A total of 46 surveys (52%) was returned from the 89 ICUs approached. Of these, 21 (46%) had discharged patients home at the request of the patient or their family so that the anticipated death could take place at home. Of the respondents, 39 (85%), supported discharge home for these patients, and 7 (15%) were opposed to it. These opinions were equally divided across all three ICU levels in the Netherlands. Higher-level ICUs had discharged patients home more often in comparison with lower-level ICUs (19%, 43% and 75% for levels 1, 2 and 3, respectively). The preconditions for transfer can be subdivided into patient conditions, care conditions and general conditions.
ICU patients do sometimes want to die at home. It does not happen every day, but the wish is often granted in the Netherlands. There are certain general and patient-related conditions that have to be fulfilled. This article suggests a national guideline that could provide support on this subject.
Professional behaviour during medical training van Mook, Walther N K A; van Luijk, Scheltus J; van der Vleuten, Cees P M
Nederlands tijdschrift voor geneeskunde,
2009, Letnik:
153
Journal Article
Assessment of professional behaviour (PB) is increasingly receiving attention in undergraduate and postgraduate medical training. Its aim is to prevent later inappropriate behaviour and to strengthen ...appropriate behaviour by self-reflection and feedback. Assessment should start early in the curriculum and be repeated frequently, preferably by different assessors in differing educational situations, and with longitudinal follow-up. The consequences of the assessment as well as any agreements reached, must be clearly documented. If remediation of inappropriate behaviour is unsuccessful, a consilium abeundi, i.e. a recommendation to leave the programme, should be discussed with the student. The Dutch Higher Education and Scientific Research Act (WHW) does not provide for denying students access to educational activities and exams after completing the first year. However, the new Higher Education and Research Act (WHOO), which has yet not been implemented, will provide for obligatory cessation of studies.
A 41-year-old male, with no previous medical history, was admitted to our intensive care unit with severe isolated neurotrauma and a Glasgow Coma Scale of E1-M1-V1, mid-dilated unreactive pupils and ...severe abnormalities on the brain CT-scan. A severe syndrome of disseminated intravascular coagulation (DIC) and non-oliguric renal insufficiency developed. Following clinical and neurophysiological examination the patient was declared brain-dead, and the family gave permission for organ donation. The left kidney was transplanted and functioned well immediately. However, in view of the DIC and renal function disorders the right kidney was not considered usable for transplantation elsewhere. Pathological examination revealed many fibrin thrombi in the glomerular capillaries and acute tubular necrosis. This case supports the view that thrombotic microangiopathy in kidneys of patients with DIS, even with renal function impairment, is not an a priori reason for excluding donation.
Clinically significant cardiac disease during pregnancy occurs in 0.1% to 4% of pregnancies (1–4), and this incidence has remained more or less unchanged. The relative contribution of the different ...causes of heart disease preceding or diagnosed during pregnancy varies with the study population and study period (5). While rheumatic heart disease remains a major problem in developing countries (6), its prevalence in developed countries displays a decline. This implies that congenital heart disease, ischemic heart disease, and arrhythmias have become more common in the developed world (5, 7). However, in developed countries with high immigration rates, “foreign” patterns of disease cause shifts in the incidence and distribution of the different causes of heart disease in pregnancy. Examples are Chagas’ disease, syphilis, rheumatic valvular disease, and beriberi cardiomyopathy (5, 8). Nevertheless, in these countries the group of patients with congenital heart disease currently comprises 70% to 80% due to improved pediatric surgery outcomes, and medical therapy, followed by the group of women with rheumatic heart disease, which has decreased due to the decrease in the incidence of rheumatic fever (7, 9, 10).
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