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Doctoral Degrees (Family Medicine)

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Browsing Doctoral Degrees (Family Medicine) by Subject "Theses--Family medicine."

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    The ethical dilemmas of critical care specialists encountered in the admission of patients with HIV infection to intensive care.
    (2012) Naidoo, Kantharuben.; Lalloo, Umesh Gangaram.; Singh, Jerome Amir.
    South Africa has one of the fastest growing HIV epidemics in the world with 5.6 million people living with HIV/AIDS. As a consequence of the delayed implementation of the ARV rollout and failure to control the epidemic, the number of people living with HIV/AIDS who seek or need intensive care places a huge burden on precious, expensive and sparse intensive care unit facilities. Critical care specialists are faced with complex challenges when making decisions about the provision of such care. Aim: The aim of the study was to develop best practice criteria for admitting HIV-infected patients to intensive care. Methods: The study was done utilising: 1. A comprehensive literature review of the legal and ethical framework governing such decisions in South Africa and compared with that in different countries, both developed and developing. Further, legal precedents and clinical best practice that could inform policy and practice in South Africa were applied to the decision making process. 2. An audit of ICU beds in South Africa by first making a comprehensive and contemporary review of critical care facilities in South Africa, to place in context the ethical dilemmas faced by critical care specialists in the admission of HIV/AIDS infected patients to intensive care in a resource limited environment. 3. Critical care practitioners’ response to a standardised questionnaire regarding ethical decisions and provision of intensive care to five hypothetical clinical case scenarios. Results: The study showed that: The ICU bed availability in South Africa is limited and the problem is worse in the public sector with widespread variations across the provinces. The lack of skilled staff for ICU is insufficient for our needs in the public sector. For people living with HIV/AIDS, specific variables influence their survival in intensive care. The benefits of anti-retroviral treatment in intensive care are still being debated. Clinical prediction tools should be considered as an aid to clinical judgment on decisions about whom to admit to intensive care. Rational decision making should include central questions such as ‘ whether the patient too ill or too well for ICU care’ and whether there is a reasonable prospect of ‘reversibility of organ-dysfunction’? Non-invasive ventilation using a continuous positive airway pressure (CPAP) ventilation mask is showing promise for patients with Pneumocystis jeroveci pneumonia (PJP), especially in a resource-constrained environment. Further studies need to validate this. People living with HIV/AIDS are not discriminated against on admissions to ICU and are not subjected to medical futility decisions. Discussion: The shortage of ICU beds results in critical care specialists being under pressure to deliberate on resource allocation decisions for competing patients. Strong regulatory and ethical frameworks exist to protect the rights of people living with HIV/AIDS and access to intensive care. The ‘Limitation Clause’ of the South African Constitution, as canvassed by the courts resulting in the refusal of renal dialysis in the case of Mr. Subramoney, a utilitarian judgment, would not be justiciable for people living with HIV/AIDS and access to intensive care. The National Health Insurance Plan envisages making more ICU beds available through a public-private sector partnership. There is a compelling need for regionalisation of intensive care services in the country. Respiratory failure in HIV/AIDS patients remains the commonest indication for intensive care unit admissions, and other diagnosis such as non-PCP pneumonia, sepsis, cardiac, gastrointestinal, and renal diseases, are becoming more common. The ART era has seen an improvement in ICU to ward survival rates of 70% (similar to that of the general medical population) as well as the three month and long-term survival outcomes post-ICU discharge. ICU prognostic systems should be regarded as an aid to clinical judgment. Daniels ‘accountability for reasonableness’ provides a moral framework for ethical decision-making and priority setting. In its determined efforts to control the pandemic of HIV/AIDS, some countries, notably Botswana and South Africa are accused of violating international treaties. Conclusion: South Africa has made many legal provisions to protect the rights of its HIV infected patients. People living with HIV/AIDS are neither discriminated against in admission to intensive care units, nor being subjected to medical futility decisions. With the advent of HAART, people living with HIV/AIDS admitted to ICUs, have similar outcomes to that of the general population. Admission guidelines for ICU as advised by the professional bodies for use by the general population should be equally applicable to people living with HIV/AIDS, i.e. is the patient too ill or too well to warrant ICU admission, and is there a realistic prospective of 'reversibility of organ dysfunction'?
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    Identification of suicidal ideation in HIV-infected patients : development of a suicide risk assessment tool and a suicide intervention plan for HIV-infected patients following voluntary counselling and testing.
    (2014) Govender, Romona Devi.; Schlebusch, Lourens.
    ABSTRACT Background. Globally, suicide and HIV/AIDS remain two of the greatest healthcare issues, particularly in low- and middle-income countries where approximately 85% of suicides occur. Every year, more than 800,000 people die from suicide; this roughly corresponds to one death every 40 seconds, and the World Health Organization (WHO) estimates that by 2020 the rate of death will increase to one every 20 seconds. HIV/AIDS patients in South Africa have a higher suicide risk than the general population and may an increased frequency and severity of suicidal ideation depending on the different intervals in the continuum of HIV disease progression. Several studies have observed a relationship between the increase in suicide and HIV in South Africa, but due to the paucity of empirical data, this relationship remains inconclusive. Suicide in HIV-infected persons is multifactorial. Risk factors include: a history of attempted suicide; fears of social isolation; feelings of hopelessness; fear of losing control of life; elevated levels of depression; denial; and poor coping strategies. Despite the introduction of antiretroviral therapy (ART), the suicide rate remains more than three times higher among HIV-infected persons than in the general population. Although international findings on the correlation between suicide and HIV/AIDS are diverse, results show compelling evidence to screen for suicide risk and intervene as early as possible. Objectives. The main objectives of this research were: (i) to determine the prevalence of suicidal ideation in HIV-positive persons following voluntary HIV counselling and testing (VCT); (ii) to develop and validate a suicide risk screening scale (SRSS) for use in HIV-infected persons post HIV diagnosis; (iii) to implement and evaluate a brief suicide preventive intervention (BSPI) for use in the period immediately following HIV diagnosis. Methods. A quantitative methodology was used with a cross-sectional, correlational and regression analysis in the prevalence study. Participants completed a sociodemographic questionnaire, Beck’s Hopeless Scale and Beck’s Depression Inventory. Drawing 14 items from two established screening tests, the SRSS was developed and assessed. Validity, internal consistency and receiver-operating curves were used to determine the sensitivity and specificity of the tool. Following confirmation that recently diagnosed HIV-positive persons were at risk for suicidal behaviour, a BSPI was implemented and its efficacy evaluated with the validated SRSS. Statistical analysis included generalised linear modeling, and Pearson’s and McNemar’s chi-square analyses. Results. There was an increase in suicidal ideation over a six-week period following a positive HIV diagnosis, from 17.1% to 24.1%. Suicidal ideation was significantly associated with seropositivity, age and gender, with the majority of affected patients falling in the younger age category. Young males had an 1.8 times higher risk for suicidal ideation than females. Lower education and traditional beliefs were also significantly associated with an HIV-positive status upon testing. The SRSS was implemented and, despite certain limitations, was considered to be a valuable screening tool for suicidal ideation at VCT clinics. The BSPI was associated with a clinically significant decrease in the rate of suicidal ideation over time, providing preliminary evidence on its efficacy. Conclusion. Significant correlations exist between hopelessness, depression and suicidal ideation; these serve as important markers that should alert healthcare professionals to underlying suicide risks in HIV-positive patients. Screening for suicide risk and possible suicidal behaviour should form a routine aspect of comprehensive patient care at VCT clinics to assist with effective prevention and treatment. Healthcare workers at VCT clinics should be trained in suicide prevention interventions and the importance of educating vulnerable HIV-positive patients on suicide-prevention strategies. Further longitudinal studies are recommended to enable researchers to observe and differentiate between the variables that may be more prevalent at different stages of HIV, as well as the impact of ART on suicidal behaviour.