Doctoral Degrees (Family Medicine)

Permanent URI for this collectionhttps://hdl.handle.net/10413/6958

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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'?
The experience of anxiety and depression and their sequelae in breast cancer patients: effects of disease and treatment on patient self-esteem, body image, and the prevalence of hopelessness and suicidal ideation.
(2021) Van Oers, Helena.; Schlebush, Lourens.; Gaede, Bernard Martin.
Breast cancer continues to be one of the most commonly diagnosed cancers worldwide. Research suggests that the psychological needs of these patients are frequently unobserved and untreated as healthcare professionals may be insufficiently familiar with the prevalence of comorbid psychological features such as anxiety and depression and how these influence the experience of other psychological phenomena. The aim of this research was to examine the psychological effects of disease and treatment in women diagnosed with breast cancer and determine if these effects differed from those experienced by women with other cancers. While psychological distress in the form of depression and anxiety is well-documented in the literature, there is less specific reference to how these affect and mediate other concerns patients may experience during diagnosis and adjuvant treatment, namely the insult to body image and self-esteem through surgery and other treatment modalities and how these effects cumulatively inform the patient’s experience of hopelessness and possibly, suicidal ideation (SI). The aim was to identify if these forms of distress correlate, and to what degree, with a view to highlighting for oncology healthcare professionals the need to identify and treat those patients who are psychologically at risk. The samples of women with breast cancer (n=80) and other forms of cancer (n=80) was drawn from a population of outpatients receiving treatment at three private oncology clinics in the Durban, South Africa area. Convenience sampling was used and a battery of four questionnaires was completed by patients in addition to collection of relevant demographic data. The results suggest similarities and differences between the two groups. Whilst the two groups did not exhibit notable differences in overall levels of depression and self-esteem, there were significant differences in the experience of body image, with the breast group experiencing greater body image dysphoria. Likewise, in relation to stress, although both groups demonstrated elevated levels of stress in comparison to norms, the breast group evinced higher scores on psychological and behavioural responses to stress. These results suggest that breast cancer patients experience distress differently to patients with other forms of cancer, which may indicate areas for future research.
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.
Preparing medical graduates to care for older adults.
(2020) Naidoo, Keshena.; Van Wyk, Jacqueline Marina.
Background: Social accountability in medical training requires medical schools in South Africa to respond to the health needs of the country’s rapidly increasing number of older adults. Reports, however, indicate that elderly patients in South Africa receive poor quality of care from health professionals. Reports also indicate that students’ empathy towards older adults declines as they progress through their studies. These disparities necessitate greater awareness of the health needs and expectations of older adults and an inquiry into the geriatric care training of medical professionals. Aim: This 360-degree study investigated the geriatric medical curriculum at one institution from the perspectives of geriatric patients, learners and health professions educators to make recommendations for improvement, and to develop policy guidelines for the enhancement of undergraduate medical education in geriatric care. Methodology: A sequential mixed methods approach was adopted for this study. Four focus group discussions were conducted with patients aged 60 years and older from primary care facilities served by graduates of the medical institution (n=28). Data that emerged from this phase regarding patients’ expectations of quality geriatric healthcare were triangulated with a review of curriculum documents, semistructured interviews with health professions educators (n=5) and an evaluation of the levels of knowledge and attitudes of final year medical students regarding the care of older adults. Results: The key principles for quality healthcare of older adults that were elicited from patients were respectful communication, compassion, appropriate prescribing, patient-centredness and coordinated care. However, professional attributes such as compassion and patient-centered care that were valued by geriatric patients are not explicitly taught or assessed in the curriculum. The current curriculum includes a wide variety of topics relevant to the care of older adults. Teaching and assessment relevant to geriatric care were further integrated into other modules, but no minimum standards are applied in assessment of the geriatric component. Students lacked exposure to older adults in ambulatory settings and received little teaching on health promotion or rehabilitative services relevant to the care of older adults. Despite the opportunities afforded by the problem-based learning approach in the curriculum for team-based learning and collaboration, interprofessional education was absent in teaching and learning relevant to older adults. Overall, final year medical students possessed minimal levels of geriatric knowledge despite their perceptions of having had adequate exposure to geriatrics in the current curriculum. The majority of students had positive attitudes towards working with elderly patients. In particular, older students and those with a prior higher education qualification had significantly higher levels of knowledge and attitudes towards caring for older adults. Of note, there was no association between geriatric knowledge and attitudes. Medical students also reported challenges in communicating with older adults and believed that their training had not prepared them adequately for this aspect. Conclusion: The findings of the study affirmed the need to enhance the geriatric curriculum for undergraduate medical students, and to develop and implement minimum core competencies in geriatric care. Curriculum planners should consider greater attention to patient-centred care, communication skills training with older adults and interprofessional education, as well as broader community engagement. Policy guidelines based on the findings of this study were developed and recommended to the Undergraduate Committee for Teaching and Learning to improve the preparedness of medical graduates to care for older adults.

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