Refusal Of Admission Research Articles

평등의 원칙과 사법 (私法)

The principle of equality has traditionally been a topic in public law scholarship. In recent years, however, it is increasingly discussed in private law scholarship. This paper discusses how the principle of equality operates in private law. The conclusions are as follows: First, private law legislation as well as private law interpretation have been undoubtedly bound by the principle of equality. However, private law relationships between private persons are not. In this area, the so-called horizontal effect of principle of equality or rights thereto shall be denied. Second, there are examples in private law where the principle of equality appears to be applied. Resolutions, decisions, or di spositions by or in corporations, associations or long-term contractual relationship can be illegal if they are discriminatory; refusal to deal, suspension of dealings, or refusal of admission to an organization or long-term contractual relationship can be illegal if they are discriminatory; the exercise of ownership rights or the operation of an organization can be i llegal if it has been open to the publi c while excluding certain persons or groups of persons in contradiction to that practice. These are manifestations of the inherent limits of private autonomy, of the principle of good faith and fair dealing, of abuses of rights, and of the general right to personality, however, rather than of the principle of equality, especi ally constitutional equality. Finally, legislators can still impose obligations on private persons to treat other private persons equally, and many do. Given the inherent tension between private autonomy and equality, however, such legislation should be limited to specified traits and/or specified areas and should not be too broad. Relevant legislations in the United States and Germany demonstrate it. It is questionable whether the drafts for the general equal
 treatment act currently being discussed strikes such a balance.

Legal Regulation of Employment in a Digital Society

The subject of this study is the legal norms that mediate the procedures for the selection of personnel and the employment of employees. The purpose of the study is to analyze the norms of labor legislation regulating employment relations in a digital society, and the practice of their application. General and private scientific methods were used (formal dogmatic, comparative legal methods of research, interpretation, modeling). The positive role of digital platforms in the employment of citizens was noted. However, the development of digital technologies displaces people from the sphere of employment, to which the legislation is still weakly responding. Particular attention is paid to employment issues that have not been resolved in legislation, which may lead to a deterioration of the situation of citizens. The transformation of labor functions is taking place, which excludes human participation in part of operations and makes it necessary to consolidate in legislation the obligation of employees to improve their qualifications. The content of the concept of "business qualities" of an employee is expanding, including digital competencies, including the ability to interact with artificial intelligence. It is desirable to reflect the definition of the concept in legislation and take it into account when posting information about vacancies on digital platforms. The conclusion is made about the inadmissibility of making a decision on employment (refusal of admission) by artificial intelligence on the basis of data collected without the consent of the applicant. The legislation in the field of employment is not quite ready to respond to the changes taking place in connection with digitalization. The proposed solutions may be the subject of discussion and useful for the legislator.

TRAINING OF SENIOR EXECUTIVES FOR THE NATIONAL REPUBLICS AT GORKY HIGHER PARTY SCHOOL (1946—1991)

The article discusses training personnel for national republics conducted at Gorky Higher Party School in the 1940–1980s. The basis for establishing Gorky Higher Party School was a one-year party school and inter-regional courses that laid the foundations for the development of party education. The analysis of the documents of the State Socio-Political Archive of the Nizhny Novgorod region makes it possible to trace the evolution of training party and Soviet cadres for forty-five years. On August 12, 1946, a decision was taken to establish Gorky Regional Party School, geared to train top staffers of seven regions and four autonomous republics of the Volga region. The training was conducted with careful preparation on the part of students and teachers. In the early years of the school much attention was paid to the study of the Russian language. By the end of the 1950s, the problem of the shortage of party and Soviet workers was solved. This conditioned the establishment of an age limit for applicants, as well as refusal of admission to Gorky Regional Party School to persons with higher education. Advanced training courses were created for such candidates in the early 1960s. Subsequently, a correspondence department received a significant development, along with the inter-regional courses of party and Soviet workers. Organization of the educational process is also transformed: three new study support centers were opened in the regional centers of the recruitment zone in 1979. The result of opening new educational and consulting centers was a decrease in the number of full-time students from national republics. At the same time, there is an increase in the number of students at the correspondence department and at inter-regional courses. Retraining of personnel at inter-regional courses was carried out in the form of theoretical as well as practical classes, at which representatives of the party and Soviet elite spoke to the audience (for corresponding cohorts). In the 1980s, practical training on the basis of regional government bodies was actively developed as part of coursework. In the 1980s, the area of Gorky Higher Party School was expanded due to training managerial personnel for the Azerbaijanian, Armenian, Georgian, Kazakh and Uzbek Soviet Socialist Republics. Respectively, the composition of students’ nationalities in the school significantly expanded, too. Thus, establishment of Gorky Higher Party School was of great importance for training national senior executives.

Limiting ICU admission from emergency services and wards

IntroductionDecisions not to admit a patient to intensive care units (ICU) as a way of limiting life support treatment (LLST) is a practice that can affect the operation of the emergency services and the way in which patients die. MethodsPost hoc analysis of the ADENI-UCI study. The main variable analysed was the reason for refusal of admission to the ICU as a measure of LLST. For the present post hoc analysis, the registered patients were divided into 2 groups: the patients assessed in the intensive medicine services from the emergency department and the patients assessed from the conventional hospitalization areas. Student t was used in the comparative statistics when the mean values of the patient sub-cohorts were compared. Categorical variables were compared with the χ2 tests. ResultsThe ADENI-ICU study included 2284 decisions not to admit to the ICU as a measure of LLST. Estimated poor quality of life (p = 0.0158), the presence of severe chronic disease (P = 0.0169) and futility of treatment (P = 0.0006) were percentage decisions with greater weight within the population of hospitalized patients. The percentage of disagreement between the consulting physician and the intensivist was significantly lower in patients assessed from the emergency services (P = 0.0021). ConclusionsThere are appreciable differences in the reasons for consultation, as well as in those for refusal of admission to an ICU between the consultations made from an emergency department and a conventional hospitalization facility.

The Challenge of the Non-Compliant Patient: A Case of Caesarean Section Scar Ectopic Pregnancy

Ectopic pregnancy is a quite common and life-threatening pregnancy. The most common site of ectopic implantation of a fertilized embryo is the fallopian tube. In extremely rare situations, the embryo can implant in other locations, which makes the diagnosis and management even more complex. Although close observation of a new pregnancy is key in the diagnosis and treatment of an ectopic pregnancy, there is still a major risk of life-threatening outcomes. This is a case report of a 31-year-old patient with a history of multiple pregnancies who presented to a community hospital in the spring of 2021 with an ectopic caesarean scar pregnancy. A diagnosis of ectopic pregnancy was on a timely basis, and surgical management was advised. Upon refusal of treatment and admission, pharmacological management was initiated, but patient compliance challenged the success of the therapy. Patient non-compliance to close follow-up resulted in a ruptured uterus. Emergency laparotomy with supracervical hysterectomy was performed as a life-saving procedure.

Analisis Sosio-Yuridis Terkait Pelaksanaaan Peraturan Perundang – Undangan atau Kebijakan Hukum Terhadap Pelayanan Rawatan Intensif Rumah Sakit di Kota Batam Tahun 2019

In the health service system, the hospital acts as a referral place and a further health service facility. The refusal of admission of patients with intensive care at the hospital, accompanied by efforts to avoid the provision of facilities and facilities from the hospital for ICU treatment, appeared in several hospitals. Even though the role of the hospital itself as a place for further treatment of primary care is so big and important. This also contradicts the main duties and functions of the hospital itself, although it still pays attention to the class of the hospital itself. There is a legal or policy conflict in the application of ICU services, between Law number 44 of 2009 concerning Hospitals, Minister of Health Regulations number 1778 of 2010 concerning guidelines for intensive care services, and Law number 24 of 2011 concerning BPJS. The ineffective application of the law is seen from the 5 factors of legal effectiveness theory described by Soerjono Soekanto, namely the legal factors themselves, law enforcers, facilities or facilities, society and culture. The implementation of Minister of Health Regulations number 1778/2010 and Law number 44/2009 on ICU tends to run less effectively, so there are still many cases of rejection of ICU admission. At the end of the study, it was found that there was a need to expalin legal / regulatory oversight of Minister of Health Regulations number 1778/2010 and Law number 44/2009 strengthening of laws / policies to become the legal basis for health services.

Admission to the psychiatric ward of a patient with paranoid syndrome and recommended COVID-19 quarantine: a case report

In this paper we discuss admission procedure to the COVID-19 quarantine department of a psychiatric hospital on the example of a patient diagnosed with paranoid syndrome. We also present hospital admission criteria set out by the Ministry of Health, recommended procedures during inpatient treatment and discharge a patient from the hospital. Special attention is given to the fact that referral of a patient who does not meet the above criteria may cause unneeded stress related to transport and refusal of admission. Careful planning of referrals may help avoid unnecessary costs associated with the use of protective gear by all persons who come into contact with such a patient at every stage of his stay in the hospital. We believe that in a context where any timeframe of the current epidemic in Poland remains unknown, familiarity and observance of the recommendations set out by the Ministry of Health is of particular importance.

Limitación del ingreso en unidades de cuidados intensivos desde los servicios de urgencias y las plantas de hospitalización

IntroductionDecisions not to admit a patient to intensive care units (ICU) as a way of limiting life support treatment (LLST) is a practice that can affect the operation of the emergency services and the way in which patients die. MethodsPost hoc analysis of the ADENI-UCI study. The main variable analysed was the reason for refusal of admission to the ICU as a measure of LLST. For the present post hoc analysis, the registered patients were divided into 2 groups: the patients assessed in the intensive medicine services from the emergency department and the patients assessed from the conventional hospitalization areas. Student t was used in the comparative statistics when the mean values of the patient sub-cohorts were compared. Categorical variables were compared with the χ2 tests. ResultsThe ADENI-ICU study included 2,284 decisions not to admit to the ICU as a measure of LLST. Estimated poor quality of life (p=.0158), the presence of severe chronic disease (P=.0169) and futility of treatment (P=.0006) were percentage decisions with greater weight within the population of hospitalized patients. The percentage of disagreement between the consulting physician and the intensivist was significantly lower in patients assessed from the emergency services (P=.0021). ConclusionsThere are appreciable differences in the reasons for consultation, as well as in those for refusal of admission to an ICU between the consultations made from an emergency department and a conventional hospitalization facility.

Conditions, possibility and priority for admission into inpatient hospice/palliative care units in Japan: a nationwide survey.

Known barriers to admission into inpatient hospice/palliative care units (PCUs) include poor accessibility and stringent conditions for admission. However, the exact criteria are unclear. The aim of this study was to clarify the actual conditions, possibilities and priorities for admission to PCU in Japan. We conducted a nationwide, anonymous, self-administered questionnaire survey to the responsible physicians of all 251 PCUs in 2014. Responses were received from 190 institutions (response rate 76%). The most frequent condition for admission was 'either the patient or the family knows the diagnosis' [86%, 95% confidence interval (CI): 80-90]. For the conditions for admission to PCU, 10-40% fewer facilities answered that the patient's consent or understanding was required compared with those that answered the patient or family's consent was sufficient. Seventy-one percent (95% CI: 64-77) of PCUs answered that either the patient or a family member needed to agree to a do-not-resuscitate (DNR) policy. The factors most likely to result in refusal of admission to a PCU varied greatly. Ninety-four percent (95% CI: 90-97) of PCUs answered that patients who had undergone a long waiting time after applying for admission would be given higher priority, and approximately 50% of PCUs answered they gave priority to their outpatients and inpatients. The findings of this study should be used to modify the system so that appropriate palliative care can be provided to patients who wish to be admitted to PCU.

Interprofessional case conferences to bridge perception gaps regarding ethical dilemmas in home-based end-of-life care: a qualitative study

Objective: The aim of this study was to examine the effectiveness and efficiency of interprofessional case conferences on home-based end-of-life care to bridge perceptions gaps regarding ethical dilemmas among different healthcare professionals and analyze essential issues extracted the interprofessional discussions.Patients and Methods: The participants could spend only a limited amount of time after their working hours. Therefore, we shortened and simplified each of three case scenarios so that the discussions do not last longer than 90 minutes. For the case conferences, we selected 3 cases, which entailed the following ethical dilemmas pertaining to home-based end-of-life care: refusal of hospital admission, passive euthanasia, and emergency transport. Participant responses were audio-recorded, transcribed, and analyzed using qualitative content analysis and Jonsen’s four topics approach.Results: A total of 136 healthcare professionals (11 physicians, 35 nurses, and 90 care workers) participated in the case conferences. The physicians, nurses, and care workers differed in their perceptions of and attitudes toward each case, but there were no interprofessional conflicts. Despite the short duration of each case conference (90 minutes), the participants were able to discuss a wide range of medical ethical issues that were related to the provision of appropriate home-based end-of-life care to older adults. These issues included discrimination against older adults (ageism), self-determination, an unmet desire for caregiver-patient communication, insufficient end-of-life care skills and education, healthcare costs, and legal issues.Conclusion: The physicians, nurses, and care workers differed in their perceptions of and attitudes toward each case, but there were no interprofessional conflicts.

Factors influencing decisions to admit or refuse patients entry to a South African tertiary intensive care unit.

When critically ill patients with life-threatening conditions need urgent, expensive, life-sustaining care, admission and triage decision-making may be extremely challenging as critical care practitioners strive to balance these high-stakes, high-stress, time-sensitive decisions against a limited resource. The factors affecting the decision to admit or refuse a patient entry to an intensive care unit (ICU) have not been described in the South African (SA) context. To identify and describe the factors that influence ICU triage decision-making for patients referred to a regional/tertiary facility for intensive care. A retrospective review of recorded data from January 2014 to December 2017 was conducted for all referrals to the 12-bed, intensivist-led, closed general ICU at King Edward VIII Hospital, an 800-bed tertiary public facility in KwaZulu-Natal Province, SA. Data were extracted to identify factors associated with the decision to admit or refuse patients referred to the unit. Significant factors on univariate analysis were then included in a multivariable analysis using binary logistic regression to identify significant independent factors. A total of 4 469 referrals were received over the 48-month period studied. Of these, 507 (11.3%) were withdrawn before a final decision of acceptance or refusal and 94 (2.1%) had an unknown outcome, leaving 3 868 referrals where an acceptance/refusal decision was made as our study cohort. Of these, 38.7% were refused admission. The commonest reason for refusal (57.0%) was assessment of the patient as 'too sick' by the admitting specialist. Multivariable analysis identified age, referring discipline as medicine, poor or unknown premorbid functioning, and comorbidities of HIV, malignancy and cardiac failure as significant factors for refusal of admission to the ICU. Referrals were significantly more likely to be accepted from private institutions, and if the comorbidity was asthma or psychiatric disease. A better understanding of factors affecting ICU admission/refusal decisions will allow for a more effective and appropriate referral process and more rational utilisation of scarce ICU resources. Further prospective studies are necessary to elucidate fully the impact of various other factors.

Determinants and outcomes associated with decisions to deny intensive care unit admission in Tunisian ICU.

Introductionintensive care unit (ICU) beds are a scarce resource, and admissions may require prioritization when demand exceeds supply. However, there are few data regarding both outcomes of admitted patients to intensive care unit (ICU) in comparison with outcomes of not admitted patients. The aim of this study was to assess reasons and factors associated to refusal of admission to ICU as well as the impact on mortality at 28 days and patients' outcomes.MethodsSingle-center, cross-sectional descriptive study conducted in 8-bed Medical ICU at a Tunisian University hospital. All consecutive adult patients referred for admission to ICU during 6 months were included. We collected demographic data, ICU admission/refusal reasons, co-morbidity and diagnosis at time of admission, mortality probability model (MPMII0) score, day and time of admission, request for admission and mortality at 28 days.Results327 patients were evaluated for ICU admission and 260 were refused to ICU (79.5%). Patients refused because of unavailability of beds represented 50% and patients considered “too sick to benefit” represented 22%. Multivariate analysis showed that the presence of acute respiratory failure and request by direct contact in the unit were independently associated to admission to ICU (OR: 0.15; 95% CI: 0.07-0.31 and OR: 0.16; 95% CI: 0.08-0.31, respectively). Higher mortality rates were shown in patients “too sick to benefit” (80.7%) and unavailable beds (26.56%).ConclusionRefusal of ICU admission was correlated with the severity of acute illness, lack of ICU beds and reasons for admission request. ICU clinicians should evaluate their triage decisions and, if possible, routinely solicit patient preferences during medical emergencies, taking steps to ensure that ICU admission decisions are in line with the goals of the patient. Ultimately, these efforts will help ensure that scarce ICU resources are used most effectively and efficiently.

Prognosis of patients with primary malignant brain tumors admitted to the intensive care unit: a two-decade experience.

The purpose of this study is to describe the reasons for ICU admission and to evaluate the outcome and prognostic factors of patients with primary malignant brain tumors (PMBT) admitted to the intensive care unit (ICU). This is a retrospective observational cohort study of 196 PMBT patients admitted to two ICUs over a 19-year period. Acute respiratory failure was the main reason for ICU admission (45%) followed by seizures (25%) and non-epileptic coma (14%). Seizures were more common in patients with glial lesions (84 vs. 67%), whereas patients with primary brain lymphoma were more frequently admitted for shock (42 vs. 18%). Overall ICU and 90-day mortality rates were 23 and 50%, respectively. Admission for seizures was independently associated with lower ICU mortality [odds ratio (OR) 0.06], whereas the need for mechanical ventilation (OR 6.85), cancer progression (OR 7.84), respiratory rate (OR 1.11) and Glasgow coma scale (OR 0.85) were associated with higher ICU mortality. Among the 95 patients who received invasive mechanical ventilation, ICU mortality was 37% (n=35). For these patients, admission for seizures was associated with lower ICU mortality (OR 0.050) whereas cancer progression (OR 7.49) and respiratory rate (OR 1.08) were associated with higher ICU mortality. The prognosis of PMBT patients admitted to the ICU appears relatively favorable compared to that of hematologic malignancies or solid tumors, especially when the patient is admitted for seizures. The presence of a PMBT, therefore, does not appear to be sufficient for refusal of ICU admission. Predictive factors of mortality may help clinicians make optimal triage decisions.

Этапы развития законодательства США по борьбе с терроризмом после 11 сентября 2001 года

The article is devoted to development of the USA legislation on the fight against terrorism. The author considered the objectives and tasks of the state in a particular historical period; analyzed the laws passed by the USA Congress aimed at combating home and international terrorism; identifies the main directions of the state policy of the USA in the field of counter-terrorism. The article covers the events after 11 September 2001 to the present. The author gives a brief overview of the events of 11 September 2001, discusses the Patriot Act and other laws, aimed at combating terrorism. The Patriot Act allows the Federal Bureau of Investigation to intercept telephone, verbally and electronic communications relating to terrorism, computer and mail fraud; introduces special measures to combat money-laundering; expands immigration rules, in particular, mandatory requirement of detention of persons suspected of terrorism appeared; reveals the procedure of multilateral cooperation to combat terrorism, strengthening measures to investigate terrorist crimes; established rewards for information on terrorism; introduces the procedure of identification of DNA of persons charged for committing terrorist crimes or any violent crime; introduced the concept of domestic terrorism and Federal crimes of terrorism, the prohibition on harboring terrorists and material support; there is a new crime — terrorist and other acts of violence against public transportation systems. The law abolished for the statute of limitations for crimes of terrorist orientation. In 2002 5 laws wer adopted: “Homeland Security Act of 2002”, “Maritime Transportation Security Act of 2002”, “Aviation and Transportation Security Act“, “Public Health Security and Bioterrorism Preparedness and Response Act of 2002”, “Terrorism Risk Insurance Act of 2002”. The Palestinian Anti-Terrorism Act was adopted in 2006. This law restricted the financial assistance to the Palestinian national authority; Haqqani Network Terrorist Designation Act of 2012 included the Haqqani Network in the list of international terrorist organizations; the political act of refusal of admission to the United States representative to the United Nations, because he was accused of the occupation of the espionage or terrorist activities against the United States and poses a threat to the national security interests of the United States.

Outcomes of nighttime refusal of admission to the intensive care unit: The role of the intensivist in triage

PurposeTo compare outcomes of patients refused medical intensive care unit (MICU) admission overnight to those refused during the day and to examine the impact of the intensivist in triage. Materials and methodsRetrospective, observational study of patients refused MICU admission at an urban university hospital. ResultsOf 294 patients, 186 (63.3%) were refused admission overnight compared to 108 (36.7%) refused during the day. Severity-of-illness by the Mortality Probability Model was similar between the two groups (P=.20). Daytime triage refusals were more likely to be staffed by an intensivist (P=.01). After risk-adjustment, daytime refusals had a lower odds of subsequent ICU admission (OR 0.46, 95% CI 0.22–0.95, P=.04) than patients triaged at night. There was no evidence for interaction between time of triage and intensivist staffing of the patient (P=.99). ConclusionsPatients refused MICU admission overnight are more likely to be later admitted to an ICU than patients refused during the day. However, the mechanism for this observation does not appear to depend on the intensivist's direct evaluation of the patient. Further investigation into the clinician-specific effects of ICU triage and identification of potentially modifiable hospital triage practices will help to improve both ICU utilization and patient safety.

ANALIZA PRZYCZYN ODMÓW PRZYJĘCIA PACJENTÓW Z ROZLEGŁYMI RANAMI I AMPUTACJAMI RĄK, ZGŁASZANYCH DO SERWISU REPLANTACYJNEGO

Introduction: Total or partial upper limb amputation significantly reduces ability of normal functioning in the society. Development of microsurgical skills enabled to replantation of the amputated limb (or part) and to regain its partial or sometimes full function.Material and methods: The study analyses the causes of refusal of admission to 55 of 141 patients referred to the replantation service of the Department of General and Hand Surgery PUM, over the period 2012–2013.Results: The causes of denied admission included: injury without compromise of blood supply to the limb (35%), distal amputations (27%), crush injuries (11%), single finger amputation (9%), severe damage of the amputated part (9%) and lower limb amputations (5%). The age of the patient had no significant influence on the decision to refuse admission. The distance between the referring hospital and the replantation centre was statistically significantly shorter in accepted cases (252 km vs 496 km, p < 0.05).Conclusion: Our outcomes show a variety of causes of refusal of admission to patients with severe trauma and amputation of the hand. The main factors influencing decision making regarding admission or denial were associated with the actual danger to the survival of the involved limb, and estimation/calculation of the chance for limb saving.

Treatment escalation in the intensive care unit among patients with preexisting treatment limitations: best-laid plans gone awry?

In this issue of JAMA Internal Medicine, Hart and colleagues 1 provide, to our knowledge, the first known epidemiologic data on treatment patterns among patients admitted to the intensive care unit (ICU) with preexisting treatment limitations. Treatment limitations areexplicit statementsby thepatient,documented in themedical record, refusing certain treatments, as is their right according to the Patient Self-determination Act of 1990.2 In a hospital context, treatment limitationsmostoften includedonot resuscitate (DNR) or do not intubate orders. UsingProject IMPACT, anonrepresentative sampleof ICUs across the United States with detailed clinical data on all ICU admissions, Hart et al1 document that 5% of all ICU admissionswere amongpatientswith preexisting treatment limitations. Most treatment limitations were DNR orders. Many of thesepatients experiencedanescalationof treatment, including some form of life-supporting treatment, while in the ICU, and 1 in 4 of these patients received cardiopulmonary resuscitation (CPR), seemingly in violation of their wishes. Overall, 65% survived to discharge, but 35% died, corresponding to theobservation that 1 in 6patients admitted to the ICUwith a preexisting DNR order had received CPR. The authors further document substantial between-unit variation inmanagementof ICUpatientswithpreexisting treatment limitations. Although the 95%CIs arewide and unmeasured confounding cannot be ruled out, this variation nonetheless leads us to ask: What are the “right” rates? First,what is the right proportionof admissions to the ICU that should be made up of patients with preexisting treatment limitations?There isa lotof controversyabout thisamong clinicians, but guidelines promulgated by the Society of Critical Care Medicine3 regarding ICU admission criteria indicate that apreexistingDNRorder is not a criterion for refusal of ICU admission. Patients with DNR orders frequently desire curativemeasures shortofCPR, including treatmentsavailableonly in an ICU setting, such as hemodynamic support and noninvasivemechanical ventilation,4 andpatientsmaybenefit from such treatment. If there is a potential for meaningful clinical benefit from an escalation of treatment (suggested by a 65% survival rate) andpatientswould accept treatment escalation short of CPR, then the right rate of ICU admission will be directly proportional to the prevalence of preexisting treatment limitations in the critically ill population. The overall prevalence of treatment-limiting advance directives among Medicare decedents is 39%, and this varies significantly byUS region.5 Given a lack of information about the prevalence of preexisting treatment limitations inpatients admitted to each of the study hospitals, we cannot know whether the observed rates are too high, too low, or just right. But what about CPR, which most patients with DNR orders say theywish to forgo?What is the right rateofCPRamong ICUpatientswithpreexisting treatment limitations?Receiptof CPR in this population requires a reversal (ie, revocation) or reflects a violation (ie, ignoring) of the patient’s DNRorder. A reversalmight occur in 2ways: first, the patient and/or their surrogatemightreversetheDNRorderafterreasonedconversations with themedical care teambased on expected treatment benefit and thepatient’sunderlyinggoals for treatment.This could be because the patient’s treatment preference changed. Studies show that patients’ treatment preferences are unstable. In one study, competentpatientswillingly acceptedburdensome Related article page 1019 Research Original Investigation ICU Care and Preexisting Limits on Sustaining Life

Why do women not deliver in health facilities: a qualitative study of the community perspectives in south central Ethiopia?

BackgroundIn Ethiopia most childbirth occurs at home and is not assisted by skilled birth attendants. On the other hand having a birth attendant with midwifery skills during child birth is one of the most important interventions in reducing maternal morbidity and mortality. The objective of this study was to make an in-depth assessment of reasons why mothers do not use health facilities for child delivery.MethodsFocus Group Discussions were used to gather information on use of health facilities for delivery in Butajira districts of South Central Ethiopia. The study was conducted from January to February 2012. Information was collected from four groups of women who had delivered in the past two years and four groups of men whose wives/partners have delivered in the same period. Data was coded and categorized using open code, qualitative data management software and analyzed based on thematic analysis.ResultsA total of eight FGD sessions, four with women and four with men groups were conducted involving 81 residents of the Butajira district. FGD participants answered that a large majority of women in the district gave birth at home. Two major themes, client related factors and facility/staff factors, emerged. Factors that emerged within major themes of client factors were decision making on place of delivery, reliance on Traditional Birth Attendants (TBAs), misconception about services provided at health facility, inability of family members to be present at time of labor and delivery, lack of privacy, traditional and/or spiritual factors, economic factors and accessibility to health care facilities. Within major themes of facility/staff factors subthemes that emerged were poor reception, refusal of admission, lack of privacy, information gap, poor competence and shortage of staff and materials at health facilities.ConclusionWomen in the study areas do not deliver in health facilities because of reasons that can be attributed to health care system and client related factors. These need to be addressed by considering the specific factors related to the health system and community perspectives.

Factors Influencing Triage Decisions in Patients Referred for ICU Admission

BackgroundFew data is available on triage of critically ill patients. Because the demand for ICU beds often exceeds their availability, frequently intensivists need to triage these patients in order to equally and efficiently distribute the available resources based on the concept of potential benefit and reasonable chance of recovery. The objective of this study is to evaluate factors influencing triage decisions among patients referred for ICU admission and to assess its impact in outcome.MethodsA single-center, prospective, observational study of 165 consecutive triage evaluations was conducted in patients referred for ICU admission that were either accepted, or refused and treated on the medical or surgical wards as well as the step-down and telemetry units.ResultsSeventy-one patients (43.0%) were accepted for ICU admission. Mean Acute Physiology and Chronic Health Evaluation (APACHE)-II score was 15.3 (0 - 36) and 13.9 (0 - 30) for accepted and refused patients, respectively. Three patients (4.2%) had active advance directives on admission to ICU. Age, gender, and number of ICU beds available at the time of evaluation were not associated with triage decisions. Thirteen patients (18.3%) died in ICU, while the in-hospital mortality for refused patients was 12.8%.ConclusionRefusal of admission to ICU is common, although patients in which ICU admission is granted have higher mortality. Presence of active advance directives seems to play an important role in the triage decision process. Further efforts are needed to define which patients are most likely to benefit from ICU admission. Triage protocols or guidelines to promote efficient critical care beds use are warranted.

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Introduction: Despite of current approval of brain death national law, many physicians are reluctant to withdrawal care despite of patient’s living ill. The epidemiological data of hypoxic encephalopathy including brain death and severe brain damage secondary to cerebral hemorrhage after cardiac pulmonary arrest (CPA) is limited. In addition, the objective data of impact to medical cost does not exist. Hypothesis: To elucidate the epidemiology data and impact to medical cost of hypoxic encephalopathy including brain death secondary to CPA and severe brain damage secondary to cerebral hemorrhage. Methods: All cases with hypoxic encephalopathy including brain death secondary to CPA hospitalized to adult mixed ICU in our institution, who survived more than 72 hours, have been enrolled from April, 2008 to March, 2012 (study ongoing). Primary outcome was the consequence of hypoxic encephalopathy evaluation of survival / function consequence in each disorder group. Secondary outcomes were the length of stay (LOS) in ICU hospitalization, the LOS of total ward hospitalization, main diagnosis related to CPA, the desire of organ donation, the desire of medical care withholding, and medical cost. Results: 64 cases of anoxic encephalopathy, 17 cases with intrinsic cerebral hemorrhage and 9 cases with extrinsic cerebral hemorrhage were reviewed. Average age was 63.8 years old. Sex ratio of male to female was 2.5:1. Eighty percent of all cases died in a ward. The average LOS in ICU was 6.0 days, but the average LOS in hospital was extended to 17.5 days. EEG was performed to 57 cases. 3 cases was legal brain death and 9 cases were clinical brain death (no apnea test applied due to Japanese law). 32 cases were inquired about organ donation and 12 cases were organ donated. Average expense per case after CPA was 15,750 US dollar. Conclusions: In Japan, the medical expense for anoxic brain encephalopathy is costly despite poor prognosis. The occupancy of beds by these cases makes ICU admission turn over slow and may result in refusal of admission of a case requiring ICU hospitalization.