Withdrawal Of Support Research Articles

Percutaneous approach to left ventricular assist device decommissioning.

ObjectiveTo assess the outcomes of a single‐center experience with percutaneous left ventricular assist device (LVAD) decommissioning.BackgroundPatients with LVADs may eventually require their removal, either due to recovery of left ventricular function or recurrent complications. Traditionally, withdrawal of LVAD support has been managed with surgical device explantation, which carries significant procedural risks. Transcatheter LVAD decommissioning, with outflow graft occlusion and driveline transection, has recently been described as an alternative to surgical removal.MethodsHere, we report on a retrospective cohort of five consecutive cases treated with transcatheter LVAD decommissioning.ResultsThe procedure was effective in all cases, and no patient experienced procedure‐related complications. At midterm follow‐up, the three patients who had myocardial function recovery were alive and had not experienced heart failure‐related symptoms or complications.ConclusionPercutaneous LVAD decommissioning appears to be a safe and effective approach to LVAD treatment discontinuation.

(How) Perceived Descriptive Underrepresentation Decreases Political Support: The Case of East Germans

This article asks whether the persistent descriptive underrepresentation of East Germans in Germany’s elite positions contributes to lower levels of political support in Eastern Germany. Based on a population survey including a survey experiment, it shows that citizens in both parts of Germany perceive a descriptive underrepresentation of East Germans. This perception remains stable, even when new information is provided. It is, however, not an attitudinal prejudice about decoupled elites but also based on citizens’ cognitions. Citizens assess this underrepresentation negatively drawing on its negative impact on legitimacy, efficiency, and substantive and symbolic representation. The interaction of perception and negative assessment decreases political support for community, regime and institutions. The perceived impairment of legitimacy and symbolic representation fuels the withdrawal of support more strongly than impaired efficiency and substantive representation. Since both East and West Germans’ political support is connected to descriptive representation, self-interest and sociotropic considerations are relevant. The contribution confirms that the descriptive underrepresentation of East Germans is one determinant of the lower levels of political support for democracy in Eastern Germany impairing the efficiency and legitimacy of democracy in the entire country.

Three-year outcome following neonatal encephalopathy in a high-survival cohort

This study investigated the 3-year clinical outcomes in relation to the severity of encephalopathy in high-survival infants who underwent therapeutic hypothermia. This retrospective observational study was conducted in level II/III neonatal intensive care units in Japan. The nationwide cohort included 474 infants registered in the Baby Cooling Registry of Japan between January 2012 and December 2016. Clinical characteristics, mortality rate and severe neurological impairment at age 3 years were evaluated. Of the infants, 48 (10.4%), 291 (63.1%) and 122 (26.5%) had mild, moderate and severe encephalopathy, respectively, upon admission. By age 3, 53 (11.2%) infants died, whereas 110 (26.1%) developed major disabilities. The mild group survived up to age 3. In the moderate group, 13 (4.5%) died and 44 (15.8%) developed major disabilities. In the severe group, 39 (32.0%) died by age 3. Adverse outcomes were observed in 100 (82.0%) infants. Mortality was relatively low in all subgroups, but the incidence of major disabilities was relatively high in the severe group. The relatively low mortality and high morbidity may be due to Japanese social and ethical norms, which rarely encourage the withdrawal of intensive life support. Cultural and ethical backgrounds may need to be considered when assessing the effect of therapeutic interventions.

Coincidence of Events Causing Paradoxical Hypotension in a Patient with an Intra-Aortic Balloon Pump.

The left ventricular outflow tract is a region of the left ventricle that lies between the anterior leaflet of the mitral valve and the ventricular septum. Dynamic left ventricular outflow tract obstruction (LVOTO) has classically been observed in patients with hypertrophic obstructive cardiomyopathy (HOCM) where it occurs secondary to asymmetric septal hypertrophy and systolic anterior motion (SAM) of the mitral valve. However, there are some instances that lead to hypercontractility of the myocardium, and with a combination of other physiological conditions, result in SAM of a mitral valve leaflet, leading to LVOTO in the absence of phenotype.We present such a case of an acute inferolateral wall myocardial infarction that was complicated by cardiogenic shock, requiring an intra-aortic balloon pump (IABP) and inotropic support which paradoxically provoked LVOTO. A reduction in IABP counterpulsation from 1:1 to 1:3 and the addition of intravenous fluids and a beta blocker resulted in significant improvement in blood pressure with rapid tapering of pressors.Inotropes and IABP, although helpful in cardiogenic shock, have the potential to induce or worsen the LVOTO, which can lead to a vicious cycle of worsening hypotension and increasing adrenergic drive that further deteriorates myocardial viability. Timely diagnosis with an echocardiogram and the withdrawal of inotropic and IABP support has the potential to improve haemodynamics and, thereby, outcome.LEARNING POINTSDynamic left ventricular outflow tract obstruction (LVOTO) should be one of the differentials in patients with cardiogenic shock, especially if it is refractory in the setting of an intra-aortic balloon pump.The diagnosis of LVOTO by echocardiography should result in immediate implementation of therapy to eliminate the factors that can potentially intensify the obstruction.

Nursing Care at End of Life in Pediatric Intensive Care Unit Patients Requiring Mechanical Ventilation.

Parents' perceptions of critical care during the final days of their child's life shape their grief for decades. Little is known about nursing care needs of children actively dying in the pediatric intensive care unit (PICU). To examine associations between patient characteristics, circumstances of death, and nursing care requirements for children who died in the PICU. A secondary analysis of the data set from the Randomized Evaluation of Sedation Titration for Respiratory Failure trial was conducted. This analysis included 104 children; 67 died after withdrawal of life-sustaining treatments; 21, after failed resuscitation; and 16, after brain death. Patients had a median age of 7.5 years, were cognitively appropriate, and were intubated for acute respiratory failure. Daily pain and sedation scores indicated patients' comfort was well managed (mean pain scores: modal, 0; peak, 2; mean sedation scores: modal, -2; peak, -1). Patients with longer PICU stays more often experienced pain and agitation on the day of death. Illness trajectory (acute, complex chronic condition, or cancer) was associated with pain scores (P = .04). Specifically, children with cancer had higher pain scores than children with acute illness trajectories (P = .01). Many patients (62%) had no change in critical care devices in their last days of life (median, 5 devices). Patterns of pain, sedation, comfort medications, and nursing care requirements did not differ by circumstances of death. Children with cancer and longer PICU stays may need comprehensive comfort management. Invasive devices left in place during withdrawal of life support may have inhibited parents' ability to connect with their child. Future research should incorporate parents' perspectives.

Improving ABCDEF Bundle Compliance and Clinical Outcomes in the ICU: Randomized Control Trial to Assess the Impact of Performance Measurement, Feedback, and Data Literacy Training.

OBJECTIVES:Describe the effects of data literacy training and continuous performance reports on ICU staff compliance with the 6-element ICU quality bundle approach known as the ABCDEF (A–F) bundle and patient outcomes.DESIGN:Stepped-wedge cluster randomized trial conducted during an institutional A–F bundle implementation program.SETTING:Single-center study conducted in eight adult ICUs.PATIENTS:Adult patients admitted for at least 24 hours, not undergoing active withdrawal of life support or palliative care.INTERVENTIONS:Four ICUs in the intervention group received bundle-related staff education, data literacy training, and weekly bundle performance reports during the 12-month study period. The four ICUs in the nonintervention group received none of these interventions. Bundle compliance and patient outcomes were tracked, including ICU and hospital mortality, transfer and discharge, discharge disposition, mechanical ventilation, and ICU delirium.MEASUREMENT AND RESULTS:In the intervention group, staff education alone increased bundle compliance from 9% to 16% (p < 0.0001); data literacy training further increased compliance from 16% to 21% (p = 0.03). This improvement was sustained throughout the study period including the onset of the COVID-19 pandemic and was greater than improvement in the nonintervention group (p < 0.001). Full A–F bundle compliance was associated with a lower likelihood of next-day ICU and hospital mortality, discharge to a facility other than home, and was associated with a higher likelihood of next-day extubation in patients. Next-day ICU and hospital discharge likelihood decreased, and delirium frequency was not affected.CONCLUSIONS:This is the first study demonstrating that the combination of staff education, data literacy training, and access to performance data improves A–F bundle compliance, sustains performance, and improves ICU patient outcomes (ICU and hospital mortality, mechanical ventilation duration, and home discharge rates). In contrast to previous studies, increased bundle compliance did not hasten ICU or hospital discharges or reduce delirium frequency in patients.

School-Based Cognitive-Behavioral Therapy in an Inclusion Model for an Adolescent with Comorbid Major Depressive Disorder, Generalized Anxiety Disorder, and Attention Deficit Hyperactivity Disorder: A Case Study

The goal of the current case study was to illustrate evidence-based cognitive-behavioral treatment (CBT) for an adolescent female with comorbid major depressive disorder, generalized anxiety disorder, attention deficit hyperactivity disorder, suicidal ideations, and a history of multiple involuntary hospitalizations. Multimodal assessment of the child’s symptoms was conducted, including parent, teacher, and child self-report, academic data, and hospital records to inform case conceptualization. Treatment included a combination of psychoeducation, cognitive restructuring, positive self-talk, relaxation skills, and the support of a school-based personal aide. Significant improvements with inattentive, anxiety, and depressive symptoms were reported, with gains being maintained at 1 year follow-up. In addition to a reduction of reported psychosocial problems, treatment benefits also included a decrease in classroom disruptions, improvement in academic performance, and withdrawal of paraprofessional support at school. This study illustrates the use of school-based CBT strategies coupled with additional focused Tier 4 behavior supports as an efficacious treatment for youth with significant comorbidity.

Corporate Vulnerabilities in the Middle East, North Africa, and Pakistan in the Wake of COVID-19 Pandemic

This paper analyzes corporate vulnerabilities in the Middle East, North Africa and Pakistan (MENAP hereafter) in the wake of the COVID-19 pandemic shock. Using a sample of nearly 700 firms from eleven countries in MENAP, we assess the non-financial corporate (NFC) sector’s liquidity and solvency risk and viability over the medium term under different stress test scenarios. Our findings suggest that the health crisis has exacerbated vulnerabilities in the corporate sector, though the effects are heterogenous across the region. Small firms, which entered the pandemic in a more vulnerable position, would remain under high liquidity stress over the medium term, putting a substantial share of these firms’ debt at risk of default. Similarly, liquidity needs of firms in contact-intensive sectors have also worsened and would remain elevated in 2022-23. We also show that an adverse scenario of subdued growth and premature withdrawal of policy support would impair the capacity to service interest expenses, especially among small firms, resulting in higher insolvency risk. Overall, our results indicate that some segments of the MENAP corporate sector could remain reliant on policy support during the recovery phase and that structural reforms are critical to save distressed but viable firms from bankruptcy and ensure an efficient liquidation of “zombie” firms.

Longitudinal Echocardiographic Assessment of Donor Hearts in DCD Donors Using Thoracoabdominal Normothermic Regional Perfusion

<h3>Purpose</h3> In the U.S., multiple centers are beginning to develop protocols for DCD organ donation. We describe our intraoperative echo thoracoabdominal normothermic regional perfusion (TA-NRP) DCD protocol for initial donor acceptance and mid-term follow up <h3>Methods</h3> After identification of a suitable DCD donor, withdrawal of life support is performed in the OR until circulatory death occurs. After 5 minutes of observation, circulatory death is declared. The sternum is opened, cerebral vessels are ligated, and cardiopulmonary bypass (CPB) is initiated. Transesophageal echocardiogram (TEE) monitors the following parameters to ensure the heart is acceptable: left ventricular ejection fraction (LVEF) ≥50%, mitral valve annulus lateral S wave (MV S wave) ≥10 cm/sec, left ventricular outflow tract time integral (LVOT VTI) ≥15 cm, and right ventricular systolic function (RVEF) normal by visual estimation. The recipient's LVEF and global longitudinal strain rate (GLS) were followed longitudinally for up to 18 months <h3>Results</h3> From January 2020 to October 2021, 10 TA-NRP DCD transplants were performed: 7 isolated hearts, 2 heart-bilateral lung, and 1heart-kidney. Median donor age was 43.5 years (26-51) and there were 9 males (90%). Fifty percent of donors had a history of opioid drug overdose. The mean preoperative donor LVEF was 68%. Mean TEE parameters while weaning off CPB: LVEF 65%, MV lateral S wave 12 cm/sec, and LVOT VTI 19 cm. RVSF was normal for all donors. None of the donors required inotropic support. The recipient median age was 54 years (44-72) and 70% were male. None of the recipients developed cardiac graft failure. At mean follow-up of 392 days, mean LVEF is 64% and mean GLS is -16.7% and all patients are alive. <h3>Conclusion</h3> A standardized intraoperative TEE protocol to assess TA-NRP DCD donor heart function while weaning CPB is of paramount importance to ensure excellent longitudinal recipient graft function.

Theophylline Post Heart Transplantation to Prevent Permanent Pacing: The Rotterdam Experience

<h3>Purpose</h3> Sinus node dysfunction and atrioventricular conduction disorders occur increasingly after orthotopic heart transplantation (HTX) due to aging donors and may require permanent pacemaker (PM) implantation. Theophylline has been used in the past in selected cases as an alternative to PM implantation. The aim of this study was to investigate the rate and success of oral theophylline administration after orthotopic heart transplantation preventing permanent PM implantation. <h3>Methods</h3> We included all patients treated with theophylline post HTX due to bradyarrhythmia's in our center from January 1985 to January 2020. Data was obtained retrospectively through electronic patient files. Re-transplants and patients who died within one month post HTX were excluded from the analysis. <h3>Results</h3> Of the total of 751 heart transplant recipients, 73 (9,7%) patients (mean age 46+-15.2 years; 73% male) were treated with theophylline for bradyarrhythmia's early post HTX. Of these patients, 14 (19%) patients needed a permanent PM during hospitalization and 10(14%) patients stopped using theophylline because of adequate heart rhythm. In the end, 49 (6.5% of the total) patients were discharged with a theophylline (mean maintenance doses of 354+-143 mg). At the outpatient clinics, additional 6 (12%) patients needed a PM within 7 months after discharge, with the rest stable sinus rhythm. <h3>Conclusion</h3> In this retrospective data analyses oral theophylline remained a viable alternative to permanent PM implantations in patients post HTX with increased heart rates, facilitating the withdrawal of chronotropic support and avoiding the need of permanent PM implantation.

A RARE ASSOCIATION OF ANTI- GABA-B RECEPTOR WITH ANTI HU ANTIBODIES IN AUTOIMMUNE ENCEPHALITIS: A CASE REPORT

Antibodies to the gamma aminobutyric acid-B receptor (Anti-GABA-B-R) encephalitis is an uncommon subtype of autoimmune encephalitis (AE) in which IgG antibodies directed against the B1 subunit of the GABA-B-R has been described. Clinically it presents as limbic encephalitis (LE) which is characterized by seizures, psychosis, and memory loss with progression to autonomic dysfunction, altered consciousness and death. We present a case of an elderly male who presented in the ER due to progressive agitation, confusion, and irritability. Immunological workup revealed anti GABA-B-R antibody and anti Hu. After admission his consciousness rapidly deteriorated over the next few days, and he was incubated. The patient developed septic shock and due to poor prognosis, the patient’s family requested withdrawal of ventilatory support.

Risk factors for renal allograft survival with China novel donation category: Donation after brain death followed by cardiac arrest

IntroductionTo meet the need for transplantable organs, a new donation program was initiated by the Chinese government. This novel policy created three categories for deceased organ donations: donation after circulatory death cardiac death (DCD), donation after brain death (DBD), and donation after brain death followed by circulatory death (DBCD) meaning complete cardiac arrest. In fact, the DBCD method is a combination of both DBD and DCD methods. A DBCD donor meets the criteria of for brain death, but the organ procurement begins after the withdrawal of life support and the subsequent cardiac arrest death. The purpose of this study was to evaluate the long-term outcomes of kidney transplantation in our center with the DBCD policy. Potential risk factors for affecting the renal allograft survival were also analyzed based on our data. MethodA retrospective study, involving 421 kidney transplants derived from 214 donors, was conducted between December 2011 and October 2019. In particular, 373 (88.6%) transplanted organs met the criteria for DBCD, and 48 (11.4%) for DCD. The log-rank test was used to compare the difference in survival. The Cox regression analysis was used for risk factor screening. ResultAnalysis showed that the DBCD group was better than the DCD group in terms of overall (p = 0.031) as well as death-censored (p = 0.026) allograft survival using the log-rank test. A Cox regression analysis revealed that increasing donor age (p = 0.002, HR = 1.820/10 years incremental older), increasing recipient age (p = 0.028, HR = 1.521/10 years increment older), prolonged dialysis duration (p = 0.007, HR = 1.018), occurrence episodes of acute rejection (p = 0.016, HR = 2.697), delayed graft function (p = 0.012, HR = 2.962), mismatch ≥4 HLA loci (p = 0.038, HR = 3.606), and warm ischemia time > 15 min (p = 0.022, HR = 2.915), were all independent risk factors affecting the graft survival. ConclusionThe new DBCD policy of donation produced acceptable results similar or even better than the DCD practice. Based on our analysis, the graft survival of DBCD transplants may be better than DCD transplants. The main risk factors for allograft loss included an increasing donor age, recipient age, warm ischemia time > 15 min, prolonged dialysis duration, acute rejection, delayed graft function, and HLA mismatch ≥4 HLA loci.

Accelerated adulthood, extended adolescence and the care cliff: Supporting care leavers' transition from care to independent living

AbstractThe pressures of ‘accelerated adulthood’ are a critical challenge for young people ageing out of the care system. Despite the trauma related to their placement history, young people ‘aging out’ are expected to adapt to adulthood at younger age and faster pace than their non‐care peers, who enjoy an ‘extended adolescence’ a far more gradual progression into adulthood than previous generations. This article draws on first‐person narratives of care leavers in Ireland who have aged out of care and transitioned into independent living in a dedicated social housing programme to examine their strategies for coping with these competing pressures. It examines their worries about the sudden withdrawal of supports after they reach 18 years, which they characterized as a ‘care cliff’. The emotional and practical challenges they faced when transitioning to independent living at a comparatively young age are explored, and strategies for mitigating these are identified. These include better preparing care leavers for this transition, maintaining supports for longer and withdrawing them in a more gradual way, which is tailored to meet the specific needs of each care leaver and grounded in more comprehensive after care planning than has been the norm in Ireland.

Privileged Precariat: White Workers and South Africa’s Long Transition to Majority Rule by Danelle van Zyl-Hermann

<i>Privileged Precariat: White Workers and South Africa’s Long Transition to Majority Rule</i> by Danelle van Zyl-Hermann

Predictors of treatment limitations in Finnish intensive care units.

Few studies have examined the factors that predict the limitations of life-sustaining treatment (LST) to patients in intensive care units (ICUs). We aimed to identify variables associated with the decision of withholding of life support (WHLS) at admission, WHLS during ICU stay and the withdrawal of ongoing life support (WDLS). This retrospective observational study comprised 17,772 adult ICU patients who were included in the nationwide Finnish ICU Registry in 2016. Factors associated with LST limitations were identified using hierarchical logistic regression. The decision of WHLS at admission was made for 822 (4.6%) patients, WHLS during ICU stay for 949 (5.3%) patients, and WDLS for 669 (3.8%) patients. Factors strongly predicting WHLS at admission included old age (adjusted odds ratio [OR] for patients aged 90years or older in reference to those younger than 40years was 95.6; 95% confidence interval [CI], 47.2-193.5), dependence on help for activities of daily living (OR, 3.55; 95% CI, 3.01-4.2), and metastatic cancer (OR, 4.34; 95% CI, 3.16-5.95). A high severity of illness predicted later decisions to limit LST. Diagnoses strongly associated with WHLS at admission were cardiac arrest, hepatic failure and chronic obstructive pulmonary disease. Later decisions were strongly associated with cardiac arrest, hepatic failure, non-traumatic intracranial hemorrhage, head trauma and stroke. Early decisions to limit LST were typically associated with old age and chronic poor health whereas later decisions were related to the severity of illness. Limitations are common for certain diagnoses, particularly cardiac arrest and hepatic failure.

Freedom’s Dominion: A Saga of White Resistance to Federal Power by Jefferson Cowie

Reviewed by: Freedom’s Dominion: A Saga of White Resistance to Federal Power by Jefferson Cowie Greta De Jong (bio) Freedom’s Dominion: A Saga of White Resistance to Federal Power. By Jefferson Cowie. (New York: Basic Books, 2022. Pp. x, 497. $35.00 cloth; $19.99 ebook) Jefferson Cowie provides a comprehensive and timely analysis of white racists’ longstanding antipathy toward the federal government in this book. In recent decades, scholars such as Joseph Crespino, Kevin Kruse, and Matthew Lassiter have examined connections between antigovernment beliefs and opposition to racial equality that were evident in the mid-twentieth century as white southerners mobilized to fight the enforcement of civil rights legislation. Similarly, Kathleen Belew has shown how white supremacist ideologies motivated antigovernment groups and domestic terrorism after the 1960s. Cowie extends the story back in time, arguing that for most of the history of the United States—from settler colonialism to Trumpism—attacks on federal “tyranny” and resistance to government power aimed to preserve white Americans’ freedom to oppress other people. Cowie uses developments in the town of Eufaula in Barbour County, Alabama, to trace the evolution of what he calls “racialized anti-statism” through four key periods in the nation’s history: the dispossession and removal of Indigenous people from their lands; the violent destruction of interracial democracy during Reconstruction; [End Page 201] the license to murder provided to white southerners during the Jim Crow era; and the nationalized opposition to government action on behalf of racial and economic justice in the late twentieth century (p. 5). In each case, antigovernment rhetoric and calls to defend “freedom” were used to justify actions that only protected the ability of some Americans to deny freedom and democracy to others. Conflicts over the enforcement of the Treaty of Cusseta in the 1830s provide an early instance where arguments over federal power, states’ rights, and white freedom emerged and were resolved on the side of white dominance. Armed white invaders illegally squatting on Creek land refused to abide by the law and violently resisted the federal agents sent in to remove them. The deaths that resulted and accusations that the government’s actions amounted to “tyranny” weakened the resolve of U.S. forces, and they eventually abandoned their efforts, setting the pattern for later interventions. Creek dispossession allowed the rise of a slaveholding economy where white freedoms were based on extreme exploitation and abuse of African Americans. When this system was destroyed and Black people gained citizenship rights during Reconstruction, white supremacists mobilized to cast the experiment in interracial democracy as an illegitimate form of coerced equality that they were justified in overthrowing through fraud and violence. The federal government’s withdrawal of support for racial equality helped to usher in the Jim Crow era, when adherence to the doctrine of states’ rights meant white southerners could cheat, imprison, beat, maim, and kill Black southerners with impunity. Despite the civil rights movement’s success in ending legalized racial discrimination in the 1960s, angry white resistance and the resurgence of racialized anti-statism once again undermined federal efforts to fully enforce civil rights laws. Cowie’s analysis is persuasive and supported by evidence drawn from government records, the papers of political leaders and activists, presidential speeches, oral histories, and other archival sources. The book’s most important contribution is its powerful demonstration of [End Page 202] the need for the federal government to play a forceful role in expanding the definition of freedom beyond the narrow vision of those who think it means the unrestrained ability to dominate others. Greta De Jong GRETA DE JONG is a professor of history at the University of Nevada, Reno. Her most recent book is You Can’t Eat Freedom: Southerners and Social Justice after the Civil Rights Movement (2016). Copyright © 2022 Kentucky Historical Society

Shifting and intersecting needs: Parents’ experiences during and following the withdrawal of life sustaining treatments in the paediatric intensive care unit

ObjectivesTo examine parents’ perceptions of nursing care needs; including specific concerns, preferences and supportive actions for themselves and their dying child during and following the withdrawal of life support in the paediatric intensive care unit. Research designQualitative description with content analysis. SettingInterviews with eight parents of eight children who died in the paediatric intensive care unit 7-11 years prior. Main Outcome MeasuresDescriptive categories of parents’ perceptions of end-of-life needs. FindingsParents identified four shifting and intersecting categories of needs: To be together, To make sense of the child’s evolving clinical care, To manage institutional, situational, and structural factors, and To navigate an array of emotions in a sterile context. Being closely connected with the child was highly important, but often intersected with other domains, requiring nurses’ support. Parents’ memories demonstrated persistent uncertainty about their child’s end-of-life care that influenced their long-term grief. ConclusionsIntersections between parent-identified care needs suggest potential mechanisms to strengthen nurses’ care for dying children. Equipped with the knowledge that the parent-child bond often shapes parents’ priorities; nurses should aim to facilitate connections amidst paediatric intensive care unit processes. Ongoing uncertainty in parents’ adaptation to loss suggests that attention to instances when needs intersect can have a lasting impact on parents’ grief.

Donación en asistolia controlada: cómo iniciar un programa

Introduction and objectivesDonation after circulatory death has become one of the main strategies to increase the number of donors. Until now, the heart of this type of donor was not evaluated due to the risk of ischaemic injury during the withdrawal of life support. In recent years, ex situ perfusion systems have initiated cardiac donation programmes after circulatory death that have demonstrated myocardial viability. The use of normothermic regional perfusion in our environment and the experience of other countries in cardiac recovery led us to develop a protocol for cardiac procurement in donation after circulatory death with in situ assessment and cold preservation. MethodsA multidisciplinary team was formed to create a cardiac extraction protocol with donation after circulatory death. After a phase of animal experimentation, the protocol was approved by the Ethics Committee for Health Care and by the National Transplant Organization. ResultsA protocol was drawn up establishing the criteria for donor and recipient selection and regulating the donation procedure with thoracic-abdominal perfusion after exclusion of the supra-aortic trunks. Cardiac evaluation is in situ and static preservation in cold storage. This protocol was sent to the rest of the donor hospitals and this led us to perform the first heart transplant in Spain with this donation modality. ConclusionsCardiac transplantation with donation after circulatory death is a clinical reality that will increase the number of potential donors. The technical characteristics of the procedure mean that this type of donation should be performed in experienced centres.

Experiences of adolescents and parents on the mental health management of depression in adolescents, North West province, South Africa.

BackgroundLiving with or managing an adolescent suffering from depression predisposes the adolescent and parents to various experiences, considering the multifactorial nature of depression and associated symptoms.ObjectiveThis study explored and described the experiences of adolescents and their parents on the mental health management of depression in the North West province (NWP), South Africa.MethodA qualitative, exploratory, descriptive, contextual research design was adopted. Data was collect from two mental health care institutions and two mental health care units attached to two general hospitals in the NWP, SA. Thirty-two participants (18 adolescents and 14 parents) were purposefully selected for the study. Data were collected through individual interviews and analysed using Tesch’s open-coding method to generate themes and categories which were presented with the concurrent support of participants direct quotations.ResultsThe study revealed that the experiences of adolescents with depression and their parents taking care of them at homes include the following: emotional distress, poor coping mechanisms, financial burden, repeated suicidal attempts, negative attitudes from support systems and withdrawal behaviours. Appropriate therapeutic environments, ongoing monitoring by mental healthcare practitioners and adequate support systems were suggested by participants as management approaches that could enhance the recovery of adolescents from depression.ConclusionThe findings revealed the devastating experiences of adolescents with depression and their parents taking care of them in their various homes which confirms the dire need for attention on the plights of these groups in order to facilitate adolescents’ recovery and strengthen the adolescents’ and parents’ coping mechanisms for a healthier family.

ICU Clinicians’ Experiences of Terminal Weaning and Extubation

ContextAside from spontaneous death, a majority of ICU deaths occur after a decision to either withhold or withdraw life-sustaining measures, including withdrawal of ventilatory support. While terminal weaning or terminal extubation are both used, the lack of evidence on the superiority of one method over the other can create challenges for ICU clinicians. There is a need to explore clinicians’ experiences related to terminal weaning/extubation to understand their decision-making processes as well as the context and mechanisms that guide this process. ObjectivesThis study aimed to explore ICU clinicians'experiences of Terminal Weaning of Mechanical Ventilation (TWMV) in order to better understand the process, and clinicians’ feelings about the process. MethodsThis study used an exploratory descriptive qualitative design. Data were collected via semi-structured, face-to-face interviews with 20 ICU clinicians. An inductive, data driven thematic analysis approach was used for data analysis. ResultsAnalysis of the data resulted in four themes: Fine-tuning the Process of TWMV; Focusing on the Family; Ensuring Patient-Centered Care; and Impact on Health care Clinicians and Support Needs. ConclusionThe identified themes provide insight into the complexity of the withdrawal of mechanical ventilation within the context of end-of-life care in the ICU. The themes highlight the need for clear communication of a TWMV plan between clinicians to avoid conflict during the process, ensuring medication is in place for potential distressing symptoms, incorporating patient and family wishes in planning, supporting the family during the process, and training and support for clinicians.