Despite cardiopulmonary resuscitation (CPR) and do-not-attempt-resuscitation (DNAR) decisions are increasingly considered an essential component of hospital practice and patient inclusion in these conversations an ethical imperative in most cases, there is evidence that such discussions between physicians and patients/surrogate decision-makers (the person or people providing direction in decision making if a person is unable to make decisions about personal health care, e.g., family members or friends) are often inadequate, excessively delayed, or absent. We conducted a study to qualitatively explore physician-reported CPR/DNAR decision-making approaches and CPR/DNAR conversations with patients hospitalized in the internal medicine wards of the four main hospitals in Ticino, Southern Switzerland. We conducted four focus groups with 19 resident and staff physicians employed in the internal medicine unit of the four public hospitals in Ticino. Questions aimed to elicit participants’ specific experiences in deciding on and discussing CPR/DNAR with patients and their families, the stakeholders (ideally) involved in the discussion, and their responsibilities. We found that participants experienced two main tensions. On the one side, CPR/DNAR decisions were dominated by the belief that patient involvement is often pointless, even though participants favored a shared decision-making approach. On the other, despite aiming at a non-manipulative conversation, participants were aware that most CPR/DNAR conversations are characterized by a nudging communicative approach where the physician gently pushes patients towards his/her recommendation. Participants identified structural cause to the previous two tensions that go beyond the patient-physician relationship. CPR/DNAR decisions are examples of best interests assessments at the end of life. Such assessments represent value judgments that cannot be validly ascertained without patient input. CPR/DNAR conversations should be regarded as complex interventions that need to be thoroughly and regularly taught, in a manner similar to technical interventions.

La grippe sous ses pires facettesL'infection par les virus de la grippe de types A et B (influenza A et B) est grevée d'une morbidité variable, pouvant évoluer en diverses complications respiratoires, circulatoires et neurologiques sévères, voire fatales. Les complications pulmonaires sont les plus fréquentes et l'on distingue parmi elles les pneumonies dues au virus de celles par surinfection bactérienne ou fongique. Les complications extrapulmonaires, plus rares, peuvent toucher divers organes, dont le coeur (myocardite, infarctus du myocarde de types 1 et 2) et le système nerveux (AVC, encéphalite, syndrome de Guillain-Barré). Cet article aborde les aspects physiopathologiques de base de la grippe, passe en revue les principales complications sévères pulmonaires et extrapulmonaires, et discute les indications, contre-indications et limites des différents traitements disponibles. The flu in its worse formsInfluenza A and B infections are marred with variable morbidity and, in some cases, develop into severe or even fatal respiratory, circulatory and neurologic complications. Respiratory complications are most common and involve primary-Influenza pneumonia and pneumonia from bacterial or fungal superinfections. Nonrespiratory complications can affect several organs/systems, namely the heart (myocarditis, type 1 and 2 myocardial infarction) and the nervous system (stroke, encephalitis, Guillain-Barré Syndrome). This article provides an overview of the basic pathophysiological aspects of Influenza virus infection, reviews the main severe respiratory and nonrespiratory complications and discusses the different treatments with their respective indications, contraindications and limitations.

Die Peritonealdialyse ist neben der Hämodialyse eine der extrarenalen Blutreinigungsmethoden (Nierenersatzverfahren), die Patientinnen und Patienten mit terminaler Niereninsuffizienz angeboten wird. Bei dieser Technik findet ein Konzentrationsgradienten-gesteuerter Stoffaustausch über eine semipermeable Membran -in diesem Falle das Peritoneum -statt, um harnpflichtige Sub stanzen zu eliminieren. Trotz der Vorteile der Peritonealdialyse, darunter die längere Erhaltung der residuellen Nierenfunktion, die Patientenautonomie und die geringeren Kosten, wird diese Form der Nierenersatztherapie in der Schweiz bei weniger als 10% der Personen mit terminaler Niereninsuffizienz angewendet [1]. Gleichwohl sollte diese sichere und effiziente Methode diskutiert und allen dafür in Betracht kommenden Patientinnen und Patienten in gleicher Weise wie die Hämodialyse angeboten werden [1, 2]. Die meistgefürchtete Komplikation der Peritonealdialyse ist die infektiöse Peritonitis -die Kenntnis der Prinzipien ihrer Diagnostik und Therapie ist wichtig, um die Unversehrtheit der Peritonealmembran so lange wie möglich zu erhalten und den Schritt zur Hämodialyse zu vermieden.

No abstract