Background The COVID-19 pandemic has created ethical challenges for intensive care unit (ICU) professionals, potentially causing moral distress. This study explored the levels and causes of moral distress and the ethical climate in Dutch ICUs during COVID-19. Methods An extended version of the Measurement of Moral Distress for Healthcare Professionals (MMD-HP) and Ethical Decision Making Climate Questionnaire (EDMCQ) were online distributed among all 84 ICUs. Moral distress scores in nurses and intensivists were compared with the historical control group one year before COVID-19. Results Three hundred forty-five nurses (70.7%), 40 intensivists (8.2%), and 103 supporting staff (21.1%) completed the survey. Moral distress levels were higher for nurses than supporting staff. Moral distress levels in intensivists did not differ significantly from those of nurses and supporting staff. “Inadequate emotional support for patients and their families” was the highest-ranked cause of moral distress for all groups of professionals. Of all factors, all professions rated the ethical climate most positively regarding the culture of mutual respect, ethical awareness and support. “Culture of not avoiding end-of-life-decisions” and “Self-reflective and empowering leadership” received the lowest mean scores. Moral distress scores during COVID-19 were significantly lower for ICU nurses (p < 0.001) and intensivists (p < 0.05) compared to one year prior. Conclusion Levels and causes of moral distress vary between ICU professionals and differ from the historical control group. Targeted interventions that address moral distress during a crisis are desirable to improve the mental health and retention of ICU professionals and the quality of patient care.
Background A patient who fulfils the due diligence requirements for euthanasia, and is medically suitable, is able to donate his organs after euthanasia in Belgium, the Netherlands and Canada. Since 2012, more than 70 patients have undergone this combined procedure in the Netherlands. Even though all patients who undergo euthanasia are suffering hopelessly and unbearably, some of these patients are nevertheless willing to help others in need of an organ. Organ donation after euthanasia is a so-called donation after circulatory death (DCD), Maastricht category III procedure, which takes place following cardiac arrest, comparable to donation after withdrawal of life sustaining therapy in critically ill patients. To minimize the period of organ ischemia, the patient is transported to the operating room immediately after the legally mandated no-touch period of 5 min following circulatory arrest. This means that the organ donation procedure following euthanasia must take place in the hospital, which appears to be insurmountable to many patients who are willing to donate, since they already spent a lot of time in the hospital. Case presentation This article describes the procedure of organ donation after euthanasia starting at home (ODAEH) following anesthesia in a former health care professional suffering from multiple system atrophy. This case is unique for at least two reasons. He spent his last conscious hours surrounded by his family at home, after which he underwent general anaesthesia and was intubated, before being transported to the hospital for euthanasia and organ donation. In addition, the patient explicitly requested the euthanasia to be performed in the preparation room, next to the operating room, in order to limit the period of organ ischemia due to transport time from the intensive care unit to the operating room. The medical, legal and ethical considerations related to this illustrative case are subsequently discussed. Conclusions Organ donation after euthanasia is a pure act of altruism. This combined procedure can also be performed after the patient has been anesthetized at home and during transportation to the hospital.
Objective: This case report describes convulsions and hemiparesis after retrobulbar injection with good outcome in a patient undergoing outpatient cryocoagulation of his right eye.Case Report: We report a young man in which localized convulsions of the ipsilateral face occurred 9 minutes after retrobulbar injection followed shortly by convulsions of the contralateral arm and leg. After the convulsions, the patient experienced left-sided hemiparesis resolving approximately 1 hour after the injection. There was no hemodynamic instability during this period. It was difficult to determine the exact cause of convulsions and hemiparesis. Conclusions:We believe these complications occurred because of unintentional injection of local anesthetic agent into the subarachnoid space without affecting the brainstem. Possible mechanisms of spread of local anesthetic agent into the central nervous system after retrobulbar block are discussed. Reg L ocal anesthesia for major ophthalmic surgical procedures includes peribulbar, retrobulbar, and sub-Tenon's block, 1-3 but the exact frequency of their use is not known. Although the classical retrobulbar technique 4 is still in use, the technique has evolved over the years. In current or modern retrobulbar block, a needle Յ32 mm long is inserted through the extreme inferolateral quadrant just below the lateral rectus muscle. 5 Despite its careful use, sight and/or life-threatening complications have occurred. 6-8 Numerous case reports of apnea, respiratory difficulties, cardiovascular collapse, convulsions, and paralysis of 1 or more limbs have been reported after local anesthetic spread to unusual neurologic locations. 9 The exact mechanism of spread is not fully understood in most cases. A variety of signs and symptoms after injection of local anesthetic agent into the optic nerve sheath have been reported. 9 A case of contralateral hemiparesis was reported after retrobulbar block in addition to which the patient developed bilateral ophthalmoplegia and loss of consciousness for approximately 2 hours. 10 We present a case in which localized ipsilateral convulsions occurred 9 minutes after retrobulbar injection, and this was followed shortly by convulsions in the contralateral arm and leg. Contralateral hemiparesis occurred, but the patient recovered full muscle power within an hour. To our knowledge, delayed convulsions and contralateral hemiparesis after retrobulbar block have not been reported. Case ReportA 36-year-old man (height 1.73 m, weight 80 kg, and American Society of Anesthesiologists 2) was scheduled for outpatient cryocoagulation of his right eye. The medical history included congenital blindness in the right eye and non-Hodgkin's lymphoma with leptomeningeal metastasis. He received intrathecal chemotherapy and skull radiotherapy more than 5 years before. Although his medical conditions remained stable, he developed radiation retinitis in both eyes. He was addicted to nicotine and
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