What Constitutes a "Good Death"?-A Representative Cross-Sectional Survey Among the General Public in Croatia.

Understanding the attitudes of a particular society on a "good death" is important when it comes to end-of-life decision-making and palliative care. In the Republic of Croatia no systematic research has been done on the attitudes of the general population about the concept of a "good death". This cross sectional survey was conducted on a three-stage random sample, stratified by regions, counties and locations within those counties (N = 1203) during November and December, 2019. ANOVA, to determine differences, factor analysis and multiple regression analysis were used. The most important characteristics of a good death outlined by the respondents were: the absence of pain, the presence and unencumberedness of family and loved ones, the importance of a sense of fulfilment and meaning in life in this regard, reconciliation with God, the presence of awareness and sobriety, and the possibility of treatment.

End-of-Life Decision-Making in Pediatric and Neonatal Intensive Care Units in Croatia-A Focus Group Study among Nurses and Physicians.

Background and Objectives: Working in pediatric and neonatal intensive care units (ICUs) can be challenging and differs from work in adult ICUs. This study investigated for the first time the perceptions, experiences and challenges that healthcare professionals face when dealing with end-of-life decisions in neonatal intensive care units (NICUs) and pediatric intensive care units (PICUs) in Croatia. Materials and Methods: This qualitative study with focus groups was conducted among physicians and nurses working in NICUs and PICUs in five healthcare institutions (three pediatric intensive care units (PICUs) and five neonatal intensive care units (NICUs)) at the tertiary level of healthcare in the Republic of Croatia, in Zagreb, Rijeka and Split. A total of 20 physicians and 21 nurses participated in eight focus groups. The questions concerned everyday practices in end-of-life decision-making and their connection with interpersonal relationships between physicians, nurses, patients and their families. The constant comparative analysis method was used in the analysis of the data. Results: The analysis revealed two main themes that were the same among the professional groups as well as in both NICU and PICU units. The theme "critical illness" consisted of the following subthemes: the child, the family, myself and other professionals. The theme "end-of-life procedures" consisted of the following subthemes: breaking point, decision-making, end-of-life procedures, "spill-over" and the four walls of the ICU. The perceptions and experiences of end-of-life issues among nurses and physicians working in NICUs and PICUs share multiple common characteristics. The high variability in end-of-life procedures applied and various difficulties experienced during shared decision-making processes were observed. Conclusions: There is a need for further research in order to develop clinical and professional guidelines that will inform end-of-life decision-making, including the specific perspectives of everyone involved, and the need to influence policymakers.

Attitudes about withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide, and physician assisted suicide: a cross-sectional survey among the general public in Croatia.

BACKGROUND: There has been no in-depth research of public attitudes on withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. The aim of this study was to examine these attitudes and their correlation with sociodemographic characteristics, religion, political orientation, tolerance of personal choice, trust in physicians, health status, experiences with death and caring for the seriously ill, and attitudes towards death and dying. METHODS: A cross-sectional study was conducted on a three-stage random sample of adult citizens of the Republic of Croatia, stratified by regions, counties, and locations within those counties (N = 1203). In addition to descriptive statistics, ANOVA and Chi-square tests were used to determine differences, and factor analysis (component model, varimax rotation and GK dimensionality reduction criterion), correlation analysis (Bivariate correlation, Pearson's coefficient) and multiple regression analysis for data analysis. RESULTS: 38.1% of the respondents agree with granting the wishes of dying people experiencing extreme and unbearable suffering, and withholding life-prolonging treatment, and 37.8% agree with respecting the wishes of such people, and withdrawing life-prolonging treatment. 77% of respondents think that withholding and withdrawing procedures should be regulated by law because of the fear of abuse. Opinions about the practice and regulation of euthanasia are divided. Those who are younger and middle-aged, with higher levels of education, living in big cities, and who have a more liberal worldview are more open to euthanasia. Assisted suicide is not considered to be an acceptable practice, with only 18.6% of respondents agreeing with it. However, 40.1% think that physician assisted suicide should be legalised. 51.6% would support the dying person's autonomous decisions regarding end-of-life procedures. CONCLUSIONS: The study found low levels of acceptance of withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. In addition, it found evidence that age, level of education, political orientation, and place of residence have an impact on people's views on euthanasia. There is a need for further research into attitudes on different end-of-life practices in Croatia.

Experiences and attitudes of medical professionals on treatment of end-of-life patients in intensive care units in the Republic of Croatia: a cross-sectional study.

BACKGROUND: Decisions about limitations of life sustaining treatments (LST) are made for end-of-life patients in intensive care units (ICUs). The aim of this research was to explore the professional and ethical attitudes and experiences of medical professionals on treatment of end-of-life patients in ICUs in the Republic of Croatia. METHODS: A cross-sectional study was conducted among physicians and nurses working in surgical, medical, neurological, and multidisciplinary ICUs in the total of 9 hospitals throughout Croatia using a questionnaire with closed and open type questions. Exploratory factor analysis was conducted to reduce data to a smaller set of summary variables. Mann-Whitney U test was used to analyse the differences between two groups and Kruskal-Wallis tests were used to analyse the differences between more than two groups. RESULTS: Less than third of participants (29.2%) stated they were included in the decision-making process, and physicians are much more included than nurses (p < 0.001). Sixty two percent of participants stated that the decision-making process took place between physicians. Eighteen percent of participants stated that 'do-not-attempt cardiopulmonary resuscitations' orders were frequently made in their ICUs. A decision to withdraw inotropes and antibiotics was frequently made as stated by 22.4% and 19.9% of participants, respectively. Withholding/withdrawing of LST were ethically acceptable to 64.2% of participants. Thirty seven percent of participants thought there was a significant difference between withholding and withdrawing LST from an ethical standpoint. Seventy-nine percent of participants stated that a verbal or written decision made by a capable patient should be respected. Physicians were more inclined to respect patient's wishes then nurses with high school education (p = 0.038). Nurses were more included in the decision-making process in neurological than in surgical, medical, or multidisciplinary ICUs (p < 0.001, p = 0.005, p = 0.023 respectively). Male participants in comparison to female (p = 0.002), and physicians in comparison to nurses with high school and college education (p < 0.001) displayed more liberal attitudes about LST limitation. CONCLUSIONS: DNACPR orders are not commonly made in Croatian ICUs, even though limitations of LST were found ethically acceptable by most of the participants. Attitudes of paternalistic and conservative nature were expected considering Croatia's geographical location in Southern Europe.

Burnout in International Medical Students: Characterization of Professionalism and Loneliness as Predictive Factors of Burnout.

BACKGROUND: Burnout is a common mental problem in medical students. For those who are following medical studies abroad there is a higher risk of suffering this syndrome, due to the combination of academic stress and the stress derived from their new living situation. This study was performed with the purpose of testing the following hypothesis: in medical students enrolled in medical programs abroad, abilities associated with professionalism and family support play a protective role in the prevention of suffering burnout. METHODS: A cross-sectional study was performed in the Faculty of Medicine of the University of Zagreb, where a fully English medical program is offered. The general version of the Maslach Burnout Inventory (MBI-GS) was used as a dependent variable, while Jefferson Scales of empathy, teamwork, and physician lifelong learning and the Social and Emotional Loneliness Scale for Adults were used as predictive variables. In addition, information related to sex, country of birth, native language, age, academic achievement, and living situation were collected in a socio-demographic form. Linear regression models were applied to identify predictors of burnout. RESULTS: In a sample composed of 188 medical students (38 Croatians and 144 foreigners from 28 countries), 18% of the global score in the MBI-GS was explained by lifelong learning and family loneliness. A separate analysis for each domain of the MBI-GS allowed the creation of three models: the first model explained 19% of the variance of the "exhaustion" domain by "country of birth", "living with parents", "academic year", and "cynicism"; a second model explained 24% of the variance of the "cynicism" domain by "academic year", "empathy", "lifelong learning", and "exhaustion"; and finally, a third model explained 24% of the variance of the "professional efficacy" domain by "lifelong learning", "family loneliness", and "cynicism". All obtained models presented an effect size between medium and large, as well as matching the required conditions for statistical inference. CONCLUSIONS: These findings confirm the important role that family plays as a source of support for medical students. Empathy and lifelong learning, two specific elements of medical professionalism, appear as protective factors in the prevention of burnout in international students.

Trust in the Healthcare System and Physicians in Croatia: A Survey of the General Population.

Trust in healthcare systems and physicians is considered important for the delivery of good healthcare. A cross-sectional survey was conducted on a random three-stage sample of the general population of Croatia (N = 1230), stratified by regions. Of respondents, 58.7% displayed a high or very high level of trust in the healthcare system, 65.6% in physicians, and 78.3% in their family physician. Respondents' views regarding patients' roles in the discussion of treatment options, confidence in physicians' expertise, and underlying motives of physicians were mixed. Respondents with a lower level of education, those with low monthly incomes, and those from smaller settlements had lower levels of trust in physicians and the healthcare system. Trust in other institutions, religiosity and religious beliefs, tolerance of personal choice, and experience of caring for the seriously ill and dying were predictors of trust in healthcare and physicians. Our findings suggest that levels of healthcare-related trust in Croatia are increasing in comparison with previous research, but need improvement. Levels of trust are lowest in populations that are most vulnerable and most in need of care and protection.

End-of-Life Decisions in Intensive Care Units in Croatia-Pre COVID-19 Perspectives and Experiences From Nurses and Physicians.

Healthcare professionals working in intensive care units (ICUs) are often involved in end-of-life decision-making. No research has been done so far about these processes taking place in Croatian ICUs. The aim of this study was to investigate the perceptions, experiences, and challenges healthcare professionals face when dealing with end-of-life decisions in ICUs in Croatia. A qualitative study was performed using professionally homogenous focus groups of ICU nurses and physicians (45 in total) of diverse professional and clinical backgrounds at three research sites (Zagreb, Rijeka, Split). In total, six institutions at the tertiary level of healthcare were included. The constant comparative analysis method was used in the analysis of the data. Differences were found between the perceptions and experiences of nurses and physicians in relation to end-of-life decisions. Nurses' perceptions were more focused on the context and features of immediate care, while physicians' perceptions also included the wider sociocultural context. However, the critical issues these specific professional groups face when dealing with end-of-life decisions seem to overlap. A high variability of practices, both between individual practitioners and between different organizational units, was omnipresent. The lack of adequate legal, professional, and clinical guidelines was commonly expressed as one of the most critical source of difficulties.

Survey on the Research Misconduct and Questionable Research Practices of Medical Students, PhD Students, and Supervisors at the Zagreb School of Medicine in Croatia.

This cross-sectional study evaluates the knowledge, attitudes, experiences, and behavior of final year medical students, PhD students, and supervisors at the School of Medicine of the University of Zagreb in relation to research misconduct, questionable research practices, and the research environment. The overall response rate was 36.4% (68%-100% for the paper survey and 8%-15% for the online surveys). The analysis reveals statistically significant differences in attitude scores between PhD students and supervisors, the latter having attitudes more in concordance with accepted norms. The results overall show a nonnegligible incidence of self-reported misconduct and questionable research practices, as well as some problematic attitudes towards misconduct and questionable research practices. The incidence of problematic authorship practices was particularly high. The research environment was evaluated as being mostly supportive of research integrity.

How health care professionals confront and solve ethical dilemmas - a tale of two countries: Slovenia and Croatia.

AIM: To assess the differences in the way how Slovenian and Croatian health care professionals (HCPs) confront ethical dilemmas and perceive the role of hospital ethics committees (HECs). METHODS: This cross-sectional, survey-based study involved HCPs from three Slovenian and five Croatian university medical centers (UMC). The final sample sizes were 308 (244 or 79.2% women) for Slovenia and 485 (398 or 82.1% women) for Croatia. RESULTS: Compared with Croatian physicians, Slovenian physicians reported a higher share of ethical dilemmas regarding waiting periods for diagnostics or treatment, suboptimal working conditions due to interpersonal relationships in the ward, and end-of-life treatment withdrawal, and a lower share regarding access to palliative care and patient information protection. Compared with Croatian nurses, Slovenian nurses reported a lower share of ethical dilemmas regarding the distribution of limited resources, recognizing the patient's best interests, and access to palliative care. Compared with Croatian other HCPs, Slovenian other HCPs reported a lower burden of ethical dilemmas regarding waiting periods for diagnostics or treatment, distribution of limited resources, and access to palliative care. When encountering an ethical dilemma, all HCPs in both countries would first consult their colleagues. Slovenian and Croatian HCPs recognized the importance of the HECs to a similar extent, but viewed their role differently. CONCLUSION: Croatian and Slovenian HCPs are confronted with different ethical dilemmas and perceive the role of HECs differently.

80th Anniversary of the Publication of Endemic Syphilis in Bosnia: Survey by the School of Public Health in Zagreb.

Certain regions of Bosnia and Herzegovina were prominent European sites of endemic syphilis. In 1934 and 1935 the School of Public Health in Zagreb, later the Andrija Stampar School of Public Health, conducted two surveys on endemic syphilis in Bosnia and Herzegovina. The surveys were well-described in the monograph published in 1939 by the School, under the title Endemic Syphilis in Bosnia: Survey by the School of Public Health in Zagreb ("Endemski sifilis u Bosni anketa Skole narodnog zdravlja u Zagrebu"). This paper provides a description of the publication for the first time, presents the most important data from it, and explores its significance from the historical perspective.

The first nationwide study on facing and solving ethical dilemmas among healthcare professionals in Slovenia.

BACKGROUND: Healthcare professionals (HCPs), patients and families are often faced with ethical dilemmas. The role of healthcare ethics committees (HECs) is to offer support in these situations. AIM: The primary objective was to study how often HCPs encounter ethical dilemmas. The secondary objective was to identify the main types of ethical dilemmas encountered and how HCPs solve them. SUBJECTS AND METHODS: We conducted a cross-sectional, survey-based study among HCPs in 14 Slovenian hospitals. A questionnaire was designed and validated by HCPs who were selected by proportional stratified sampling. Data collection took place between April 2015 and April 2016. RESULTS: The final sample size was n = 485 (385 or 79.4%, female). The response rates for HCPs working in secondary and tertiary level institutions were 45% and 51%, respectively. Three hundred and forty (70.4%) of 485 HCPs (very) frequently encountered ethical dilemmas. Frequent ethical dilemmas were waiting periods for diagnostics or treatment, suboptimal working conditions due to poor interpersonal relations on the ward, preserving patients' dignity, and relations between HCPs and patients. Physicians and nurses working in secondary level institutions, compared to their colleagues working in tertiary level institutions, more frequently encountered ethical dilemmas with respect to preserving patients' dignity, protecting patients' information, and relations between HCPs and patients. In terms of solutions, all HCPs most frequently discussed ethical dilemmas with co-workers (colleagues), and with the head of the department. According to HCPs, the most important role of HECs is staff education, followed by improving communication, and reviewing difficult ethical cases. CONCLUSIONS: Waiting periods for diagnostics and treatment and suboptimal working conditions due to poor interpersonal relations are considered to be among the most important ethical issues by HCPs in Slovenian hospitals. The most important role of HECs is staff education, improving communication, and reviewing difficult ethical cases.

Ethical content of expert recommendations for end-of-life decision-making in intensive care units: A systematic review.

PURPOSE: Intensive care unit health care professionals must be skilled in providing end-of-life care. Crucial in this kind of care is end-of-life decision-making, which is a complex process involving a variety of stakeholders and requiring adequate justification. The aim of this systematic review is to analyse papers tackling ethical issues in relation to end-of-life decision-making in intensive care units. It explores the ethical positions, arguments and principles. METHODS: A literature search was conducted in bibliographic databases and grey literature sources for the time period from 1990 to 2019. The constant comparative method was used for qualitative analysis of included papers in order to identify ethical content including ethical positions, ethical arguments, and ethical principles used in decision-making process. RESULTS: In the 15 included papers we have identified a total of 43 ethical positions. Ten positions were identified as substantive, 33 as procedural. Twelve different ethical principles emerged from the ethical arguments. The most frequently used principles are the principles of beneficence, autonomy and nonmaleficence. CONCLUSIONS: We have demonstrated that recommendations and guidelines designed specifically by intensive or critical care experts for intensive care units promote similar ethical positions, with minimal dissenting positions.

Abdominal aortic and iliac aneurysm presented as lower limb deep vein thrombosis: case report.

Introduction: We report a rare case of a symptomatic abdominal aneurysm presented as a lower limb deep vein thrombosis (DVT).Case presentation: A 63-year old male presented to our hospital with a recent progressive onset of the right lower limb swelling and pain. The patient had a history of a previous cardiovascular disease. A Duplex ultrasound was performed, which confirmed a right lower limb DVT extending to the right iliac vein. The patient had a pulsatile abdominal mass. Computed tomography scan of the abdomen showed an abdominal aortic and a right iliac artery aneurysm compressing the thrombosed inferior caval and the right iliac vein. The patient was treated with low molecular weight heparin. After resolution of the DVT on day 3 of hospitalization, a surgery on the abdominal and iliac artery aneurysm was performed. The aneurysm was resected and an aortobifemoral bypass was placed using a Dacron prosthesis. The patient remained to be asymptomatic for 6 months after the surgery. Follow up computed tomography demonstrated a fully patent inferior caval and iliac vein and the absence of the aneurysmal disease.Conclusion: Although rare, our case confirms that the DVT should be considered as a possible symptom of an abdominal aneurysm in selected patients.

Reprogenetics, reproductive risks and cultural awareness: what may we learn from Israeli and Croatian medical students?

BACKGROUND: Past studies emphasized the possible cultural influence on attitudes regarding reprogenetics and reproductive risks among medical students who are taken to be "future physicians." These studies were crafted in order to enhance the knowledge and expand the boundaries of cultural competence. Yet such studies were focused on MS from relatively marginalized cultures, namely either from non-Western developing countries or minority groups in developed countries. The current study sheds light on possible cultural influences of the dominant culture on medical students in two developed countries, potentially with different dominant cultures regarding reprogenetics and reproductive risks: Israel and Croatia. METHODS: Quantitative-statistical analyses were employed, based on anonymous questionnaires completed by 150 first year medical students in Israel and Croatia. The questionnaires pertained to the knowledge and attitudes regarding genetics, reproduction and reproductive risks. These questionnaires were completed before the students were engaged in learning about these topics as part of the curriculum in their medical school. RESULTS: Substantial differences were revealed between the two groups of medical students. Israeli medical students were less tolerant regarding reproductive risks and more knowledgeable about genetics and reproductive risks than Croatian medical students. For example, while nearly all Israeli medical students (96%) disagreed with the idea that "Screening for reproductive risks in prospective parents is wrong," less than 40% of their Croatian counterparts shared a similar stance. Similarly, all (100%) Israeli medical students correctly observed that "A carrier of a recessive genetic disease actually has the disease" was wrong, as opposed to only 82% of Croatian students. CONCLUSIONS: By linking applicable theoretical literature to these findings, we suggest that they may reflect the hidden influence of the dominant culture in each country, disguised as part of the "culture of medicine." Acknowledging and learning about such influence of the dominant culture, may be an important addition to the training of medical students in cultural competence, and specifically their cultural awareness. Such an acknowledgement may also pave the road to drawing the attention of existing physicians regarding a less known yet an important aspect of their cultural competence, insofar as the cultural awareness component is concerned.

A Cross-sectional Study Among Healthcare and Non-healthcare Students in Slovenia and Croatia About Do-not Resuscitate Decision-making.

OBJECTIVE: To survey university students on their views concerning the respect for autonomy of patients and the best interest of patients in relation to the withholding of resuscitation. METHODS: A cross-sectional survey among university students of medicine, nursing, philosophy, law and theology of the first and the final study years at the University of Ljubljana and the University of Zagreb was conducted during the academic year of 2016/2017. A questionnaire constructed by Janiver et al. presenting clinical case vignettes was used. RESULTS: The survey response rates for students in Ljubljana and Zagreb were 45.4% (512 students) and 37.9% (812 students), respectively. The results of our research show statistically significant differences in do-not resuscitate decisions in different cases between medical and non-medical students in both countries. Male and religious students in both countries have lower odds of respecting relatives' wishes for the withholding of resuscitation (odds ratio 0.49-0.54; 95% confidence interval). All students agreed that they would first resuscitate children if they had to prioritize among patients. CONCLUSIONS: Our study clearly shows that gender, religious beliefs, and type of study are important factors associated with the decisions pertaining to the respect for autonomy, patient's best interest, and initiation or withholding of resuscitation.

The frequencies of micronuclei, nucleoplasmic bridges and nuclear buds as biomarkers of genomic instability in patients with urothelial cell carcinoma.

Bladder urothelial cell carcinoma (UCC) is an increasingly prevalent cancer worldwide, and thus, gaining a better understanding of its identifiable risk factors is a global priority. This study addressed this public health need with the understanding that cancer-initiating events, such as chromosome breakage, loss and rearrangement, can be reasonably used as biomarkers to evaluate an individual's cancer risk. Overall, forty bladder cancer patients and twenty controls were evaluated for genomic instability. To the best of the investigators' knowledge, this is the first study to perform micronucleus (MN) assays simultaneously in urothelial exfoliated cells (UEC), buccal exfoliated cells (BEC), and peripheral blood lymphocytes (PBL) in first-diagnosed, non-smoker bladder UCC patients. Additionally, the frequency of nucleoplasmic bridges (NPBs) and nuclear buds (NBUDs) in PBL was evaluated. The MN frequencies in UEC, BEC, and PBL, as well as the frequencies of NPBs and NBUDs, were significantly higher in patients than in controls. In conclusion, MN assays, particularly in UEC, may be used to identify individuals who are at high risk of developing UCC, as single or as additional triage test to UroVysion FISH test. Our results further validate the efficacy of biomarkers, such as MN, NPBs, and NBUDs, as predictors of genomic instability.

Informed consent and ethics committee approval in laboratory medicine.

Informed consent is a process in which a human subject who is to participate in research needs to give his or her consent after being properly informed of the expected benefits as well as the potential harm of the research that will be performed. The function and purpose of the research ethics committee is to ensure that the research that will take place is in accordance with the relevant ethical standards. This means that the committee must assess the appropriateness of the design of the study reviewed. Research in the field of laboratory medicine has specific features, i.e. the use of samples that remain after routine analysis, data collection from databases containing patient information, data mining, collection of laboratory management data, method/instrument comparisons and validation, etc. As most of such research is either retrospective or not directly associated with patients, the question arises as to whether all types of research require informed consent and ethics committee approval. This article aims to clarify what is specific about obtaining informed consent and ethical approval in laboratory medicine, to provide general guidance on informed consent and ethical approval requirements based on the type of study, and what information should be included in applications for ethical approval and informed consent. This could also provide some guidance for future contributors to the Biochemia Medica.

Social egg freezing under public health perspective: Just a medical reality or a women's right? An ethical case analysis.

In recent years, a social trend toward delaying childbearing has been observed in women of reproductive age. A novel technomedical innovation was commercialized for non-medical reasons to healthy, ostensibly fertile women, who wished to postpone motherhood for various reasons such as educational or career demands, or because they had not yet found a partner. As a consequence, these women may be affected by age-related infertility when they decide to conceive, and fertility preservation techniques can be obtained through the so-called social egg freezing. This paper examines, from an ethical point of view, the impact of social egg freezing under some aspects that can involve policy making and resources allocation in public health. Due to the increasing demand for this procedure, some debated issues regard if it is reasonable to include social egg freezing in Public Healthcare System and consequently how to manage the storage of cryopreserved oocytes also from individual donors, how to support these egg banks and how to face, in the future, with the possibility that egg freezing will play a role in enabling childbearing for gays, lesbians, and unmarried persons. Social freezing may be advertised to harmonise gender differences, but we wonder if it is the proper solution to the problem or if it could also create further challenges. An ethical argumentation on these topics should address some questions that will be discussed.