Barriers and perceptions regarding code status discussion with families of critically ill patients in a tertiary care hospital of a developing country: A cross-sectional study.

BACKGROUND: In Asian societies including Pakistan, a complex background of illiteracy, different familial dynamics, lack of patient's autonomy, religious beliefs, and financial constraints give new dimensions to code status discussion. Barriers faced by physicians during code status discussion in these societies are largely unknown. AIM: To determine the barriers and perceptions in discussion of code status by physicians. DESIGN: Questionnaire-based cross-sectional study. SETTING AND PARTICIPANTS: This study was conducted in the Department of Medicine of The Aga Khan University Hospital, Karachi, Pakistan. A total of 134 physicians who had discussed at least five code statuses in their lifetime were included. RESULTS: A total of 77 (57.4%) physicians responded. Family-related barriers were found to be the most common barriers. They include family denial (74.0%), level of education of family (66.2%), and conflict between individual family members (66.2%). Regarding personal barriers, lack of knowledge regarding prognosis (44.1%), personal discomfort in discussing death (29.8%), and fear of legal consequences (28.5%) were the top most barriers. In hospital-related barriers, time constraint (57.1%), lack of hospital administration support (48.0%), and suboptimal nursing care after do not resuscitate (48.0%) were the most frequent. There were significant differences among opinions of trainees when compared to those of attending physicians. CONCLUSION: Family-related barriers are the most frequent roadblocks in the end-of-life care discussions for physicians in Pakistan. Strengthening communication skills of physicians and family education are the potential strategies to improve end-of-life care. Large multi-center studies are needed to better understand the barriers of code status discussion in developing countries.

Chronic presentation of Boerhaave's syndrome.

BACKGROUND: Spontaneous rupture of the esophagus (Boerhaave's syndrome) is a rare, well-defined clinical syndrome caused by a longitudinal perforation of the esophagus. It is a life-threatening condition that necessitates rapid diagnosis and treatment. Patients typically present acutely with a history of vomiting followed by chest or abdominal pain. However, the diagnosis may be difficult or missed when patients present with chronic symptoms that mimic other conditions. CASE PRESENTATION: In this report, we present a unique case of Boerhaave's syndrome in a 53-year-old male patient. In contrast to the more common acute presentation, our patient developed non-specific symptoms in association with an intrathoracic cyst. In this report, we will also review the usual presenting signs, symptoms, and treatment of Boerhaave's syndrome. CONCLUSION: Our emphasis in this paper will be on the importance of recognizing and diagnosing Boerhaave's syndrome in an acute as well as a chronic state.

A case of pseudohyperkalemia in a patient presenting with leucocytosis and high potassium level: a Case Report.

Pseudohyperkalemia can appear in a variety of settings and should be recognized early. Treatment of pseudohyperkalemia can lead to an inappropriate decrease of actual serum potassium levels which may lead to life threatening conditions. In the case presented, an 81-year-old male presented with massive leucocytosis and an extremely elevated potassium level. This case report emphasizes the importance of recognizing pseudohyperkalemia in a patient with a severely increased potassium and WBC level; such patients may be clinically asymptomatic or may have a normal ECG.