South African Medical Journal - September 2023 Vol 113 No 9

Introduction

Failure to obtain informed consent – is it a criminal o­ffence?

The practice of obtaining informed consent has its history rooted in medicine and medical research, in terms of which disclosure of information as well as withholding of certain information occurs daily. South African (SA) law has various instruments that specifically provide for the right to informed consent. The Constitution is the first port of call. Section 12 states that ‘Everyone has the right to bodily and psychological integrity, which includes the right – to make decisions concerning reproduction; to security in and control over their body; and not to be subjected to medical or scientific experiments without their informed consent’. The National Health Act No. 61 of 2003 makes it abundantly clear in terms of section 7 that a health service may not be provided to a patient without the patient’s informed consent, subject to section 8 and the subsections of section 7. SA case law also highlights the importance of informed consent. McQuoid Mason refers to Smith, who observes that ‘obtaining proper informed consent is usually regarded as a time-consuming task that is a diversion from the work for which a surgeon is uniquely qualified. He goes on to say that it is abundantly clear in law that there is a definite obligation on the part of the healthcare practitioner to ensure that informed consent is obtained from a patient before operating on him/her.

What doctors should know when working with surrogate decision-makers who disagree with their treatment plans

What should medical practitioners do if a lawfully appointed surrogate decision-maker wishes to decide on a course of action for a mentally incompetent patient that is against the patient’s best interests? For instance, in the following situations: 

(i) There is no advance directive, and a decision to withhold or undertake treatment is made by the surrogate decision-maker on religious grounds. 

(ii) The medical practitioners are of the opinion that the surrogate decision-maker’s decision is not in the best interests of the patient. 

(iii) The close relatives of the patient do not agree with the decision by the surrogate decision-maker. 

(iv) The surrogate decision-maker asks the medical practitioners to undertake treatment or a procedure on the patient that is unlawful or unethical.

Causation of term perinatal hypoxic-ischaemic basal ganglia and thalamus injury in the context of cerebral palsy litigation: Position statement

Basal ganglia and thalamus (BGT) hypoxaemic ischaemic injury is observed on magnetic resonance imaging in the CP-affected child. It usually involves not only the BGT, but also a cluster of structures including the perirolandic cortex, giving a BGT-pattern injury. The tissues in this cluster are highly metabolically active, and thus vulnerable at term to sudden-onset severe ischaemia, where the brain has insufficient time to autoregulate and redirect blood flow. In the context of hypoxia-ischaemia, BGT pattern injury has been termed ‘acute profound’, reflecting the suddenness and severity of the insult. A less severe insult, with a ‘prolonged partial’ injury, involves gradual-onset ischaemia that damages the cortical watershed areas, sparing the BGT. With acute profound asphyxia, BGT injury may occur in as little as 10 minutes from onset of the acute insult, allowing no time for effective obstetric intervention.

Utilisation and optimisation of beta-adrenergic receptor blockers over a 6-month period among chronic heart failure patients with reduced ejection fraction

Heart failure (HF) continues to be a worldwide growing problem owing to an increasing elderly population and comorbidity. HF affects >26 million people worldwide, and significantly contributes to the global burden of cardiovascular disease. The burden of HF has been growing in sub-Saharan African countries over the past decades, and Zambia has not been exempted. Despite the associated morbidity and mortality, there have been notable advances in the management of HF. The growing body of knowledge has shown a decrease in HF-associated morbidity and mortality after implementation of evidence-based guidelines for management of HF. However, HF remains a major cause of morbidity and mortality owing to a number of factors such as polypharmacy, comorbidities, advanced age and lack of proper titration of doses of evidence-based beta-blockers (EBBBs) in line with recommended guidelines.

Further evidence of misclassi cation of injury deaths in South Africa: When will the barriers to accurate injury death statistics be removed?

Although South Africa (SA) has a high burden of injury mortality, official mortality statistics in SA do not necessarily provide an accurate profile of the causes of injury deaths. In order to code an injury cause accurately, the manner of death and intent of the injury are essential. Intentional injuries include homicide and suicide, and unintentional injuries include any inadvertent causes. When the intent is not reported for a firearm injury, International Statistical Classification of Diseases, 10th revision (ICD-10) coding guidelines specify that these injuries are coded as unintentional. While this may be a reasonable assumption for countries where unintentional injuries predominate, it is not necessarily appropriate for countries with high levels of violence. Alignment to the international ICD-10 guidelines was not possible, as SA legislation does not allow for reporting the manner of death on the medical certificate of cause of death. As a result, official injury mortality statistics are likely to over-estimate accidental injuries and under-estimate homicide and suicide, limiting public health planning and monitoring of interventions for injury prevention in a country known to have an extremely high burden of injuries.

Longitudinal data resource from the Wellbeing of Older People cohort of people aged >50 years in Uganda and South Africa from 2009 to 2019

The number of older people living with HIV continues to increase globally. This is mainly due to the introduction of antiretroviral drugs, which have improved the survival of people living with HIV, and due to populations of older people who are acquiring new HIV infections. As of 2020, an estimated 21% of all people living with HIV, >6.5  million people, were aged ≥50 years. Most of these older people living with HIV reside in sub-Saharan Africa. Despite the increase in the number of older people living with HIV, there are limited reliable data on HIV and ageing in the African region. Reliable data on HIV and ageing, and how these individually and combined affect the health of older people in low- and middle-income countries, will provide knowledge about health and social needs and facilitate interventions for improved health maintenance as people age. Longitudinal research in multiple settings has provided reliable data about the health and wellbeing of older people with and without HIV within Africa, with results that can be used for effective planning for both health and social programmes for this ageing population.

Perinatal outcome of maternal deaths at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa, January 2014 - June 2019

Maternal mortality is still a global challenge, with the maternal mortality ratio (MMR) in low- and middle-income countries (LMICs) at least 14 times greater than in high-income countries (HICs). The full impact of maternal deaths on families and communities has yet to be fully understood, with minimal research in this field. The global MMR came down from 342 to 211 deaths per 100 000 live births between 2000 and 2017. This represents a 38% reduction in the global MMR, with an estimated 2.9% annual decrease. Data collected by the World Health Organization (WHO) show that 99% of maternal deaths occur in LMICs, especially in Africa. In the 2017 - 2019 Saving Mothers and Babies report, the MMR in South Africa (SA) was 154 per 100 000 live births in the 2014 - 2016 triennium and 113.8 per 100 000 in the 2017 - 2019 triennium.

Prevalence of comorbid disease and associated risk factors among homeless people living in temporary shelters during the COVID-19 lockdown in Tshwane, South Africa

Homelessness is a complex issue that is estimated to affect >200 000 South Africans. There are many definitions for homelessness, but for this study we focused on street dwellers who have no access to a roof or shelter, live and sleep on the streets for various reasons, and have done so for any length of time. Homelessness is both a contributor to and a consequence of poor health, and people experiencing homelessness have a mortality risk three to six times greater than the general population. The influences that homelessness and health have on each other operate through various reinforced mechanisms that make people experiencing homelessness one of the most socially and medically vulnerable populations. In most studies, it has been reported that respiratory diseases, mental illness, infectious diseases and poor dental health are highly prevalent in this population. A study by Bowen et al. supports these findings and reported an increased prevalence of substance dependence and hepatitis C (HCV) in the homeless population. In addition, many people who experience homelessness suffer from multimorbidity, which increases their risk of experiencing poorly co-ordinated care. This lack of co-ordination compromises the quality of care received, increases healthcare costs, and leads to poor clinical outcomes. In most cases, these conditions tend to interact and therefore affect the long-term course of disease and the prognosis of the individual.

Time to thrombolysis and factors contributing to delays in patients presenting with ST-elevation myocardial infarction at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa

Acute coronary syndrome (ACS) is a public health burden that is on the rise owing to epidemiological transition and urbanisation that have led to an increased prevalence of non-communicable diseases such as hypertension, dyslipidaemia and obesity. Cardiovascular disease is now the second most common cause of death in most African countries, with mortality rates of 165.3 per 100 000 for white and 5.3 per 100 000 for black South Africans. Ischaemic heart disease ranked 8th for natural causes of death among adults, 5th for the age group >65 years and 7th in Gauteng Province, according to figures for South Africa (SA) for 2018.