RESUMEN
INTRODUCTION: Stroke is a leading cause of morbidity and mortality globally. Endovascular mechanical thrombectomy is considered for patients with large vessel occlusion stroke presenting up to 24 hours from onset and is being increasingly utilized across diverse clinical contexts. Proactive consideration of distinctive ethical dimensions of endovascular thrombectomy (EVT) can enable stroke care teams to deliver goal-concordant care to appropriately selected patients with stroke but have been underexplored. METHODS: A narrative review with case examples was conducted. RESULTS: We explain and critically evaluate the application of foundational bioethical principles and narrative ethics to the practice of EVT, highlight key ethical issues that may emerge in neuroendovascular practice and develop an ethical framework to aid in the responsible use of EVT for people with large-vessel occlusive ischemic stroke. CONCLUSIONS: EVT for stroke introduces important ethical considerations. Salient challenges include decision-making capacity and informed consent, the telos of EVT, uncertainty, access to care, and resource allocation. An ethical framework focusing on combining patient values and preferences with the best available evidence in the context of a multidisciplinary care team is essential to ensure that the benefits of EVT are responsibly achieved and sustained.
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Procedimientos Endovasculares , Trombectomía , Humanos , Procedimientos Endovasculares/ética , Procedimientos Endovasculares/métodos , Trombectomía/métodos , Trombectomía/ética , Accidente Cerebrovascular/cirugía , Accidente Cerebrovascular/terapia , Accidente Cerebrovascular Isquémico/cirugía , Accidente Cerebrovascular Isquémico/terapia , Consentimiento Informado/éticaRESUMEN
[Figure: see text].
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Consentimiento Informado/ética , Ensayos Clínicos Controlados Aleatorios como Asunto/ética , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/terapia , Canadá/epidemiología , Procedimientos Endovasculares/ética , Procedimientos Endovasculares/normas , Humanos , Consentimiento Informado/normas , Ensayos Clínicos Controlados Aleatorios como Asunto/normasRESUMEN
Coronavirus disease 2019 (COVID-19) pandemic has struck many countries and caused a great number of infected cases and death. Healthcare system across all countries is dealing with the increasing medical, social, and legal issues caused by the COVID-19 pandemic, and the standards of care are being altered. Admittedly, neurology units have been influenced greatly since the first days, as aggressive policies adopted by many hospitals caused eventual shut down of numerous neurologic wards. Considering these drastic alterations, traditional ethical principles have to be integrated with state-of-the-art ethical considerations. This review will consider different ethical aspects of care in neurologic patients during COVID-19 and how this challenging situation has affected standards of care in these patients.
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COVID-19 , Procedimientos Endovasculares/ética , Enfermedades del Sistema Nervioso/terapia , Neurología/ética , Cuidados Paliativos/ética , Sistemas de Apoyo Psicosocial , Respiración Artificial/ética , Triaje/ética , HumanosRESUMEN
The emergency department is where the patient and potential ethical challenges are first encountered. Patients with acute neurologic illness introduce a unique set of dilemmas related to the pressure for ultra-early prognosis in the wake of rapidly advancing treatments. Many with neurologic injury are unable to provide autonomous consent, further complicating the picture, potentially asking uncertain surrogates to make quick decisions that may result in significant disability. The emergency department physician must take these ethical quandaries into account to provide standard of care treatment.
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Lesiones Traumáticas del Encéfalo/terapia , Cuidado Terminal/ética , Manejo de la Vía Aérea/ética , Manejo de la Vía Aérea/métodos , Beneficencia , Muerte Encefálica/diagnóstico , Lesiones Traumáticas del Encéfalo/diagnóstico , Servicio de Urgencia en Hospital/ética , Procedimientos Endovasculares/ética , Ética Médica , Humanos , Consentimiento Informado/ética , Pronóstico , Accidente Cerebrovascular/terapia , Obtención de Tejidos y Órganos/éticaAsunto(s)
Investigación Biomédica/tendencias , Implantación de Prótesis Vascular/tendencias , Prótesis Vascular/tendencias , Angiografía por Tomografía Computarizada/tendencias , Angiografía Coronaria/tendencias , Procedimientos Endovasculares/tendencias , Stents/tendencias , Técnicas de Sutura/tendencias , Animales , Investigación Biomédica/economía , Investigación Biomédica/ética , Prótesis Vascular/economía , Prótesis Vascular/ética , Implantación de Prótesis Vascular/economía , Implantación de Prótesis Vascular/ética , Implantación de Prótesis Vascular/instrumentación , Compensación y Reparación , Angiografía por Tomografía Computarizada/economía , Angiografía por Tomografía Computarizada/ética , Angiografía Coronaria/economía , Angiografía Coronaria/ética , Difusión de Innovaciones , Procedimientos Endovasculares/economía , Procedimientos Endovasculares/ética , Procedimientos Endovasculares/instrumentación , Humanos , Propiedad Intelectual , Patentes como Asunto , Diseño de Prótesis/tendencias , Stents/economía , Stents/ética , Técnicas de Sutura/economía , Técnicas de Sutura/ética , Técnicas de Sutura/instrumentaciónRESUMEN
BACKGROUND: The Endovascular Acute Stroke Intervention (EASI) trial was conceived as a pragmatic care trial, designed to integrate trial methods with clinical practice. Reporting the EASI experience was met with objections and criticisms during peer review concerning both scientific and ethical issues. Our goal is to discuss these criticisms in order to promote the pragmatic approach of care trials in outcome-based medical care. METHODS: The comments and criticisms of 11 reviewers from 5 journals were collected and analyzed. The EASI protocol was also compared to the protocols of seven thrombectomy trials using the pragmatic-explanatory continuum indicator summary (PRECIS). RESULTS: Main criticisms of EASI concerned selection criteria that were judged to be too vague and too inclusive, brain and vascular imaging methods that were not sufficiently prescribed by protocol, lack of blinding of outcome assessment, and lack of power. EASI was at the pragmatic end of the spectrum of thrombectomy trials. CONCLUSION: The pragmatic care trial methodology is not currently well-established. More work needs to be done to integrate scientific methods and ethical care in the best medical interest of current patients.
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Protocolos de Ensayos Clínicos como Asunto , Procedimientos Endovasculares/ética , Ética Clínica , Ética en Investigación , Revisión de la Investigación por Pares/ética , Publicaciones Periódicas como Asunto/ética , Proyectos de Investigación , Accidente Cerebrovascular/terapia , Trombectomía/ética , Procedimientos Endovasculares/efectos adversos , Humanos , Accidente Cerebrovascular/diagnóstico , Trombectomía/efectos adversos , Resultado del TratamientoAsunto(s)
Procedimientos Endovasculares/economía , Sector de Atención de Salud/economía , Ensayos Clínicos Controlados Aleatorios como Asunto/economía , Proyectos de Investigación , Apoyo a la Investigación como Asunto , Procedimientos Quirúrgicos Vasculares/economía , Sesgo , Bibliometría , Conflicto de Intereses , Procedimientos Endovasculares/ética , Sector de Atención de Salud/ética , Humanos , Ensayos Clínicos Controlados Aleatorios como Asunto/ética , Apoyo a la Investigación como Asunto/ética , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/éticaRESUMEN
Dr C. Lever is the undisputed expert in a new endovascular procedure he developed and brought to fruition over the years. Other professionals publishing their results call it by his name, although he has strictly avoided that nomenclature. Lever is at a medical center with several participating hospitals, which boast aggressive ultracompetitive marketing departments. His hospital wants to concentrate on him as proof that the best care is available at their facility. A successful campaign certainly would add to Lever's and perhaps to his group's referrals. He looks at the first advertisement and a Greek god would have been less vaunted but nothing said is untrue. What should he do? A. Ask that all advertising identifying him be discontinued immediately. B.Tell them to hype it up. C. Ask that marketing stick to the facts completely sans hype. D. Check with the Ethics Committee of the hospital. E. Check with the Ethics Committee of the American Medical Association (AMA) or American College of Surgeons or the appropriate surgical subspecialty professional association.
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Publicidad/ética , Procedimientos Endovasculares/ética , Comercialización de los Servicios de Salud/ética , Revelación de la Verdad/ética , Actitud del Personal de Salud , Comités de Ética Clínica , Humanos , Rol del MédicoAsunto(s)
Procedimientos Endovasculares , Esclerosis Múltiple , Ensayos Clínicos Controlados Aleatorios como Asunto , Insuficiencia Venosa , Enfermedad Crónica , Procedimientos Endovasculares/ética , Procedimientos Endovasculares/métodos , Procedimientos Endovasculares/tendencias , Humanos , Esclerosis Múltiple/diagnóstico , Esclerosis Múltiple/etiología , Esclerosis Múltiple/terapia , Ultrasonografía , Insuficiencia Venosa/diagnóstico , Insuficiencia Venosa/diagnóstico por imagen , Insuficiencia Venosa/terapiaRESUMEN
BACKGROUND: This paper describes existing inconsistencies as well as the disparate processes and logistics required when obtaining ethics approval in Australia and New Zealand in order to initiate a multi-centre bi-national surgical trial. METHODS: The endovascular aortic aneurysm repair trial is a large multi-centre trial that aims to obtain pre- and post-operative data from patients in hospitals across Australia and New Zealand. As the trial was research based, ethics applications were submitted to all hospitals where surgeons wished to be involved in the trial. RESULTS: Few ethics committees have embraced attempts to simplify the application process for multi-centre trials. There was limited mutual review between Human Research Ethics Committees necessitating the submission of multiple applications. Though the use of the National Ethics Application Form in ethical review is increasing, some Human Research Ethics Committees do not accept it in its entirety; many require site-specific applications or sections of the Common Application Form modules. CONCLUSIONS: Queensland, New South Wales and New Zealand were the easiest systems to prepare, submit and lodge ethics applications because of their understanding and accommodation of reviewing multi-centred trials. The time, expense and complexity of obtaining ethics approval for multi-centre research projects are impediments to their establishment and reduce the time available for research. Australia is working to implement a system named the Harmonisation of Multi-centre Ethical Review to ease the process of obtaining multi-centre ethics clearance. Our experience suggests there will be some teething problems with implementation and acceptance.