[Medicolegal aspects of tumor boards]. / Medizinrechtliche Aspekte von Tumorboards.

The presentation of tumor patients to tumor boards has widely developed into a medical standard. The necessary compliance to the medical standard can lead to obligatory presentation if the complexity of a case dictates that this cannot be comprehensively covered by a single treating physician. The organization of a tumor board must be so that the structure and specialist competence guarantees an adequate consultative function of the represented specialties. Tumor board members are not automatically promoted to become part of the treating team just by participation and therefore do not have a guarantor position but do have the obligation of care of a consulting physician. Tumor board decisions have a recommendation character, are not binding in the legal sense and do not relieve the treating physician from the obligation to critically scrutinize the recommendations before implementation. On the other hand the treating physician must be able to justify not following the recommendations on the basis of the medical obligation to care. The tumor board must fulfil the same requirements for documentation as any other consultative activity.

Nurses recovering from substance use disorders: a review of policies and position statements.

The authors review policy initiatives and professional organization position statements that hospital and nursing administrators should be familiar with to respond effectively to public and policy-maker concerns about substance use in healthcare settings. Detecting and addressing substance use disorders proactively and systematically are essential for 2 reasons: to protect patient safety and to enable healthcare professionals to recognize problems early and intervene swiftly. The authors identify key points and gaps in existing policy statements.

To detain or to release? Correlates of dispositions for individuals declared not criminally responsible on account of mental disorder.

OBJECTIVE: The extent to which risk assessment advances have influenced release decision-making by review boards (RBs) of individuals found not criminally responsible on account of mental disorder (NCRMD) remains unclear. Our objective is to identify the psychosocial, criminological, and risk measure correlates of RB decision-making. METHOD: Data were collected through structured interviews and file reviews conducted between October 2004 and August 2006 in the sole forensic psychiatric hospital in Quebec and in 2 civil psychiatric hospitals in a large metropolitan area designated to care for people found NCRMD. The final sample consisted of 96 men. RESULTS: Dynamic, clinical risk factors are associated with decisions to detain or release people found NCRMD, rather than traditional historical risk factors such as criminal history. CONCLUSION: Dynamic variables seem appropriate for the RBs to consider given the intention of the NCRMD legislation. Further, dynamic variables provide direction for titration of treatment and supervision. Results are discussed regarding enhancing evidence-informed RB dispositions.

'Mental health is everybody's business': roles for an intersectoral approach in South Africa.

Intersectoral action is increasingly recognized as necessary to address the social determinants of mental health. This study aims to assess South Africa's progress in intersectoral collaboration for mental health, and provide recommendations for intersectoral collaboration, to generate lessons for other low- and middle-income countries. We conducted a survey of the existing mental health system in South Africa using the World Health Organization Assessment Instrument for Mental Health Systems. We also conducted 96 semi-structured interviews and 12 focus group discussions with a range of stakeholders at national, provincial and district level. Data were analysed thematically to understand the roles and responsibilities of different sectors in realizing the right to mental health. A range of key sectors were identified as having roles in mental health promotion, illness prevention and service delivery. In discussing South Africa's progress, respondents gave several suggestions about how to formulate an intersectoral response in this context, including increasing high level political commitment, and using leadership from the health sector. We outline roles and responsibilities for various sectors and lessons that can be learnt from this context. These include the importance of developing programmes alongside legislation, employing targeted awareness-raising to engage sectors, and developing a structured approach to intersectoral action.

[Possibilities of medical opinionating in cases associated with "exposure to direct danger of death or serious health damage"]. / Mozliwosci opiniowania lekarskiego w sprawach o "narazenie na bezposrednie niebezpieczenstwo utraty zycia lub ciezkiego uszczerbku na zdrowiu".

In the opinion of some forensic medicine experts, assessment of potential consequences in keeping with Article 160 of the Polish Penal code, which refers to the crime of "exposure to direct danger of death or severe health damage", lies within the competence of medicolegal specialists. This view is accepted by courts and prosecution offices. However, the knowledge of physicians in the field of predicting consequences which did not occur is only somewhat better than that of lawyers. In simple cases, e.g. in trauma involving a sensitive area of the body, passing an opinion confirming a serious danger is not associated with any major problems. Similarly, no problems arise when passing an opinion on the lack of such a danger e.g. in the case of traumawithout any injuries. In complex cases, however, which include the majority of medical error cases, passing an opinion on exposure to direct danger of death or severe health damage may be not feasible.

[Medico-legal opinion in establishing "exposure to direct danger of death or grave detriment to health"]. / Opiniowanie sadowo-lekarskie a ustalanie "narazenia na bezposrednie niebezpieczenstwo utraty zycia lub ciezki uszczerbek na zdrowiu".

This paper deals with the problem of competence of the forensic expert opinions on the exposure to "direct danger of death or grave detriment to health". According to the analysis of judicial verdicts and the comments of lawyers "direct danger" depends closely on the probability, time and number of occurrences between the behavior of the perpetrator and the threatening act. The competence of the forensic expert does not allow for the legal qualification of the act but for the assessment of from the medicolegal point of view, defining the threat and possible outcomes in a descriptive fashion. The assessment of "direct danger" should be the result of close cooperation between the judicial representative and forensic expert.

O papel das comissões de controle de infecções hospitalares / The role of the infection-control commitee

A infecção hospitalar é importante problema de saúde pública. Exigências legais reforçam o interesse pelo estabelecimento de programas de controle. Dados coletados sistematicamente, analisados e devolvidos para o corpo clínico, fazem com que todos se motivem para enfrentar seriamente o problema. Diante da necessidade de se conhecerem indicadores, melhorar a prática assistencial, padronizar medicamentos e materiais médico-hospitalares, realizar educação continuada, elaborar guias e protocolos e gerenciar "pela qualidade", equilibrando múltiplos interesses divergentes, enquadram-se as Comissões de Controle de Infecções Hospitalares - comitês de profissionais constituídos de uma equipe multidisciplinar. Urge que se redefina o termo infecção hospitalar para mantê-lo coerente com o seu significado atual. A idéia que ele traduz é a de infecção relacionada à assistência - onde quer que ela seja prestada. Cabe à CCIH conhecer a epidemiologia da instituição, controlar infecção cruzada e manter programa que promova a melhoria da qualidade assistencial e educacional: a proteção do paciente e circunstantes; a redução dos custos da assistência, financeiro e social: da dor, sofrimento, agravos psicológicos e morte. As CCIH, em integração com a Vigilância Sanitária, poderão transformar o momento da vistoria do estabelecimento em salutar troca de educação em saúde. O esforço ,dessas duas instâncias poderá ser potencializado, no sentido de alcançarem a efetividade para a melhoria da qualidade assistencial no município de Belo Horizonte. É fundamental que todos os profissionais entendam que a prevenção e o controle de infecções são questão de cidadania e direitos humanos: dependem muito mais deles próprios do que das leis que se lhes impõem. A transformação da organização é responsabilidade de todos.

Nosocomial infection is an important public health problem. Legal requirements enforces the expectation that hospitals establish formal infection control programs. Systematically collected and analyzed data on cross-infection rates showed to clinicians motivates everybody to seriously address the problem. Since it is necessary to know outcomes, to improve the quality of health care, to standardize medicines and medical supplies and equipments, to perform continuous education, to make guidelines and to manage using continuous quality improvement tools - balancing many different wishes, the infection control committee is established - being a multidisciplinary teamwork. It is high time to make the words hospital infection more understandable to present days! It means infection associated to the health care - wherever it is provided. The professional staff committees must know the epidemiology of the medical center, take prevention measures and perform a program to enhance the quality of health care and health education, to protect patients and stand-bys, to reduce health care financial and social costs; and the pain, distress, psychological harms and death. The infection control committee and the health surveillance team can exchangeknowledge on health education during the e latter work on accreditation of hospitals. In would function as a task force to improve the quality of health care in the city of Belo Horizonte. It is a key point to understand that prevention and control of nosocomial infections is much more a matter of citizenship and human rights than that of legal issues. The transformation of the organization is everybody's job!

Antropología, Teología y Etica del sufrimiento / Antropology, Teology and Ethics of suffering

El sufrimiento es experimentado por personas, no sólo por cuerpos, y tiene su origen en una amenaza a la pérdida de la integridad de la persona como ente social, psicológico y espiritual. Como cualquier situación - límite, produce conflictos internos y aislamientos del sufriente, generador de más sufrimiento a su vez. Se revisa el concepto y el significado del sufrimiento en las distintas culturas dado que las mismas han buscado dar una explicación al porqué de su presencia en el mundo a lo largo de los tiempos y, en lo posible, un camino hacia el alivio, sea por la aceptación o el descubrimiento de un significado. Si entre las metas de la medicina está el alivio del sufrimiento humano, esto debería incluir la comprensión y, de ser posible, el alivio del componente espiritual del sufrimiento, lo que implica entenderlo también desde lo cultural y lo religioso, ya que una intervención exclusivamente técnica, aún la más adecuada y avanzada, puede fallar en su intento de aliviarlo...

When do medical students become human subjects of research? The case of program evaluation.

Intense national dialogue exists around federal requirements protecting the rights of human subjects in clinical research. There is much less discussion surrounding protections for human subjects in such areas as evaluation research when the subjects are also students. Differential interpretation of 45 CFR 46 (the standing regulation on research involving human subjects) by institutional review boards (IRBs) leaves many confused about whether research using student data requires IRB review. At the heart of the uncertainty are "dual purpose activities," for example, when student data from program evaluation or routine assessments subsequently become the basis for faculty scholarship that is disseminated as "generalizable knowledge" to the community of medical educators. The authors identify two factors that should be considered as institutions develop applications and interpretations of 45 CFR 46. First, medical educators should enter into dialogues with their IRBs to become more familiar with these regulations and their application in evaluation or assessment studies. Second, for reasons of professionalism, faculty should seek opportunities to model in their role as researchers those ethical behaviors that are central to an honest relationship between physician and patient. In the educational context this means faculty disclosure of how student data may be used by faculty in their own scholarship and determination of when student consent is needed. The authors also describe how one medical school addressed this thorny challenge with assistance from the university IRB and offer suggestions to improve institutional procedures.