Impact of the Human Microbiome in Forensic Sciences: a Systematic Review.

Numerous studies relate differences in microbial communities to human health and disease; however, little is known about microbial changes that occur postmortem or the possible applications of microbiome analysis in the field of forensic science. The aim of this review was to study the microbiome and its applications in forensic sciences and to determine the main lines of investigation that are emerging, as well as its possible contributions to the forensic field. A systematic review of the human microbiome in relation to forensic science was carried out by following PRISMA guidelines. This study sheds light on the role of microbiome research in the postmortem interval during the process of decomposition, identifying death caused by drowning or sudden death, locating the geographical location of death, establishing a connection between the human microbiome and personal items, sexual contact, and the identification of individuals. Actinomycetaceae, Bacteroidaceae, Alcaligenaceae, and Bacilli play an important role in determining the postmortem interval. Aeromonas can be used to determine the cause of death, and Corynebacterium or Helicobacter pylori can be used to ascertain personal identity or geographical location. Several studies point to a promising future for microbiome analysis in the different fields of forensic science, opening up an important new area of research.

Age and education as factors associated with medication literacy: a community pharmacy perspective.

BACKGROUND: Aging implies a higher prevalence of chronic pathologies and a corresponding increase in medication. The correct adherence and use of the medication are prerequisites for reducing risks of disease progression, comorbidity, and mortality. Medication literacy (ML) is the specific ability to safely access and understand the information available concerning medication, and to act accordingly. Currently, there are few specific instruments that ascertain the extent of ML in the general population. The aim of this work was to analyse ML in a large cohort of pharmacy customers. METHODS: A total of 400 community pharmacy clients were analyzed to assess the level of ML (documental and numeracy) through the validated MedLitRxSE tool. RESULTS: The results showed that out of a total of 400 community pharmacy clients only 136 (34%) had an adequate degree of ML, while the rest of the clients (n = 264; 66%) were adjudged not to have this ability. Statistically significant differences were found between the different age groups in terms of ML (P < 0.001; OR = 0.312; 95% CI: 0.195-0.499), the 51-65 and >65-year age groups having a lower frequency of adequate ML (23.5 and 7.1%, respectively) than the rest of the age groups. A statistically significant increase in adequate ML was observed as the academic level of the clients increased (P < 0.001; OR = 15.403; 95% CI: 8.109-29.257). Multivariate logistic regression confirmed the influence of both variables on ML. CONCLUSIONS: An inadequate ML level was found in community pharmacy clients over the age of 51, and also in those with primary or non-formal studies. Our data add to our knowledge about ML, and should pharmacists and other health professionals to adopt new strategies to prevent, or at least reduce, errors in taking medicines, thus avoiding the undesirable effects of any misuse.

Combined determination of B-type natriuretic peptide and high-sensitivity troponin I in the postmortem diagnosis of cardiac disease.

Cardiac disease is the most common cause of sudden death in Western countries. It is known that high-sensitivity troponin I (hs-cTnI), widely used for detection of myocardial injury, is a sensitive biochemical marker. B-type natriuretic peptide (BNP) is a reliable tool for diagnosing heart failure, and for establishing prognosis or disease severity. We aimed to evaluate the diagnostic efficacy of the postmortem determination of BNP in serum alone or in addition to other biomarkers, such as hs-cTnI and MB isoenzyme of creatine kinase (CK-MB), to ascertain whether its determination improves the post-mortem diagnosis of heart failure-associated causes of death. This study involved 133 cadavers with a mean age of 58.2 (± 17.6) years and a mean postmortem interval of 12.8 (±6.6) h. Cases were assigned into two diagnostic groups, according to the cause of death: cardiac deaths (N = 62) and control (N = 71). In the cardiac group, two categories were established according to morphological features of the heart: 'ischemic deaths' (N = 39), and 'congestive heart' (n = 23). Both hs-cTnI and BNP were useful in diagnosing cardiac deaths, whereas CK-MB did not have any diagnostic relevance. hs-cTnI is higher in cases which acute ischemia as the principal pathology, while the presence of high BNP values is significantly related with chronic cardiac situations with significant ventricular overload. Our findings show that postmortem determination of hs-cTnI and BNP provides valuable information; hs-cTnI is useful for diagnosis of cardiac deaths, mainly with ischemic implications, and BNP gave better results for the diagnosis of congestive heart failure.

Caesarean delivery: conflicting interests.

Within the maternal-fetal relationship, interests may sometimes diverge. In this paper, a pregnant woman's refusal to undergo a caesarean delivery, which was recommended both to save the life of the fetus and to minimize risks to her, is described. The legal aspects involved in the conflict between maternal autonomy and fetal well-being are analysed. The patient requested an abortion because of the poor condition of the fetus; however, according to Spanish legislation, the possibility of abortion was rejected as the pregnancy was in its 27th week. The woman still persisted in her refusal to accept a caesarian delivery. After the medical team sought guidance on the course to follow, the Duty Court authorized a caesarean delivery against the wishes of the patient. From a legal point of view, at stake were the freedom of the woman - expressed by the decision to reject a caesarean delivery - and the life of the unborn child. In clinical treatment, the interests of the fetus are generally aligned with those of the pregnant woman. When they are not, it is the pregnant woman's autonomy that should be respected, and coercion should form no part of treatment, contrary to the decision of this court.

Involvement and Autonomy of Minors in Medical Settings: Perceptions of Children Undergoing Surgery and Parents.

Informed consent presupposes competence and represents a formal decision by an informed person who has the legal capacity to accept medical action or participate in research. Our aim was to analyze the perceptions of minors and their parents about the age at which they consider that a minor is competent for making health decisions. A descriptive observational study was carried out in 302 minors between 12 and 17 years of age undergoing elective surgery, and 302 parents (range 30 to 62 years). Two semistructured questionnaires were designed, one for the minors and the other, for the parents. A total of 20.1% of minors and 31.1% of parents believe that patients should not make decisions related to their health until they are 18 years old. A total of 74.9% of the minors surveyed consider that from 16 years of age, the minor is empowered to make decisions. In parents, this percentage is 60%. In the pediatric setting, each case and situation must be examined individually to determine if the minor meets the condition of maturity to decide. The ideal is to promote the minor's participation in decision-making, giving them the opportunity to participate in the process in a manner appropriate to their capacity.

A COVID Dilemma: How to Manage Pregnancies in Case of Severe Respiratory Failure?

To date, the impact of the COVID-19 pandemic on the world's health, economics and politics is still heavy, and efforts to mitigate virus transmission have caused remarkable disruption. From the early onset of the pandemic, generated by SARS-CoV-2 spread, the scientific community was aware of its impact on vulnerable individuals, including pregnant women. The purpose of this paper is to highlight scientific pitfalls and ethical dilemmas emerging from management of severe respiratory distress in pregnant women in order to add evidence to this topic through an ethical debate. In the here-presented paper, three cases of severe respiratory syndrome are analyzed. No specific therapeutic protocol was available to guide physicians in a cost-benefit balance, and unequivocal conduct was not a priori suggested from scientific evidence. However, vaccines' advent, viral variants lurking on the horizon and other possible pandemic challenges make it necessary to maximize the experience gained through these difficult years. Antenatal management of pregnancies complicated by COVID-19 infection with severe respiratory failure is still heterogeneous and ethical concerns must be pointed out.

Occupational Exposure to Inhalational Anesthetics and Teratogenic Effects: A Systematic Review.

(1) Background: In the current healthcare environment, there is a large proportion of female staff of childbearing age, so, according to existing conflicting studies, the teratogenic effects that inhalational anesthetics may have on exposed pregnant workers should be assessed. This investigation aims to analyze the teratogenic effects of inhalational anesthetics in conditions of actual use, determining any association with spontaneous abortion or congenital malformations. (2) Methods: A systematic review was carried out according to the PRISMA statement based on PICO (problem of interest-intervention to be considered-intervention compared-outcome) (Do inhalational anesthetics have teratogenic effects in current clinical practice?). The level of evidence of the selected articles was evaluated using the SIGN scale. The databases used were PubMed, Embase, Scopus, Web of Science, Google academic and Opengrey. Primary studies conducted in professionals exposed to inhalational anesthetics that evaluate spontaneous abortions or congenital malformations, conducted in any country and language and published within the last ten years were selected. (3) Results: Of the 541 studies identified, 6 met all inclusion criteria in answering the research question. Since many methodological differences were found in estimating exposure to inhalational anesthetics, a qualitative systematic review was performed. The selected studies have a retrospective cohort design and mostly present a low level of evidence and a low grade of recommendation. Studies with the highest level of evidence do not find an association between the use of inhalational anesthetics and the occurrence of miscarriage or congenital malformations. (4) Conclusions: The administration of inhalational anesthetics, especially with gas extraction systems (scavenging systems) and the adequate ventilation of operating rooms, is not associated with the occurrence of spontaneous abortions or congenital malformations.

The role of a professional dental organization in the resolution of malpractice claims the professional dentist college in the region of Murcia (Spain).

The aim of this paper is to study the role of a professional dental organization in the resolution of malpractice claims in Murcia (southeast of Spain). We analysed all the claims presented to the College of Dentists during the last sixteen years (n = 84). Professional behaviour was demonstrated as adequate in 29 cases and as malpractice in 55 (32 cases were considered technically correct but with information failures and in 23 cases technical errors were observed). The written informed consent was absent in 40 cases, although information was supplied verbally in 30 cases of the 40. The distribution of the dental interventions performed in the claim cases was: surgery, 20 cases (23.80%), prosthetic, 36 cases (42.85%) and endodontic, 28 cases (33.33%). Only in 22 cases (26.19%) was a final agreement reached between the parties. The Dental College could improve these results, acting as a real arbitral court and minimizing the problems for professionals and the claimers.

Diagnostic Application of Postmortem Cardiac Troponin I Pericardial Fluid/Serum Ratio in Sudden Cardiac Death.

In approximately 5% of unexpected deaths, establishing a conclusive diagnosis exclusively on the basis of anatomo-pathological findings in a classic autopsy is difficult. Postmortem biomarkers have been actively investigated as complementary indicators to help to reach valid conclusions about the circumstances of death. Several studies propose either the pericardial fluid or peripheral veins as a location for troponin determination, but the optimum sampling site is still a matter of debate. Our objective was to evaluate the association between the ratio of troponin values in the pericardial fluid and serum (determined postmortem) and the diagnosis of acute myocardial infarction (AMI) in the context of sudden cardiac death. We included 175 forensic cases. Two groups were established: AMI deaths (48; 27.4%) and the control group (127; 72.6%). The cardiac Troponin I (cTnI) values in the pericardial fluid and the troponin ratio were found to be associated with the cause of death. Univariate regression analyses showed that both age and the cTnI ratio were significantly associated with the diagnosis of AMI death. In a multivariate analysis, adjusting for confounding factors, the age and cTnI ratio were independent predictors of death from myocardial infarction. We performed a receiver operating characteristic (ROC) curve for the cTnI ratio for AMI death and selected a cut-off point. Our biomarker was found to be a valuable and highly effective tool for use in the forensic field as a complementary method to facilitate diagnosis in nonconclusive autopsies.

Pretransplant ascites and encephalopathy and their influence on survival and liver graft rejection in alcoholic cirrhosis disease.

INTRODUCTION: The Child-Pugh and model for end-stage liver disease (MELD) scores are widely used to predict the outcomes of liver transplant (LT). Both have similar prognostic values in most cases, although their benefits might differ in some specific conditions. The aim of our study was to analyze the influence of pre-transplant ascites and encephalopathy in post-transplant liver rejection development and survival in alcohol cirrhosis (AC) patients undergoing LT to determine the usefulness of the Child-Pugh score for the assessment of prognosis in such patients. MATERIAL AND METHODS: Two hundred and eighty-one AC patients, classified according to viral infections and pre-transplant complications, were analyzed. Acute (AR) and chronic (CR) liver rejections and Child-Pugh, MELD and albumin-bilirubin (ALBI) scores were studied in all cases. RESULTS: Similar AC rejection percentages were observed in ascites or encephalopathy groups (18.5% and 16.5%, p = 0.735), although a higher but not statistically significant AC rate was observed in patients with grade III ascites (p = 0.777) and with grade II encephalopathy (p = 0.089). Chronic rejection was only developed by 9.1% of AC patients, regardless of the presence of ascites (6.2%) or encephalopathy (5.5%). The presence of ascites and encephalopathy complications did not seem to influence post-transplant survival. Neither the Child-Pugh nor the ALBI score can be considered the best for predicting patient survival in the short or long term. CONCLUSIONS: Ascites and encephalopathy do not seem to influence AC or CR in patient survival, regardless of the presence of viral infections, so in our study neither the Child-Pugh nor ALBI score seems to be the best score to predict the outcomes of these patients.

KIR2DL2/S2 and KIR2DS5 in alcoholic cirrhotic patients undergoing liver transplantation.

INTRODUCTION: The molecular mechanisms underlying alcoholic liver fibrosis and cirrhosis are not completely understood. Hepatic fibrosis involves the interplay of diverse cells and factors, including hepatic stellate cells (HSCs), Kupffer, NK cells, and T-lymphocyte subsets. Killer-cell immunoglobulin-like receptors (KIR) are membrane receptors involved in mediation between NK and activated HSCs, regulating NK cell function through their interaction with HLA-I molecules. The aim of this study was to analyse the genetic association between KIR genes and the susceptibility to or protection from alcoholic cirrhosis (AC) in a cohort of male AC patients undergoing liver transplantation (LT) with and without concomitant viral infections. MATERIAL AND METHODS: KIR genotyping was performed in nuclear DNA extracted from 281 AC patients and compared with 319 male controls. RESULTS: Significant differences between total AC patients and healthy controls were only found in the case of KIR2DL2 and KIR2DS5. KIR2DL2 was significantly underrepresented in non-viral AC patients (52.6% vs. 63.3%; p = 0.015), while patients heterozygous for KIR2DL2 were also underrepresented in the non-viral AC group compared with controls (p = 0.034). KIR2DS5 was overrepresented in this group compared with healthy controls (p = 0.002). All these observations were only evident in AC patients older than 54 years old. CONCLUSIONS: Our data suggest a contrary effect of KIR2DL2 and KIR2DS5 in AC patients older than 54 years, in whom the presence of KIR2DL2 appears to be protective against AC, whereas the presence of KIR2DS5 seems to promote the fibrotic process, particularly in patients with no associated viral infection.

Legal protection of informed consent of minors.

One of the pillars of healthcare provision is respect for the autonomy of the patient's wishes, which is given substance by the process of obtaining informed consent. Minors deserve special protection, entitled to basic rights and increasingly autonomous as they develop. In certain situations, minors are deemed matures and able to consent to treatment without the involvement of a parent or guardian. The assessment of competence would be based on the child's functional ability, not on age or outcome of the decision. This manuscript includes a brief analysis of legal perspectives on informed consent of minors, and minors' capacities to make medical decisions. Remaining questions of how to evaluate capacity and balance parental and minor autonomy are explored. Considerations on informed consent in different situations as refusing treatment and termination of pregnancy by female children are analyzed.

The phenomenon of physical aggression against health service personnel: different perspectives.

The doctor-patient relationship has undergone important changes in recent years. Increasing levels of distrust on the part of patients toward professionals and institutions have led to an increase in the number of conflicts that end in violent actions against health service personnel. The aim of this study is to analyse this phenomenon in the public welfare services of the Region of Murcia (Spain), based on an analysis of accusations presented by doctors in the courts between 2006 and April 2008. The conclusion reached in this study can presumably be extrapolated to the rest of Spain. The violent reactions in question resulted from patients demanding drug prescriptions, the prolongation of sick leave and the demand for diagnostic tests. The Public Health Services provide directives for the anticipation of and abstention from such situations, emphasize the training of professionals in communication skills, the promotion of skills of negotiation and emotional self-control. Other measures include the installation of alarms, intercoms and video cameras, contracting security companies, collaboration with the police and posters in health facilities warning that legal action will be taken. Nevertheless, given the obvious inadequacy of the above mentioned measures Plans of Prevention have been put in place. In addition legal defence has been granted to all such professionals. From a judicial point of view, these aggressions are judged as minor crimes of injury or insult. The most recent view taken on such conduct is to consider it as a crime of attempt or an offence against the authority, which has been confirmed in law by the recent judgment passed down by the Spanish High Court on 4th December, 2007.

Proteomics in Deaths by Drowning: Diagnostic Efficacy of Apolipoprotein A1 and α-1Antitrypsin, Pilot Study.

Drowning is one of the leading causes of death worldwide. The pathophysiology of drowning is complex and, sometimes, interpretation of the circumstances of death in the autopsy becomes the main source of information in its diagnosis. New advances in medical research, such as proteomics, especially in forensic pathology, are still in the development. We proposed to investigate the application of Mass Spectrometry-based technologies, to identify differentially expressed proteins that may act as potential biomarkers in the postmortem diagnosis of drowning. We performed a pilot proteomic experiment with the inclusion of two drowned and two control forensic cases. After applying restrictive parameters, we identified apolipoprotein A1 (ApoA1) and α-1 antitrypsin as differentially expressed between the two diagnostic groups. A validation experiment, with the determination of both proteins in 25 forensic cases (16 drowned and 9 controls) was performed, and we corroborated ApoA1 higher values in the drowning group, whereas α-1 antitrypsin showed lower levels. After adjusting by confounder factors, both remained as predictive independent factors for diagnosis of drowning (p = 0.010 and p = 0.022, respectively). We constructed ROC curves for biomarkers' levels attending at the origin of death and established an ApoA1 cut-off point of 100 mg/dL. Correct classification based on the diagnosis criteria was reached for 73.9% of the cases in a discriminant analysis. We propose apolipoprotein A1 (with our cutoff value for correct classification) and α-1 antitrypsin as valuable biomarkers of drowning. Our study, based on forensic cases, reveals our proteomic approach as a new complementary tool in the forensic diagnosis of drowning and, perhaps, in clinical future implications in drowned patients. However, this is a pilot approach, and future studies are necessary to consolidate our promising preliminary data.

Analysis of the information in mandatory reporting in victims of gender violence.

The healthcare professional plays a key role in the detection and subsequent channeling of a situation of violence to a judicial level for appropriate investigation. The mandatory reporting of gender violence has become a controversial issue among health care practitioners and victims. The objective of this study was to analyze the quality of the way in which injury reports on victims of gender violence is completed, through an analysis of the information they include, the readability and the degree to which the document can be understood. A retrospective study in a sample of 197 injury reports were performed from health services (primary care, hospital services and emergency services). We analyzed 22 variables related to the content, readability of the document, the victim's identification data as well as identification of the doctor responsible for assistance, the moment of assistance and the characteristics of the injury. The most frequent deficiencies in the data are identification of the doctor responsible for medical attention, the date on which the aggression occurred, a description of the injuries and the judgment of compatibility between the cause of injury (according to the victim) and the actual injury they have. The injury reports do not conform to the legal requirements needed in a document of such extraordinary importance. Greater awareness in health professionals concerning the importance of the injury report as a medicolegal document is needed so that the correct information can be provided to the relevant judicial authority.

Perceptions of health professionals about the quality of communication and deliberation with the patient and its impact on the health decision making process.

The information process is considered a core element in decision- making and an obligatory matter of concern for the health professional. Rather than information per se, we should perhaps mention the need for communication between the health professional and the patient, which should be appropriate to each specific case and situation. Interaction and communication during the relationship generates a degree of trust that contributes to improving care quality and health-related results. The aim of this study is to know the perception of professionals on the quality of communication and its impact on the decision-making process of the patient and the degree of involvement of health professionals in the process of communication with the patient. A sample of 2186 health professionals (1578 nurses, 586 physicians, and 22 pharmacists) was studied. A questionnaire composed of 20 items dealing with the process of communication with the patient and obtaining informed consent was administered. Our study revealed the high consideration that professionals hold of their communication skills with patients since almost 80% of those surveyed, think they are sufficiently skilled in this area. Professionals refers that nurses are most skilled at communicating with patients. Communication in the clinical relationship must not only serve as a way for the professional to obtain information from the patient on their pathology, but also as a means to inform patients so that they understand their illness. Patients also like to feel that they are being listened to and are co-participants in the care process. Communication should be a continuous object of study for all health professionals, both in primary and specialised attention.

Informed consent in dental malpractice claims. A retrospective study.

With the introduction of informed consent in dental practice in Spain during the last ten years activity has been focused on avoiding complaints rather than on giving adequate information to the patient. However, in the eyes of many professionals the document by which patients accept the cost or estimated charge of treatment is the equivalent of informed consent. Although Spanish law permits verbal consent in some cases (low risk therapeutic activities), some dentists interpret this law in a very broad way. The aim of this paper was to study the fulfilment of informed consent in relation to professional malpractice claims presented to the College of Dentists of the province of Murcia, south east Spain (regional professional association) during the last twelve years (n=52). Evaluation of the complaints pointed to adequate professional behaviour in 14 cases and malpractice in 38 cases (in 29 of which the treatment applied was technically correct but with inadequate information provided during the process, while nine cases represented technical errors). The written document of informed consent was absent in 40 cases, although the verbal information supplied was considered adequate in 14 cases. When the document of informed consent was present (12 cases) it was considered unsuitable, although adequately complemented by oral information.

Embryo dignity: the status and juridical protection of the in vitro embryo.

In the context of research and reproduction, the status of the human in vitro embryo ranges from being regarded as a person to being regarded as mere property. As regards the first view, one extreme of the spectrum for offering possible legal protection considers that the embryo constitutes a legal person from the moment of conception. For opponents of this view life is a continuum that runs from conception until death. In this process one of the most important stages is birth, the reason being that birth represents the transition between a potential person and a person. The term "embryo" is used to express the being that exists after fusion of the egg and a spermatozoon during the process of embryogenesis until it reaches eight weeks, after which time it is termed a foetus. The embryo's life is recognized as a constitutional value which deserves juridical protection, but not as a person. It only becomes a person with birth.

El proceso de muerte en la pandemia por coronavirus / O processo de morte na pandemia por coronavírus / The death process in the coronavirus pandemic

La muerte es un proceso biográfico, sociocultural y biológico que se vive de una forma individual, pero que se comparte con los seres queridos. Sabemos que morimos y al ser dependientes y relacionales otras personas participan de nuestra propia muerte. No somos seres aislados, sino que interaccionamos al convivir con los demás con quienes compartimos sentimientos y vivencias, por lo que nuestros actos se desarrollan en relación con quienes nos acompañan. Es la razón por la que, en la mayoría de las ocasiones, desterramos morir en soledad y la muerte de un amigo o de un familiar la percibimos como algo nuestro originando una cierta sensación de pérdida que, a su vez, manifestamos de forma íntima o compartida. Durante la pandemia por coronavirus, como consecuencia de la elevada tasa de contagio y el consiguiente peligro para la salud pública las autoridades sanitarias han adoptado medidas de aislamiento también en pacientes en fase terminal, por lo que se ha llevado a cabo la privación del derecho al acompañamiento y al apoyo espiritual o religioso recogido en numerosas legislaciones sobre derechos de los pacientes. La soledad se ha intentado solventar con el uso de medios electrónicos, pero esta práctica no ha sustituido el contacto físico necesario en estas situaciones. La adopción de medidas estrictas para prevenir la transmisión de la enfermedad no debe ser impedimento para facilitar un entorno compasivo durante el fallecimiento de estos pacientes.

Death is a biographical, sociocultural and biological process that is lived individually and shared with loved ones. The human being knows that he dies and as a relational and dependent living being, other people participate in his death. We are not isolated beings, but we interact living with others with whom we share feelings and experiences, so our actions are developed in relation to those who accompany us. It is the reason why, in most cases, we banish death alone without the company of our loved ones and why we perceive the death of a friend or relative as our own, causing a certain sense of loss. During the coronavirus pandemic, as a consequence of the high contagion rate and the consequent danger to public health, the authorities have adopted isolation measures also in terminal patients, for which they have been deprived of the right to accompaniment and spiritual or religious support included in legislations on the rights of patients. Solitude has been tried to solve with the use of electronic means, but this practice has not replaced the necessary physical contact in these situations. The adoption of strict measures to prevent the transmission of the disease should notbe an impediment to facilitating a compassionate environment during dying process in these patients.

A morte é um processo biográfico, sociocultural e biológico vivido individualmente, mas compartilhado com os entes queridos. Sabemos que morremos e, por sermos dependentes e relacionais, outras pessoas participam de nossa própria morte. Não somos seres isolados, mas interagimos convivendo com outras pessoas com quem compartilhamos sentimentos e experiências, por isso as nossas ações se desenvolvem em relação a quem nos acompanha. É por isso que, na maioria das vezes, evitamos morrer sozinhos, sem a companhia de nossos entes queridos, e percebemos a morte de um amigo ou familiar como nossa, causando um certo sentimento de perda que, por sua vez, manifestamos de forma íntima ou compartilhada. Durante a pandemia do coronavírus, em decorrência do alto índice de contágio e consequente perigo para a saúde pública, as autoridades sanitárias adotaram medidas de isolamento também em pacientes em fase terminal, razão pela qual foram privados do direito de acesso, acompanhamento e espiritual ou apoio religioso incluído em várias legislações sobre os direitos dos pacientes. Tem-se tentado fazer face à solidão com o uso de meios eletrônicos, mas essa prática não substitui o contato físico necessário nessas situações. A adoção de medidas estritas para prevenir a transmissão da doença não deve ser um impedimento para facilitar um ambiente compassivo durante a morte desses pacientes.