The Circle Method: A Novel Approach to Clinical Ethics Consultation.

AbstractDifferent methods are available in clinical ethics consultation. In our experience as ethics consultants, certain individual methods have proven insufficient, and so we use a combination of methods. Based on these considerations, we first critically analyze the pros and cons of two well-known methods in the working field of clinical ethics, namely Beauchamp and Childress's four-principle approach and Jonsen, Siegler, and Winslade's four-box method. We then present the circle method, which we have used and refined during several clinical ethics consultations in the hospital setting.

Photoinduced Autonomous Nonequilibrium Operation of a Molecular Shuttle by Combined Isomerization and Proton Transfer Through a Catalytic Pathway.

We describe a [2]rotaxane whose recognition sites for the ring are a dibenzylammonium moiety, endowed with acidic and H-bonding donor properties, and an imidazolium center bearing a photoactive phenylazo substituent. Light irradiation of this compound triggers a network of E/Z isomerization and proton transfer reactions that enable autonomous and reversible ring shuttling away from equilibrium.

Liver transplantation from active COVID-19 donors: Is it ethically justifiable?

The debate on the opportunity to use organs from donors testing positive for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in recipients with naïve resolved or active COVID-19 is ongoing. We aim to present the ethical analyses underlying the decision to perform liver transplantation (LT) in selected patients with resolved or active COVID-19 in Italy. We used Jonsen, Siegler, and Winslade's Four-Boxes casuistic method, addressing the four topics considered as constitutive of the essential structure of single clinical cases for their ethical analysis (medical indications, patient preferences, quality of life, and contextual features) to enable decision-making on a case-by-case basis. Based on these topics, we elucidate the meaning and balance among the principles of biomedical ethics. Clinical ethics judgment based on the relation between the risk of acquiring SARS-CoV-2 along with its potentially negative effects and the expected benefits of transplant lead to consider LT as clinically appropriate. Shared decision-making allows the integration of clinical options with the patient's subjective preferences and considerations, enabling a valid informed consent specifically tailored to the patients' individual circumstances. The inclusion of carefully selected SARS-CoV-2 positive donors represents an opportunity to offer lifesaving LT to patients who might otherwise have limited opportunities to receive one. COVID-19 positive donor livers are fairly allocated among equals, and respect for fundamental rights of the individual and the broader community in a context of healthcare rationing is guaranteed.The ethical analysis of the decision to perform LT in selected patients shows that the decision is ethically justifiable.

The need for clinical ethics consultation: a monocentric observational survey study in the intensive care unit (Consul.E.T.I. study).

BACKGROUND: The current organizational structure of the Italian healthcare system does not include the institutionalization of clinical ethics services. To describe the need for structured clinical ethics consultation services for ICU staff members in the intensive care unit (ICU), a monocentric observational survey study was performed utilizing a paper-based questionnaire. RESULTS: A total of 73 healthcare professionals (HCPs) responded out of a team of 84 people (87%). The results showed that the need for ethics consultation in the ICU is urgent, the institutionalization of the clinical ethics service is perceived as useful and should be a priority, and the issues on which the HCPs would like ethics consultation to focus are various and belong to "end of life" topics. CONCLUSIONS: HCPs believe that the clinical ethicist should become an integral part of ICU healthcare teams, offering consultations similar to the other specialistic consultations carried out in hospitals.

The 3-T Model of Informed Consent for Nonstandard Risk Donors: A Proposal for Transplant Clinical Practice.

BACKGROUND: The risk of disease transmission from nonstandard risk donors (NSRDs) is low, and outcomes are similar or better relative to transplants performed with standard criteria donors. However, NSRDs have posed new ethical challenges to the informed consent (IC) process. Based on the shared decision-making model, coinciding with the 3 main timings of the IC process ([1] pretransplant assessments and waiting list registration, [2] time on the waiting list, and [3] time of the organ offer), we put forward a model (3-T Model) to summarize the knowledge on IC for NSRDs and to deliver conceptual and practical support to transplant providers on this emergent issue. METHODS: We searched PubMed and analyzed data from our area to provide evidence and ethical arguments to promote standardization of the timing of patient information, degree of patient participation, and disclosure of donor risk factors throughout the 3 stages of the time continuum leading to the potential acceptance of NSRDs. RESULTS: Each of the 3 timings carries special ethical significance and entails well-defined duties for transplant providers relative to patient involvement and information of the benefits and risks associated with NSRDs. Based on our framework, experience, and interpretation of the literature, we put forward a list of recommendations to combine standardization (ie, timing, content, and degree of patient participation) and individualization of IC. CONCLUSIONS: The 3-T Model may enable the prevention of physicians' arbitrariness and the promotion of patient-centered care. Future studies will assess the effectiveness of the 3-T Model in transplant clinical practice.

Vulnerability and ethical issues faced by general practitioners during the COVID-19 pandemic in Italy: some reflections and lessons learned.

Vulnerability during the coronavirus disease 2019 (COVID-19) pandemic is an emotional state that affects all of us globally. The Italian experience shows that our general practitioners (GPs) seem to have a higher rate of death due to COVID-19 infection than other physicians.

Direct synthetic routes to functionalised crown ethers.

Crown ethers are macrocyclic hosts that can complex a wide range of inorganic and organic cations as well as neutral guest species. Their widespread utilization in several areas of fundamental and applied chemistry strongly relies on strategies for their functionalisation, in order to obtain compounds that could carry out multiple functions and could be incorporated in sophisticated systems. Although functionalised crown ethers are normally synthesised by templated macrocyclisation using appropriately substituted starting materials, the direct addition of functional groups onto a pre-formed macrocyclic framework is a valuable yet underexplored alternative. Here we review the methodologies for the direct functionalisation of aliphatic and aromatic crown ethers sporadically reported in the literature over a period of four decades. The general approach for the introduction of moieties on aliphatic crown ethers involves a radical mediated cross dehydrogenative coupling initiated either by photochemical or thermal/chemical activation, while aromatic crown ethers are commonly derivatised via electrophilic aromatic substitution. Direct functionalization routes can reduce synthetic effort, allow the later modification of crown ether-based architectures, and disclose new ways to exploit these versatile macrocycles in contemporary supramolecular science and technology.

Chemically Induced Mismatch of Rings and Stations in [3]Rotaxanes.

The mechanical interlocking of molecular components can lead to the appearance of novel and unconventional properties and processes, with potential relevance for applications in nanoscience, sensing, catalysis, and materials science. We describe a [3]rotaxane in which the number of recognition sites available on the axle component can be changed by acid-base inputs, encompassing cases in which this number is larger, equal to, or smaller than the number of interlocked macrocycles. These species exhibit very different properties and give rise to a unique network of acid-base reactions that leads to a fine pKa tuning of chemically equivalent acidic sites. The rotaxane where only one station is available for two rings exhibits a rich coconformational dynamics, unveiled by an integrated experimental and computational approach. In this compound, the two crown ethers compete for the sole recognition site, but can also come together to share it, driven by the need to minimize free energy without evident inter-ring interactions.

Act of Consoling Helps Those Who Console: A Multicenter Observational Survey Study in Hospice Services.

Background: The contemporary scientific literature documents a lack of attention toward the act of consoling put into practice by health care professionals (HCPs) in hospice services. Objective: To describe the act of consoling and its meaning for hospice-employed HCPs. Design: A multicenter observational survey study was performed through a paper-based questionnaire. Subjects: The study was sent to the directors of 10 hospices in Northern Italy and distributed to 232 HCPs. Results: A total of 218 HCPs responded (94%). The results showed that most HCPs consider the practice of consoling to be essential to their profession, but they also underscored the extreme complexity of the process. Conclusion: The act of consoling is not simply a professional duty defined in contractual clauses. Rather, it is a set of specific communicative practices and skills required of HCPs.

Hypercalciuria in Postmenopausal Women With Reduced Bone Mineral Density Is Associated With Different Mineral Metabolic Profiles: Effects of Treatment With Thiazides and Anti-resorptives.

Hypercalciuria may represent a challenge during the workup for osteoporosis management. The present study aimed: (1) to describe the phenotype associated with hypercalciuria in vitamin D-sufficient (serum 25 hydroxyvitamin D (25OHD) > 20 ng/ml) patients with osteopenia/osteoporosis; (2) to analyze the effects of thiazides and anti-resorptive drugs on urine calcium excretion (UCa), mineral metabolic markers, and bone mineral density. Seventy-seven postmenopausal women with hypercalciuria (Uca > 4.0 mg/kg body weight/24 h on two determinations) were retrospectively evaluated in a real-life setting. Median UCa was 5.39 (4.75-6.70) mg/kg/24 h. Kidney stones occurred in 32.9% of patients, who had median UCa similar to that of patients without kidney stones. Clustering analysis considering the three variables, such as serum calcium, phosphate, and parathormone (PTH), identified two main clusters of hypercalciuric patients. Cluster 1 (n = 13) included patients with a primary hyperparathyroidism-like profile, suggesting a certain degree of autonomous PTH secretion from parathyroid glands. Within cluster 2 (n = 61), two subgroups were recognized, cluster 2A (n = 18) that included patients with relatively increased PTH and normophosphatemia, and cluster 2B (n = 43) that included patients with the normal mineral profile. After a follow-up of 33.4 ± 19.6 months, 49 patients treated with thiazidic diuretics (TZD) were reevaluated; 20 patients were treated with hydrochlorothiazide (HCT; 12.5-37.5 mg/day), 29 with indapamide (IND; 1.50-3.75 mg/day). Any significant difference could be detected in all the parameters both basal and treated conditions between patients treated with HCT or IND. TZD induced a mean 39% reduction in UCa and 63.3% of patients obtained Uca < 4.0 mg/kg/24 h, independent of their mineral metabolic profile. Moreover, TZD induced a significant decrease in PTH levels. TZD-treated patients normalizing UCa experienced an increase in bone mineral densities when concomitantly treated with anti-resorptives, while any gain could be observed in TZD-treated patients with persistent hypercalciuria. Finally, multiple regression analysis showed that UCa reduction was at least in part related to denosumab treatment. In conclusion, in postmenopausal osteoporotic women, hypercalciuria is associated with kidney stones in about one-third of patients and with a wide range of impaired PTH secretion, determining a diagnostic challenge. TZD efficiently reduces UCa and normalization contributes to increasing anti-resorptives positive effect on bone mineral density.

Italy in a Time of Emergency and Scarce Resources: The Need for Embedding Ethical Reflection in Social and Clinical Settings.

The COVID-19 virus is severely testing the Italian healthcare system, as the requests for intensive treatment are greater than the real capacity of the system to receive patients. Given this emergency situation, it follows that citizens are limited in their freedom of movement in order to limit infection, and that in hospitals a significant number of critical situations must be faced. This brief contribution aims to offer a reflection on the public and clinical role of the bioethicist: a figure able to promote dialogue between the world of medicine and the community, and to face ethical dilemmas even in emergent clinical settings.

Extra-Long Nasal Wall-Directed Dental Implants for Maxillary Complete Arch Immediate Function: A Pilot Study.

Immediate loading of maxillary denture prostheses in the context of severe bone atrophy is complicated by posterior implant placement, sometimes requiring a complex surgical approach as zygomatic or pterygoid implants. To overcome this complexity, the authors developed an extra-long (20-24 mm) 24-degree angulated platform. It was tested on 33 patients, with 24 patients immediately loaded (72.7%) for a total of 115 implants (46% nasal). All delayed loading implants osseointegrated. Eight bilateral and six unilateral sinus grafts were performed. There were no complications during the follow-up period.

[Waiting time on dialysis for active access to renal transplantation: a multicenter cross-sectional study in Lombardy].

BACKGROUND: The amount of time spent in dialysis waiting for a renal transplantation significantly affects its outcome. Hence, the timely planning of patients' transplant evaluation is crucial. According to data from the Nord Italia Transplant program (NITp), the average waiting time between the beginning of dialysis and the admission to the regional transplant waiting list in Lombardy is 20.2 months. METHODS: A multicenter cross-sectional study was conducted in order to identify the causes of these delays and find solutions. Two questionnaires were administered to the directors of 47 Nephrology Units and to 106 patients undergoing dialysis in Lombardy respectively, during their first visit for admission to the transplant waiting list. RESULTS: The comparative analysis of the results revealed that both patients (52%) and directors (75%) consider the time required for registering to the waiting list too long. Patients judge information about the transplant to be insufficient, especially regarding the pre-emptive option (63% of patients declare that they had not been informed about this opportunity). Patients report a significantly longer time for the completion of pre-transplantation tests (more than 1 year in 23% of the cases) compared to that indicated by the directors. CONCLUSIONS: The study confirmed the necessity of providing better and more timely information to patients regarding the different kidney transplantation options and highlighted the importance of creating target-oriented and dedicated pathways in all hospitals.

"If an acute event occurs, what should we do?" Diverse ethical approaches to decision-making in the ICU.

The aim of this paper is to analyze an Intensive Care Unit case that required ethics consultation at a University Hospital in Northern Italy. After the case was resolved, a retrospective ethical analysis was performed by four clinical ethicists who work in different healthcare contexts (Italy, the United States, and Switzerland). Each ethicist used a different method to analyze the case; the four general approaches provide insight into how these ethicists conduct ethics consultations at their respective hospitals. Concluding remarks examine the similarities and differences among the various approaches and offer a reflection concerning the possibility of a shared resolution to the case. The authors' efforts to come to a tentative consensus may serve as an example for professionals working in medical contexts that reflect an increasing pluralism of values. This article aims to respond to some of these concerns by illustrating how different methods in clinical ethics would be used when considering a real case. The goal is not to establish the best model (if there is one) on a theoretical level, but to learn from actual practice in order to see if there are common elements in the different methods, and to validate their pertinence to clinical ethics consultation.

Certification and evaluation of the clinical ethics consultant. A proposal for Italy.

Clinical ethics, as a sub-discipline of bioethics, is subject to growing professionalization in North America, Europe and elsewhere. Since the goal of clinical ethics is the identification, analysis and resolution of ethical dilemmas and conflicts in health care settings, specific competencies for practitioners and criteria to evaluate them are strongly needed. Regarding clinical ethics consultation (CEC) many efforts have been made by American clinical ethicists and scholars to delineate the core knowledge and skills to perform it, to settle specific professional responsibilities and tasks and to identify the fundamental training and quality requirements that candidates and actual professionals should satisfy in order to serve as ethics consultants. Starting from the analysis of two meaningful international experiences, the one American and the other German, the paper discusses the process of certification of the clinical ethics consultant and encourages its implementation in the Italian context trying to outline a model which is suited to it.

Justice and Respect for Autonomy: Jehovah's Witnesses and Kidney Transplant.

That Jehovah's Witnesses may refuse lifesaving blood transfusions is a morally accepted feature of contemporary medical practice. The principle of respect for autonomy supports this, and there is seldom reason to interfere with this choice because it rarely harms another individual. Advances in surgical technique have made it possible for transplant surgeons to perform bloodless organ transplant, enabling Jehovah's Witnesses to benefit from this treatment. When the transplant organ is a directed donation from a family member or friend, no ethical dilemma arises. However, when a Jehovah's Witness cannot identify a living donor and wishes to be listed for organ transplant, the transplant team may face an ethical dilemma. On the one hand, it wishes to provide care to the patient that is compatible with her or his preferences. On the other hand, the team may wonder if it is fair to other patients who need an organ and will accept blood transfusion to include the Jehovah's Witness patient on a waiting list for a donated organ. If the Jehovah's Witness patient is listed and receives an organ, then a patient who also needs an organ, and who is willing to accept all care to optimize the success of the transplant, may be denied an organ. To frame the ethical dilemma outlined above we present an anonymized case of a Jehovah's Witness woman in urgent need of a kidney, who was referred to one of the authors' institution's transplant center. We review the evolution of the Jehovah's Witness position on blood transfusion and the medical community's efforts to provide care that accommodates this religious commitment. If Witnesses are to be denied transplant in the name of justice, there must be an ethically sound reason. We identify two rationales in the literature: (1) this allocation is unacceptable because it will cost lives; (2) resources should be allocated to patients who comply with the standard of care. We argue that neither apply to this dilemma. We also emphasize the importance of examining the data on outcomes of transplant with and without transfusion. Our interpretation of the published data on transplant without transfusion is that the outcomes are similar. We conclude that, in the absence of data that resources are risked, it is not ethical to refuse to include a Jehovah's Witness patient on a waiting list for an organ. Finally, we reflect on the heterogeneity in transplant institutes' polices for accepting Jehovah's Witness patients.