Factors associated with physician decision making on withholding cardiopulmonary resuscitation in prehospital medicine.

This study seeks to identify factors that are associated with decisions of prehospital physicians to start (continue, if ongoing) or withhold (terminate, if ongoing) CPR in patients with OHCA. We conducted a retrospective study using anonymised data from a prehospital physician response system. Data on patients attended for cardiac arrest between January 1st, 2010 and December 31st, 2018 except babies at birth were included. Logistic regression analysis with start of CPR by physicians as the dependent variable and possible associated factors as independent variables adjusted for anonymised physician identifiers was conducted. 1525 patient data sets were analysed. Obvious signs of death were present in 278 cases; in the remaining 1247, resuscitation was attempted in 920 (74%) and were withheld in 327 (26%). Factors significantly associated with higher likelihood of CPR by physicians (OR 95% CI) were resuscitation efforts by EMS before physician arrival (60.45, 19.89-184.29), first monitored heart rhythm (3.07, 1.21-7.79 for PEA; 29.25, 1.93-442. 51 for VF / pVT compared to asystole); advanced patient age (modelled using cubic splines), physician response time (0.92, 0.87-0.97 per minute) and malignancy (0.22, 0.05-0.92) were significantly associated with lower odds of CPR. We thus conclude that prehospital physicians make decisions to start or withhold resuscitation routinely and base those mostly on situational information and immediately available patient information known to impact outcomes.

[Ethical guides, criteria for admission in intensive care, palliative care. Multi-society recommendations for allocation of resources during the COVID-19 pandemic]. / Guías éticas para la atención durante la pandemia COVID-19. Recomendaciones multisocietarias para asignación de recursos.

Guidelines on resource allocation, ethics, triage processes with admission and discharge criteria from critical care and palliative care units during the pandemia are here presented. The interdisciplinary and multi-society panel that prepared these guidelines represented by bioethicists and specialists linked to the end of life: clinicians, geriatricians, emergentologists, intensivists, and experts in palliative care and cardiopulmonary resuscitation. The available information indicates that approximately 80% of people with COVID-19 will develop mild symptoms and will not require hospital care, while 15% will require intermediate or general room care, and the remaining 5% will require assistance in intensive care units. The need to think about justice and establish ethical criteria for allocation patients arise in conditions of exceeding available resources, such as outbreaks of diseases and pandemics, with transparency being the main criterion for allocation. These guides recommend general criteria for the allocation of resources relies on bioethical considerations, rooted in Human Rights and based on the value of the dignity of the human person and substantial principles such as solidarity, justice and equity. The guides are recommendations of general scope and their usefulness is to accompany and sustain the technical and scientific decisions made by the different specialists in the care of critically ill patients, but given the dynamic nature of the pandemic, a process of permanent revision and adaptation of recommendations must be ensured.

Se presentan las guías sobre ética de asignación de recursos, procesos de triaje con criterios de ingreso y egreso de unidades de cuidados críticos y atención paliativa durante la pandemia. El panel interdisciplinario y multisocietario que las preparó estuvo representado por bioeticistas y por especialistas vinculados al fin de la vida: clínicos, geriatras, emergentólogos, intensivistas, expertos en cuidados paliativos y en reanimación cardiopulmonar. La información disponible indica que aproximadamente 80% de las personas con COVID-19 desarrollarán síntomas leves y no requerirán asistencia hospitalaria, mientras que 15% precisará cuidados intermedios o en salas generales, y el 5% restante requerirá de asistencia en unidades de cuidados intensivos. La necesidad de pensar en justicia y establecer criterios éticos de asignación surgen en condiciones de superación de los recursos disponibles, como en brotes de enfermedades y pandemias, siendo la transparencia el principal criterio para la asignación. Estas guías recomiendan criterios generales de asignación de recursos en base a consideraciones bioéticas, enraizadas en los Derechos Humanos y sustentadas en el valor de la dignidad de la persona humana y principios sustanciales como la solidaridad, la justicia y la equidad. Las guías son recomendaciones de alcance general y su utilidad consiste en acompañar y sostener las decisiones técnicas y científicas que tomen los distintos especialistas en la atención del paciente crítico, pero dado el carácter dinámico de la pandemia, debe asegurarse un proceso de revisión y readaptación permanente de las recomendaciones.

Guías éticas para la atención durante la pandemia COVID-19: Recomendaciones multisocietarias para asignación de recursos / Ethical guides, criteria for admission in intensive care, palliative care. Multi-society recommendations for allocation of resources during the COVID-19 pandemic

Se presentan las guías sobre ética de asignación de recursos, procesos de triaje con criterios de ingreso y egreso de unidades de cuidados críticos y atención paliativa durante la pandemia. El panel interdisciplinario y multisocietario que las preparó estuvo representado por bioeticistas y por especialistas vinculados al fin de la vida: clínicos, geriatras, emergentólogos, intensivistas, expertos en cuidados paliativos y en reanimación cardiopulmonar. La información disponible indica que aproximadamente 80% de las personas con COVID-19 desarrollarán síntomas leves y no requerirán asistencia hospitalaria, mientras que 15% precisará cuidados intermedios o en salas generales, y el 5% restante requerirá de asistencia en unidades de cuidados intensivos. La necesidad de pensar en justicia y establecer criterios éticos de asignación surgen en condiciones de superación de los recursos disponibles, como en brotes de enfermedades y pandemias, siendo la transparencia el principal criterio para la asignación. Estas guías recomiendan criterios generales de asignación de recursos en base a consideraciones bioéticas, enraizadas en los Derechos Humanos y sustentadas en el valor de la dignidad de la persona humana y principios sustanciales como la solidaridad, la justicia y la equidad. Las guías son recomendaciones de alcance general y su utilidad consiste en acompañar y sostener las decisiones técnicas y científicas que tomen los distintos especialistas en la atención del paciente crítico, pero dado el carácter dinámico de la pandemia, debe asegurarse un proceso de revisión y readaptación permanente de las recomendaciones.

Guidelines on resource allocation, ethics, triage processes with admission and discharge criteria from critical care and palliative care units during the pandemia are here presented. The interdisciplinary and multi-society panel that prepared these guidelines represented by bioethicists and specialists linked to the end of life: clinicians, geriatricians, emergentologists, intensivists, and experts in palliative care and cardiopulmonary resuscitation. The available information indicates that approximately 80% of people with COVID-19 will develop mild symptoms and will not require hospital care, while 15% will require intermediate or general room care, and the remaining 5% will require assistance in intensive care units. The need to think about justice and establish ethical criteria for allocation patients arise in conditions of exceeding available resources, such as outbreaks of diseases and pandemics, with transparency being the main criterion for allocation. These guides recommend general criteria for the allocation of resources relies on bioethical considerations, rooted in Human Rights and based on the value of the dignity of the human person and substantial principles such as solidarity, justice and equity. The guides are recommendations of general scope and their usefulness is to accompany and sustain the technical and scientific decisions made by the different specialists in the care of critically ill patients, but given the dynamic nature of the pandemic, a process of permanent revision and adaptation of recommendations must be ensured.

Ethical and medicolegal aspects in the management of neurosurgical emergencies among Jehovah's Witnesses: Clinical implications and review.

When an incapacitated Jehovah's Witness neurologically deteriorates and requires immediate craniectomy, institutional protocols may delay surgery if the patient's refusal of blood products is ambiguous. We are among the first to describe such an ethically contentious case in emergency neurosurgery, review the morbidity of operative delays, discuss medicolegal concerns raised, and provide a detailed guide to hemostasis in patients who refuse blood products. We discuss the case of a 46-year-old woman presented with nausea, vomiting, and right-sided weakness, progressing to stupor over several hours. When an initial Computed Tomography (CT) scan showed a large, left-sided intraparenchymal hematoma with significant midline shift, she was booked for an emergency hemicraniectomy. According to the family, she was a Jehovah's Witness and would have refused blood consent, but was without the proper documentation. Despite her worsening neurological status, an indeterminate blood consent delayed surgery for more than two hours. Her neurological exam did not improve postoperatively, and she later expired. The ethical, legal, and operative concerns that arise in the emergency neurosurgical treatment of Jehovah's Witness patients pose unique management challenges. Since operative delay is a preventable cause of mortality in patients requiring urgent craniectomy, and the likelihood of requiring a transfusion from hemorrhage is minimal, an ambiguous blood consent should not postpone a potentially life-saving treatment. For the beneficence and autonomy of Jehovah's Witness patients, institutional policies should respect the family's wishes in order to expedite surgical decompression. In addition to discussing the nuances of such ethical considerations, we also provide a detailed list of commonly used, topical and parenteral hemostatic agents from the neurosurgical operating room which, depending on whether they are blood-derived, either should or should not be used when treating a Jehovah's Witness.

Pautas éticas y operativas para la evaluación ética acelerada de investigaciones en seres humanos relacionadas con el COVID-19 / Ethical and operational guidelines for the accelerated ethical evaluation of human research related to COVID-19

Ante la pandemia de COVID-19 la primera obligación es responder a las necesidades de atención de salud de las personas y comunidades afectadas. Al mismo tiempo, resulta un deber realizar investigaciones que generen evidencia para mantener, promover y mejorar la atención de la salud, la toma de decisiones y la definición de políticas en salud para el tratamiento y mitigación de la pandemia. La conducción de investigación durante la emergencia sanitaria conlleva mayores desafíos que los habituales. Demanda generar conocimiento rápidamente para dar respuesta a la pandemia, asegurar la validez científica de las investigaciones, respetar los principios éticos en su realización y mantener la confianza de la comunidad. Esta tarea requiere de la colaboración y solidaridad de la comunidad científica, investigadores, patrocinadores, comités evaluadores, personal de salud, autoridades sanitarias y la sociedad, para encontrar el mejor modo de evitar retrasos en la realización de las investigaciones. En este contexto, los comités de ética en investigación (CEI) deberían formular procedimientos para una evaluación ética rigurosa de las investigaciones en seres humanos que, a su vez, aseguren la existencia de mecanismos rápidos y flexibles para dar una respuesta eficiente a los tiempos y necesidades de una emergencia sanitaria. Estas recomendaciones buscan orientar a los CEI en el desarrollo de procedimientos operativos para una evaluación acelerada de proyectos de investigación relacionados con el COVID-19.

Transferência de cuidado realizada pelos profissionais de saúde em um serviço de urgência e emergência / Care transfer by health professionals in an emergency service

A transferência de cuidado (handoff ou handover) consiste na transferência da responsabilidade do cuidado do paciente, ou grupo de pacientes, para outra pessoa ou grupo de profissionais, de forma temporária ou definitiva. O objetivo do presente estudo foi analisar a transferência de cuidado de pacientes no cotidiano de profissionais de saúde de um pronto-socorro e sua influência na qualidade assistencial. Trata-se de um estudo de caso de natureza qualitativa, que utilizou o referencial do cotidiano de Michel de Certeau, em especial, os conceitos de tática e estratégia, realizado em um pronto-socorro de um hospital público de grande porte, localizado na cidade de Belo Horizonte, Minas Gerais. Participaram da pesquisa 30 profissionais, entre médicos, enfermeiros, técnicos de enfermagem, maqueiros, assistente social, psicólogo e cirurgião-dentista do pronto-socorro (PS), diretamente envolvidos no handover. A coleta de dados foi realizada, por meio de entrevistas individuais com roteiro semiestruturado, observação e análise documental. Utilizou-se o critério de saturação dos dados, para encerrar as entrevistas que foram gravadas, transcritas e submetidas à Análise de Conteúdo Temática. Os dados foram coletados, após a aprovação do projeto pelo Comitê de Ética da UFMG (COEP/UFMG) e Comitê de Ética e Pesquisa do hospital sob os pareceres nº 1.519.784 e nº 1.559.717, respectivamente e assinatura do Termo de Consentimento Livre e Esclarecido (TCLE) pelos participantes. Os resultados foram organizados em cinco categorias temáticas: "Compreendendo a visão dos profissionais de um pronto-socorro sobre a transferência de cuidado de pacientes: múltiplos olhares";" Comunicação efetiva: estratégias e táticas vivenciadas no cotidiano dos profissionais"; "Fatores que interferem no trabalho em equipe e comunicação nos momentos de handover"; "O trabalho em equipe no cotidiano dos profissionais e reflexos no handover"; "Cuidado centrado no paciente e família". Os dados revelaram aspectos do cotidiano do PS, assim como o perfil dos entrevistados, sujeitos que, além das normas instituídas, utilizam táticas para superar dificuldades e mostram comprometimento com a assistência. O handover é compreendido de maneiras distintas pelos profissionais e apresenta-se mais ligado à transferência de informações, mas existe, também, uma preocupação para que ocorra transferência de responsabilidade e continuidade do cuidado. Foram identificadas estratégias, para definir o fluxo de atendimento e normatizar o handover, tendo destaques o protocolo de Manchester, prontuário eletrônico, Situação-Background- Avaliação-Recomendação (SBAR) e passômetro, assim como táticas (o fazer real) reveladas pelos profissionais. Habilidades leves, como assertividade, escuta e negociação, configuram-se como táticas para aumentar a efetividade da comunicação. O enfermeiro aparece como peça-chave para o trabalho da equipe multiprofissional e organização do handover. Identificaram-se fatores relacionados ao ambiente, estrutura, processos e indivíduos, que interferem na comunicação e trabalho em equipe nos momentos de handover. O trabalho em equipe no PS é percebido mais como agrupamento do que integração, prejudicando o handover. O cuidado é realizado, de acordo com normas e definições dos profissionais, com base na realidade do hospital e menos nas necessidades do paciente e sua família, o que compromete o handover e segurança do paciente neste cenário.(AU)

The transference of care (handoff or handover) consists in temporarily or permanently transferring the responsibility of the patient care to another person or group of professionals. The objective of this study was to analyze the transfer of patient care in the daily life of healthcare professionals of an emergency room and its influence on the quality of care. This is a case study of a qualitative nature, referenced on the daily life of Michel de Certeau's, especially regarding the concepts of tactics and strategy. We conducted the study in an emergency room of a large public hospital, located in the municipality of Belo Horizonte, Minas Gerais, Brazil. Thirty professionals of the emergency room among physicians, nurses, nursing technicians, stretcher bearer, social workers, psychologists, and dental surgeons (PS) directly involved in the transfer of patient care partook of the study. We collected the data through individual interviews using a semi-structured script, observation, and documentary analysis. We used the data saturation criterion to close the interviews recorded, transcribed, and submitted to the Thematic Content Analysis. The data collection occurred after the approval of the project by the Ethics Committee of the UFMG (COEP/UFMG) and the Committee of Ethics and Research of the hospital under the decision no 1,519,784 and 1,559,717, respectively. The participants signed the Term of Free and Clarified Consent (TFCC). The results were organized in five thematic categories: "Understanding the perspective of the professionals of an emergency room on the transfer of patient care: multiple perspectives"; "Effective communication: strategies and tactics experienced in the daily life of the professionals"; "Factors that interfere in teamwork and communication during a handover"; "Teamwork in the daily life of the professionals and reflexes on the handover"; "Care centered on the patient and family". The data revealed aspects of the daily life of the ER, as well as the profile of the interviewees, subjects who, besides the established norms, use tactics to overcome difficulties and show commitment to the assistance. The handover is understood in different ways by the professionals and is more closely connected to the transfer of information. However, there is also a concern for the transfer of responsibilities and care continuity. We identified strategies to define the flow of care and standardize the handover, highlighting the Manchester protocol, electronic medical record, Situation- Background-Assessment-Recommendation (SBAR), and passometer, as well as tactics (the real acting) revealed by the professionals. Mild skills such as assertiveness, listening, and negotiation are shown as tactics to increase the effectiveness of communication. The nurse appears as a critical piece for the work of the multiprofessional team and handover organization. We identified factors related to the environment, structure, processes, and individuals that interfere in the communication and teamwork during the handover. Teamwork in the ER is perceived more as a grouping than integration, impairing the handover. Care is performed according to the standards and definitions of the professionals based more on the hospital´s reality and less on the needs of the patients and their family, which compromises patient handover and the safety of this setting.(AU)

Humanização nos serviços de urgência e emergência: contribuições para o cuidado de enfermagem / Humanización en los servicios de urgencia y emergencia: contribuciones para el cuidado en enfermería / Humanization in urgent and emergency services: contributions to nursing care

Resumo OBJETIVO Analisar as evidências das pesquisas desenvolvidas sobre a humanização no atendimento de urgência e emergência, tendo em vista suas contribuições para o cuidado de enfermagem. MÉTODOS Revisão integrativa nas bases de dados LILACS, CINAHL, SciELO, Web os Science, SCOPUS e BDENF, utilizando os descritores: humanização da assistência, urgências, emergências, serviços médicos de emergências e enfermagem. RESULTADOS A busca resultou em um total de 133 publicações, sendo 17 incluídas no escopo desta revisão. A análise possibilitou a elaboração das unidades de evidência: Acolhimento com classificação de risco: dispositivo com bons resultados e Barreiras e dificuldades para a utilização das diretrizes da Política Nacional de Humanização. CONCLUSÃO O Acolhimento com Classificação de Risco foi evidenciado como principal dispositivo para a efetiva operacionalização da Política Nacional de Humanização e existem barreiras para sua efetivação relacionadas à organização das redes de atenção à saúde, problemas estruturais e ao trabalho multiprofissional.

Resumen OBJETIVO Analizar las evidencias de las investigaciones desarrolladas sobre la humanización en la atención de urgencia y emergencia, teniendo en cuenta sus contribuciones en el cuidado de enfermería. MÉTODOS Revisión integradora con búsqueda en bases de datos LILACS, CINAHL, SciELO, Web of Science, SCOPUS y BDENF, utilizando descriptores: humanización de la asistencia, urgencias, emergencias, servicios médicos de emergencias y enfermería. RESULTADOS La búsqueda resultó en un total de 133 publicaciones, siendo 17 incluidas en el alcance de esta revisión. El análisis posibilitó la elaboración de unidades de evidencia: 'Acogida con clasificación de riesgo: dispositivo con buenos resultados' y 'Barreras y dificultades para la utilización de las directrices de la Política Nacional de Humanización'. CONCLUSIÓN El Acogimiento con Clasificación de Riesgo fue evidenciado como principal dispositivo para una efectiva operacionalización de la Política Nacional de Humanización y existen barreras para su efectividad relacionadas con la organización de las redes de atención a la salud, con los problemas estructurales y el trabajo multiprofesional.

Abstract OBJECTIVE To analyze the evidence of researches carried out on humanization in urgent and emergency care, considering their contributions to nursing care. METHODS Integrative review of LILACS, CINAHL, SciELO, Web of Science, SCOPUS, and BDENF databases, using the keywords: humanization of care, urgencies, emergencies, emergency medical services, and nursing. RESULTS The search resulted in a total of 133 publications, of which 17 were included in the scope of this review. The analysis enabled the elaboration of the evidence units: 'Reception with Risk Classification: a device with good results' and 'Barriers and difficulties to use the guidelines of the National Humanization Policy'. CONCLUSION The Reception with Risk Classification was evidenced as the main device for the effective implementation of the National Humanization Policy and there are barriers to its effectiveness related to the organization of health care networks, structural problems, and multi-professional work.

Ethics of Outbreaks Position Statement. Part 1: Therapies, Treatment Limitations, and Duty to Treat.

OBJECTIVES: Outbreaks of disease, especially those that are declared a Public Health Emergency of International Concern, present substantial ethical challenges. Here we start a discourse (with a continuation of the dialogue in Ethics of Outbreaks Position Statement. Part 2: Family-Centered Care) concerning the ethics of the provision of medical care, research challenges and behaviors during a Public Health Emergency of International Concern with a focus on the proper conduct of clinical or epidemiologic research, clinical trial designs, unregistered medical interventions (including vaccine introduction, devices, pharmaceuticals, who gets treated, vulnerable populations, and methods of data collection), economic losses, and whether there is a duty of health care providers to provide care in such emergencies, and highlighting the need to understand cultural diversity and local communities in these efforts. DESIGN: Development of a Society of Critical Care Medicine position statement using literature review and expert consensus from the Society of Critical Care Medicine Ethics committee. The committee had representation from ethics, medical philosophy, critical care, nursing, internal medicine, emergency medicine, pediatrics, anesthesiology, surgery, and members with international health and military experience. SETTING: Provision of therapies for patients who are critically ill or who have the potential of becoming critically ill, and their families, regarding medical therapies and the extent of treatments. POPULATION: Critically ill patients and their families affected by a Public Health Emergency of International Concern that need provision of medical therapies. INTERVENTIONS: Not applicable. MAIN RESULTS: Interventions by high income countries in a Public Health Emergency of International Concern must always be cognizant of avoiding a paternalistic stance and must understand how families and communities are structured and the regional/local traditions that affect public discourse. Additionally, the obligations, or the lack of obligations, of healthcare providers regarding the treatment of affected individuals and communities must also be acknowledged. Herein, we review such matters and suggest recommendations regarding the ethics of engagement in an outbreak that is a Public Health Emergency of International Concern.

Sentimentos de familiares de pacientes internados na emergência psiquiátrica: um olhar sobre a família / Sentimientos de familiares de pacientes internados en urgencia psiquiátrica: una mirada sobre la familia / Feelings of relatives of patients hospitalized in the psychiatric emergency care unit: a look on the family

RESUMO O presente estudo teve como objetivo compreender os sentimentos dos familiares que chegam à emergência psiquiátrica com um ente em agudização dos sintomas do transtorno mental. Trata-se de uma pesquisa descritiva-exploratória com abordagem qualitativa. Participaram 20 familiares de pessoas com transtorno mental atendidos na Emergência Psiquiátrica de um Hospital da Rede Pública do Interior do Estado de São Paulo. Para coleta de dados, utilizou-se um roteiro de entrevista individual. As entrevistas foram áudio-gravadas e tratadas conforme análise de conteúdo temática de Bardin. Os dados resultaram em duas categorias: A internação no serviço de emergência psiquiátrica como alívio da sobrecarga familiar; e A agudização do transtorno mental como gerador de angústia e tristeza para a família. Desta forma, compreender os sentimentos predominantes nos familiares dos pacientes no ato da internação no Serviço de Emergência contribui para a elaboração de estratégias para a construção de uma atuação profissional humanística visando à inclusão da unidade familiar em todas as etapas do cuidado.

RESUMEN El presente estudio tuvo como objetivo comprender los sentimientos de los familiares que llegan a urgencia psiquiátrica con un ente en agudización de los síntomas del trastorno mental. Se trata de una investigación descriptiva-exploratoria con enfoque cualitativo. Participaron 20 familiares de personas con trastorno mental atendidos en la Urgencia Psiquiátrica de un Hospital de la Red Pública del Interior del Estado de São Paulo. Para la recolección de datos, fue utilizado un guión de entrevista individual. Las entrevistas fueron audio-grabadas y tratadas conforme análisis de contenido temático de Bardin. Los datos resultaron en dos categorías: La internación en el servicio de urgencia psiquiátrica como alivio de la sobrecarga familiar; y La agudización del trastorno mental como generador de angustia y tristeza para la familia. De esta forma, comprender los sentimientos predominantes en los familiares de los pacientes en el momento de la internación en el Servicio de Urgencia contribuye para la elaboración de estrategias para la construcción de una actuación profesional humanística, pretendiendo la inclusión de la unidad familiar en todas las etapas del cuidado.

ABSTRACT This study has the objective to understand the feelings of relatives that arrive at the psychiatric emergency care unit with a family member in a moment of acute symptoms of mental disorder. It is an exploratory, descriptive research with a qualitative approach. The study has 20 families of individuals suffering from a mental disorder who were assisted in the Psychiatric Emergency Care Unit of a Public Hospital of the Interior of São Paulo state. For data collection, individual interviews were used. The interviews were audio-recorded and treated according to content analysis of Bardin. Data resulted in two categories: Internment in psychiatric emergency service to relieve the family burden, and The crisis of mental disorder such as anxiety generator and sadness for the family. Thus, to understand the feelings prevailing in the patients' relatives at the moment of hospitalization in the Emergency Care Unit, there was the elaboration of strategies for the construction of a professional humanistic performance seeking the inclusion of the family unit in all stages of the care.

[Patients' declared intentions and emergency medicine]. / Patientenwille und Akutmedizin.

Patients with complex medical problems and acute life-threatening diseases deserve a physician with the capability of rapid decision making. Despite an emergency scenario with several unknown or uncertain variables an individual therapeutic plan needs to be defined for each patient. In order to achieve this goal the physician must define medical indications for each form of treatment. Secondly, the patients declared intentions must be respected concerning the previously defined medical indications; however, very often the patients' will is not known. It is very difficult to define an individual treatment plan especially if the patient is not able to adequately communicate. In these situations a custodian is helpful to find out the patients declared intentions towards the current medical situation. If there is no advance directive, family members often have to act as surrogates to find out what therapy goal is best for the individual patient. The patients' autonomy is a very highly respected ethical priority even when the ability for the otherwise usual practice of shared decision-making between physician and patient is compromised. Therefore, in order to do justice to this demanding situation it is necessary to deal with the characteristics of the physician-patient-relatives relationship in emergency medicine.

Exploring ethical conflicts in emergency trauma research: the COMBAT (Control of Major Bleeding after Trauma) study experience.

BACKGROUND: Up to 25% of severely injured patients develop trauma-induced coagulopathy. To study interventions for this vulnerable population for whom consent cannot be obtained easily, the Food and Drug Administration issued regulations for emergency research with an exception from informed consent (ER-EIC). We describe the community consultation and public disclosure (CC/PD) process in preparation for an ER-EIC study, namely the Control Of Major Bleeding After Trauma (COMBAT) study. METHODS: The CC/PD was guided by the four bioethical principles. We used a multimedia approach, including one-way communications (newspaper ads, brochures, television, radio, and web) and two-way communications (interactive in-person presentations at community meetings, printed and online feedback forms) to reach the trials catchment area (Denver County's population: 643,000 and the Denver larger metro area where commuters reside: 2.9 million). Particular attention was given to special-interests groups (eg, Jehovah Witnesses, homeless) and to Spanish-speaking communities (brochures and presentations in Spanish). Opt-out materials were available during on-site presentations or via the COMBAT study website. RESULTS: A total of 227 community organizations were contacted. Brochures were distributed to 11 medical clinics and 3 homeless shelters. The multimedia campaign had the potential to reach an estimated audience of 1.5 million individuals in large metro Denver area, the majority via one-way communication and 1900 in two-way communications. This resource intensive process cost more than $84,000. CONCLUSION: The CC/PD process is resource-intensive, costly, and complex. Although the multimedia CC/PD reached a large audience, the effectiveness of this process remains elusive. The templates can be helpful to similar ER-EIC studies.

[Medical decision in a very elderly patient: a case report of application of the Leonetti law in emergency medicine]. / Décision médicale chez la personne très âgée: à propos d'un cas d'application de la loi Leonetti en médecine d'urgence.

Advanced care decision in emergency medicine is difficult for the elderly. How to be fair, avoiding an unreasonable obstinacy? Based on the case of very old person, we show how an optimal management can be decided in accordance with the spirit of the law.

Animal derived products may conflict with religious patients' beliefs.

BACKGROUND: Implants and drugs with animal and human derived content are widely used in medicine and surgery, but information regarding ingredients is rarely obtainable by health practitioners. A religious perspective concerning the use of animal and human derived drug ingredients has not thoroughly been investigated. The purpose of this study was to clarify which parts of the medical and surgical treatments offered in western world-hospitals that conflicts with believers of major religions. METHODS: Religious and spiritual leaders of the six largest religions worldwide (18 branches) were contacted. A standardised questionnaire was sent out regarding their position on the use of human and animal derived products in medical and surgical treatments. RESULTS: Of the 18 contacted religious branches, 10 replied representing the 6 largest religions worldwide. Hindus and Sikhs did not approve of the use of bovine or porcine derived products, and Muslims did not accept the use of porcine derived drugs, dressings or implants. Christians (including Jehovah's Witnesses), Jews and Buddhists accepted the use of all animal and human derived products. However, all religions accepted the use of all these products in case of an emergency and only if alternatives were not available. CONCLUSIONS: The views here suggest that religious codes conflict with some treatment regimens. It is crucial to obtain informed consent from patients for the use of drugs and implants with animal or human derived content. However, information on the origin of ingredients in drugs is not always available to health practitioners.

Operating one-handed: emergency treatment of Jehovah's Witnesses.

An elderly woman was brought to the emergency room (ER) hypotensive in a confused mental state from what turned out at exploration to be a ruptured splenic artery aneurysm. You are in the operating room, and the anesthesiologist has just hung the first unit of blood but has not started infusion when the ER calls. The patient and her husband were visiting their children and live in another state. Her husband, an elder in a Jehovah's Witness congregation, arrived and is adamant that she have no transfusions. Her blood pressure is dangerously low. It is being maintained by a high-dose Levophed (leave-um dead) drip and continues to slip. You have avoided operating on Jehovah's Witness patients because of the added unnecessary risk they pose. Your assistant is of like mind. What is the best ethical course at this time?

Ethics seminar: the hospice patient in the ED: an ethical approach to understanding barriers and improving care.

Emergency physicians (EPs) are asked to evaluate and treat a growing population of hospice patients who present to the emergency department (ED) for a number of important reasons. Hospice patients pose unique ethical challenges, and "best practices" for these patients can differ from the life-preserving interventions of usual ED care. Having a solid understanding of professional responsibilities and ethical principles is useful for guiding EP management of these patients. In end-of-life care, EPs need to recognize that there are barriers and complexities to the best management of hospice patients, but they need to commit to strategies that optimize their care. This article describes the case of a hospice patient who presented with sepsis and end-stage cancer to the ED. Patient, system, and physician factors made management decisions in the ED difficult. The goal in the ED should be to determine the best way to address terminally ill patient needs while respecting wishes to limit interventions that will only increase suffering near the end of life.

The cultural moral right to a basic minimum of accessible health care.

(1) The conception of a cultural moral right is useful in capturing the social-moral realities that underlie debate about universal health care. In asserting such rights, individuals make claims above and beyond their legal rights, but those claims are based on the society's existing commitments and moral culture. In the United States such a right to accessible basic health care is generated by various empirical social facts, primarily the conjunction of the legal requirement of access to emergency care with widely held principles about unfair free riding and just sharing of costs between well and ill. The right can get expressed in social policy through either single-payer or mandated insurance. (2) The same elements that generate this right provide modest assistance in determining its content, the structure and scope of a basic minimum of care. They justify limits on patient cost sharing, require comparative effectiveness, and make cost considerations relevant. They shed light on the status of expensive, marginally life extending, last-chance therapies, as well as life support for PVS patients. They are of less assistance in settling contentious debates about screening for breast and prostate cancer and treatments for infertility and erectile dysfunction, but even there they establish a useful framework for discussion. Scarcity of resources need not be a leading conceptual consideration in discerning a basic minimum. More important are the societal elements that generate the cultural moral right to a basic minimum.

[Save life--allow death. Collation of emergency missions for terminally ill patients]. / Leben retten--sterben zulassen. Erfassung notärztlicher Einsätze bei Patienten in der Terminalphase.

BACKGROUND: Emergency missions can also be necessary for patients in the terminal phase of a progressive incurable disease. The emergency physician, accustomed to acting under strict procedures and whose training focuses on the restoration and stabilization of acutely threatened vital functions, can face severe difficulties when treating incurably ill patients in the terminal phase. This study investigates the number of such cases, patient symptoms and the events occurring during life-threatening emergencies of terminally ill patients. METHOD: All cases of emergency events involving terminally ill patients were analyzed prospectively. In addition to the standardized protocol (following DIVI/Mind 2) an enquiry sheet was used, which contained an 8-item checklist specifically for terminally ill patients, to be filled out by the responding physician. RESULTS: The total number of patients in the terminal phase identified by the emergency physician was 55 (0.72% of total cases) and of these patients 30 (55%) were tumor patients. The most frequent complaint observed was dyspnea (30 patients, 55%), followed by relatives of the patients experiencing the stress of caring for a terminally ill person (19 patients, 35%). The leading symptom of 6 patients (11%) was pain. Only 17 cases (30.9%) required transport of the patient to hospital for further treatment. CONCLUSION: Every emergency physician can be confronted with an emergency involving a patient with a progressive incurable disease. The condition of each patient must be assessed for each medical decision. Not only medical, but also psychosocial, ethical and legal aspects have to be considered.