[Dignity and Ethics of Care in the Neurodegenerative Diseases]. / Dignidad y Ética del Cuidar en las Enfermedades Neurodegenerativas.

In the context of neurodegenerative diseases the doctor is called more than in other areas to respond not only to the simple question of health, but also to the need of assistance, which implicates the necessity of relationship, too. The scheme of symptom diagnosis treatment healing is to be replaced in these cases with a treatment based on an open system of uncertain length and results. It is a model called ″medicine of incurable″, which aims to combat the discomfort of the disease rather than the fight against the disease. In this perspective, the commitment to ensure a quality of life to the sick in itself means attention to his dignity, which is expressed in acting towards him treating him always as a person, that is protagonist of his life, and then to recognize his right to be assisted in physical, psychological and spiritual dimensions. In this model it becomes particularly important to converse with the patient, even if affected by cognitive pathologies, as well as to stimulate hope, with the belief that human being, if properly supported, is still able, even in extremely critical situations, to make out of his personal experience a chance to grow, thanks to the construction of new balances, however weak they may be.

[Ethical issues of artificial nutritional support]. / Ethische Fragen der künstlichen Ernährung.

This review article discusses some ethical issues of clinical nutrition according to the Beauchamp and Childress principles of bioethics: "respect for autonomy, nonmaleficence, beneficence, and justice".

Tailor-made finance versus tailor-made care. Can the state strengthen consumer choice in healthcare by reforming the financial structure of long-term care?

BACKGROUND: Policy instruments based on the working of markets have been introduced to empower consumers of healthcare. However, it is still not easy to become a critical consumer of healthcare. OBJECTIVES: The aim of this study is to analyse the possibilities of the state to strengthen the position of patients with the aid of a new financial regime, such as personal health budgets. METHODS: Data were collected through in-depth interviews with executives, managers, professionals and client representatives of six long-term care institutions. RESULTS: With the introduction of individual budgets the responsibility for budgetary control has shifted from the organisational level to the individual level in the caregiver-client relationship. Having more luxurious care on offer necessitates a stronger demarcation of regular care because organisations cannot simultaneously offer extra care as part of the standard care package. New financial instruments have an impact on the culture of receiving and giving care. Distributive justice takes on new meaning with the introduction of financial market mechanisms in healthcare; the distributing principle of 'need' is transformed into the principle of 'economic demand'. CONCLUSION: Financial instruments not only act as a countervailing power against providers insufficiently client-oriented, but are also used by providers to reinforce their own positions vis-à-vis demanding clients. Tailor-made finance is not the same as tailor-made care.

From cure to care: assessing the ethical and professional learning needs of medical learners in a care-based facility.

The purpose of this study was to assess the ethical and professional learning needs of medical trainees on clinical placements at a care-based facility, as they shifted from acute care to care-based philosophy. Using qualitative data analysis and grounded theory techniques, 12 medical learners and five clinical supervisors were interviewed. Five themes emerged as learning needs: the holistic approach to care, withdrawal of treatment and withholding investigations, the collaborative team model, violations to patient autonomy, Do Not Resuscitate and advance directives issues. The results illustrate the importance of preparing medical learners for a philosophical shift in their approach to patient care, as they move from the more cure-based approach of acute care to the care model of care-based facilities.

Nurses perceptions of older patients integrity in long-term institutions.

AIM: This article reports on a study into nurses' perceptions of how the integrity of older patients is maintained in long-term care institutions in Finland. BACKGROUND: Patient integrity is an important aspect of ethical decision-making in nursing care and respect for integrity is central to good care. Problems may occur in the maintenance of older patients' integrity because of reduced communication skills and decision-making authority. Data collection was by means of a purpose-designed structured questionnaire in a sample of 222 nurses from four purposively selected long-term institutions in 2004. The response rate was 74%. The questionnaire consisted of a background data sheet and integrity items in three categories: psychological, physical and social integrity. RESULTS: The nurses gave the highest ratings for the maintenance of physical integrity, particularly for respectful and gentle touching. Nonetheless, according to nurses patients were often tied to their bed or chair. The second highest ratings were give to the maintenance of social integrity. Most nurses felt that the patients had good contact with the outside world, mainly family members. On the other hand loneliness was a more common problem for older people in institutions. The maintenance of psychological integrity received the lowest rating. Satisfaction with the job and with the quality of service provided correlated positively with the nurses' views on the maintenance of patient integrity. CONCLUSION: Nurses take the view that patient integrity is maintained reasonably well in long-term institutions. There are, however, some problematic areas that require special attention, particularly in the maintenance of psychological integrity. Future research needs to look at how patients and their relatives view the situation and to explore different training delivery options that can help raise the ethical quality of nursing care.