The Team Based Biopsychosocial Model: Having a Clinical Ethicist as a Facilitator and a Bridge Between Teams.

The biopsychosocial model is characterized by the systematic consideration of biological, psychological, and social factors and their complex interactions in understanding health, illness, and health care delivery. This model opposes the biomedical model, which is the foundation of most current clinical practice. In the biomedical model, quest for evidence based medicine, the patient is reduced to molecules, genes, organelles, systems, diseases, etc. This reduction has brought great advances in medicine, but it lacks a holistic view of the person. To solve the problem, we propose an early team based approach where the primary care physician leads a group of people that can help her/him address the psychosocial issues while she/he attends to the biomedical issues. This article addresses one case where the clinical ethicist facilitating a team based biopsychosocial model for the care of a patient worked as a bridge between the primary team, the critical care team, and the psychosocial team to advance the argument that good communication among the groups can lead to a true biopsychosocial model where the collaboration of the social worker, psychologist, chaplain, ethicist and the different medical teams can improve the overall patient experience.

When a Child Needs a Transplant but Lacks Familial Social Support.

We present the case of a 19-month-old boy with complex congenital heart disease. His single father is skeptical of traditional medicine and does not offer the social support needed to make heart transplantation successful for his son. After the father demonstrates commitment to transplant success and provides enhanced social support, doctors place the child on a Berlin Heart (a biventricular assist device) as a bridge to transplantation and list him for transplant. When the child is matched to a donor heart, the father refuses transplantation, despite that it is the child's only chance for survival. His doctors report the case to child protective services, but they decline to take protective custody. The father then changes his mind and asks that the child be put back on the waiting list for transplant. By this time, the social supports the father implemented are no longer in place. This case raises a number of issues. First, should courts order heart transplantation when doctors believe that it is in the child's best interest and parents do not consent? Second, once parents refuse a transplant, can they change their minds? Third, if there are uncertainties regarding whether the child has the social support to make transplantation successful, should the child be relisted? Finally, should a child who is not currently a transplant candidate but who may become one in the future be supported with ventricular assist devices?

A Enfermagem no processo de reconhecimento da autonomia do usuário renal crônico: a importância da avaliação da qualidade de vida para uma bioética do cuidado / Nursing in the process of recognizing the autonomy of chronic renal users: the importance of assessing quality of life for a bioethics of care

Introdução: A pesquisa apresenta uma perspectiva original sobre as implicações bioéticas inerentes ao cuidado de Enfermagem e, com ela, uma nova consciência acerca da conduta profissional no diálogo com a diversidade dos sujeitos autônomos. A partir deste novo recorte, se insere o reconhecimento como componente elementar de análise da integralidade da assistência que, no caso do usuário renal crônico, se concretiza na qualidade de vida atribuída à sua condição clínica, mensurável quantitativamente através do Kidney Disease and Quality of Life ­ Short Form (KDQOL-SFTM1.3). Esta pesquisa apresenta a seguinte hipótese teórica: a avaliação da qualidade de vida do usuário renal crônico, como parte inerente do cuidado de Enfermagem, possibilita o reconhecimento da sua autonomia como ponto articulador de uma bioética do cuidado. Questão norteadora: Como a qualidade de vida resultante da avaliação dos usuários renais crônicos possibilita ao enfermeiro reconhecer o sentido da autonomia como fundamento bioético na relação do cuidado? Objeto: O reconhecimento da autonomia dos usuários renais crônicos, considerando sua percepção de qualidade de vida, como elemento fundamental para um cuidado bioético de Enfermagem. Objetivos: Avaliar a qualidade de vida dos usuários renais crônicos, de forma quantificada através do instrumento Kidney Disease and Quality of Life ­ Short Form (KDQOL-SFTM1.3), como parte integrante da compreensão do processo de reconhecimento da sua autonomia; Analisar os resultados obtidos através de uma perspectiva bioética fundada em uma concepção holística do cuidado de Enfermagem; Discutir, etnograficamente, como os elementos sócio-antropológicos, presentes na concepção de reconhecimento, integram o cuidado bioético de Enfermagem; Propor uma bioética do cuidado, capaz de auxiliar a Enfermagem na construção de uma assistência que associe competência profissional (beneficência/não-maleficência), respeito pela integridade moral do usuário (autonomia) e responsabilidade social na aplicação dos recursos de saúde (justiça). Metodologia: Trata-se de uma pesquisa transversal de investigação quantitativa, na modalidade etnometodologia. Os dados oriundos da aplicação do questionário autoaplicável KDQOL- SFTM1.3, em que o escore final varia de 0 a 100, considerando que valores próximos ao 0 correspondem a uma qualidade de vida menos favorável e os valores próximos a 100 a uma melhor qualidade de vida, sofreram análise descritiva-analítica com auxílio do software Statistical Package for the Social Sciences (SPSS) versão 21.0, com geração de média, mediana e desvio padrão além de considerar o nível de significância de 5%. Resultados e discussão: A pesquisa demonstra, através da aplicação do questionário KDQOL-SFTM1.3, a transição da quantificação dos dados para a qualificação dos procedimentos terapêuticos e serviços de saúde prestados aos usuários. Em todas e cada uma das dimensões abordadas pelo questionário,equipe de enfermagem tem relevância ímpar no processo de enfrentamento do usuário. O reconhecimento de sua autonomia permite vislumbrar a corresponsabilidade envolvida no plano terapêutico estabelecido entre usuário e profissional de saúde. Conclusão: A bioética do cuidado, entendida como forma privilegiada da condição epistemológica e pragmática da Enfermagem permite a construção de pontes entre conhecimento e entre pessoas, com o objetivo de promover bem-estar e qualidade de vida. Os três axiomas: inseparabilidade das habilidades, unidade bidimensional e aggiornamento do mundo circundante demonstram que o valor bioético do cuidado deve estar em sintonia com os imperativos instituídos pelos usuários, autônomos, inseridos em um contexto sócio-antropológico. Assim, se pode dizer que a bioética do cuidado é uma Bioética do cuidado real de uma Enfermagem real.

Introduction: The research presents an original perspective on the bioethical implications inherent to nursing care and, with it, a new awareness about professional conduct in dialogue with the diversity of autonomous subjects. Based on this new approach, recognition is inserted as an elementary component of the analysis of the comprehensiveness of care that, in the case of chronic renal users, is reflected in the quality of life attributed to their clinical condition, measurable quantitatively through the instrument Kidney Disease and Quality of Life ­ Short Form (KDQOL-SFTM1.3). This research presents the following theoretical hypothesis: the assessment of the quality of life of chronic renal users, as an inherent part of nursing care, enables the recognition of their autonomy as an articulating point of a bioethics of care. Guiding question: How does the quality of life resulting from the assessment of chronic renal users enable nurses to recognize the sense of autonomy as a bioethical foundation in the relationship of care? Object: The recognition of the autonomy of chronic renal users, considering their perception of quality of life, as a fundamental element for a bioethical nursing care. Objectives: To evaluate the quality of life of chronic renal users, quantified through the instrument Kidney Disease and Quality of Life ­ Short Form (KDQOL-SFTM1.3). as an integral part of understanding the process of recognizing their autonomy; To analyze the results obtained through a bioethical perspective based on a holistic conception of nursing care; Discuss, ethnographically, how the socio-anthropological elements, present in the conception of recognition, integrate the bioethical nursing care; Propose a bioethics of care, capable of assisting nursing in the construction of care that associates professional competence (beneficence / nonmaleficence), respect for the moral integrity of the user (autonomy) and social responsibility in the application of health resources (justice). Methodology: This is a cross-sectional research of quantitative research, in the ethnomethodology modality. Data from the self-administered KDQOL-SFTM1.3 questionnaire, in which the final score ranges from 0 to 100, considering that values close to 0 correspond to a less favorable quality of life and values close to 100 to a better quality of life. suffered descriptive-analytical analysis with the aid of the software Statistical Package for the Social Sciences (SPSS) version 21.0, with generation of mean, median and standard deviation and considering the significance level of 5%. Results and discussion: The research demonstrates, through the application of the KDQOL-SFTM1.3 questionnaire, the transition from data quantification to the qualification of therapeutic procedures and health services provided to users. In each and every one of the dimensions addressed by the questionnaire, the nursing team has unique relevance in the user's coping process. The recognition of their autonomy allows us to glimpse the co-responsibility involved in the therapeutic plan established between users and health professionals. Conclusion: The bioethics of care, understood as a privileged form of the epistemological and pragmatic condition of nursing, allows the construction of bridges between knowledge and between people, with the objective of promoting well-being and quality of life. The three axioms: inseparability of skills, two-dimensional unity and aggiornamento of the surrounding world demonstrate that the bioethical value of care must be in line with the imperatives instituted by autonomous users, inserted in a socio-anthropological context. Thus, it can be said that the bioethics of care is a real care bioethics of a real nursing.

Serving the Very Sick, Very Frail, and Very Old: Geriatrics, Palliative Care, and Clinical Ethics.

How can we provide the best care for growing numbers of very frail, very sick, or very old people? The disciplines of geriatrics, palliative care, and clinical ethics each have a good deal to offer to improve care for elders, yet each field is saddled with heavy historical baggage. Using a case as a springboard, we address specific strengths and shortcomings of each field, and what these disciplines can learn from each other. Geriatrics is currently largely focused on prevention of disability, cognitive impairment, and death; it should reorganize around a palliative approach to providing care for elders living with multiple chronic conditions, disability, and dementia. Palliative care, while paying some attention to the spectrum of advanced illness, concentrates primarily on cancer; it should expand its central purpose to include providing supportive care to elders with serious illness and their caregivers. Ethics committee members and consultants principally stress individual autonomy; they need to expand their approach and develop longitudinal relationships with patients and family members, routinely incorporating them in deliberations and the crafting of recommendations. However, improving these three disciplines will only go so far toward improving the care of very frail, very sick, or very old people. What is most needed is longitudinal care provided by interdisciplinary primary care teams steeped in the core principles of all three disciplines.

Music Therapy and Spiritual Care in End-of-Life: A Qualitative Inquiry into Ethics and Training Issues Identified by Chaplains and Music Therapists.

BACKGROUND: Music therapists are increasingly employed by hospices. As such, they are often called upon to provide additional spiritual care to patients receiving end-of-life care. However, researchers have not yet examined the appropriateness of music therapists providing spiritual care as part of the hospice team, or ethics and training issues related to music therapist-led spiritual care. OBJECTIVE: The purpose of this study was to explore the thoughts and attitudes of hospice chaplains and music therapists (MTs) about ethics and training issues related to music therapists providing spiritual care as part of the hospice interdisciplinary team. METHODS: The study used semi-structured interviews with a purposive sample of music therapists and chaplains specializing in hospice care as part of a larger exploratory mixed methods study. Each interview was recorded, transcribed, and analyzed using a two-step process including both a modified phenomenological inductive approach and thematic analysis. RESULTS: Participants discussed ethics and training issues related to the provision of music therapist-led spiritual care as part of the hospice team. These issues included scope of practice, cultural competence and maintaining personal boundaries, and spiritual care training topics such as educational content and educational methods. CONCLUSIONS: While it was clear that both chaplains and music therapists felt it was appropriate for music therapists to provide spiritual care as part of the hospice team, there is a need for formal and informal spiritual care training for music therapists doing this type of work. Training should potentially include information about comparative religions, cultural competence, scope of practice, and maintaining personal boundaries.

[What you can do when dealing with emergencies in the dementia setting]. / Notfälle bei Demenz - was Sie tun können.

Frequent emergencies in patients with dementia include aggressiveness, screaming, day/night reversal, other behavioral disorders, and falls. They are often caused by delirium, especially if there has been a rapid change in the patient's state of health. Hypoactive delirium in particular is difficult to recognize in the dementia setting. Acute somatic diseases bear a different meaning in dementia than in non-dementia patients, and priorities must be given to the impaired cerebral performance. In addition to medical decisions, ethical ones need to be made. Special attention should be paid to the resources of the caregiver network. This article describes both non-pharmacological and pharmacological treatment modalities when dealing with emergencies in dementia patients.

From interdisciplinary to integrated care of the child with autism: the essential role for a code of ethics.

To address the developmental deficits of children with autism, several disciplines have come to the forefront within intervention programs. These are speech-pathologists, psychologists/counselors, occupational-therapists/physical-therapists, special-education consultants, behavior analysts, and physicians/medical personnel. As the field of autism therapy moves toward a more comprehensive, holistic and interdisciplinary model, the complexity of an interdisciplinary service delivery model could pose significant challenges. The difficulty of carrying out this approach could lead to sub-par programs being established. With integration among the disciplines a necessity, the ethical principles and language common to all the contributing disciplines is argued as the appropriate integrating force. An outline of these principles and a draft code of ethics are offered to introduce high standards and expectations for all participating in such a program.

[Setting up of a community/hospital network providing care for patients and their families]. / Mise en place d'une structure ville/hôpital de prise en charge des patients et de leurs familles.

With the ageing of the population, dementia has become a public healthcare priority. A network designed to help the families of patients suffering from dementia on a medical as well as a social and psychological level has been set up. This structure has been developed in close coordination with community practitioners and physicians and in line with the latest recommendations in particular with regard to ethics. Its first three years of existence confirm the importance of this type of approach which complements the care provided by hospitals.

Circuloterapia: uma metáfora para o enfrentamento da dor crônica em duas clínicas de dor / Circle therapy: a metaphor for coping with chronic pains in two pain clinics

Este artigo descreve e analisa a dinâmica da clínica de dor enquanto um "artefato complexo" do sistema terapêutico biomédico, explorando as múltiplas vozes e as relações dialógicas sobre dor e a interdisciplinaridade no cotidiano clínico de duas clínicas de dor situadas em hospitais-escola nas cidades de Salvador e São Paulo. Foi realizado estudo etnográfico orientado pela antropologia interpretativa, na qual se buscou a descrição de situações singulares e expressivas da dinâmica da clínica de dor (considerada enquanto um serviço, constituído no interior da Biomedicina, destinado ao cuidado da dor crônica). Tais situações expressam tensões e soluções construídas a partir do enfrentamento da dor crônica enquanto objeto complexo que impõe, a todos, flexibilidade. Essa experiência etnográfica focalizou quatro espaços terapêuticos: a sala de espera, o corredor, a consulta médica e as discussões de caso clínico. A descrição produzida ilumina as múltiplas vozes sobre dor e interdisciplinaridade no cotidiano da clínica. Os sentidos da circulação nos espaços terapêuticos, representado no texto a partir da metáfora "circuloterapia", orientam essa discussão em torno dos limites e possibilidades da constituição e funcionamento deste serviço.

This paper describes and analyzes the pain clinic's dynamics as a "complex product" of the biomedical therapy system, exploring the many discussions about the meaning of pain and the interdisciplinary collaboration in the therapeutic daily routines of two pain clinics, located in university hospitals in the cities Salvador and São Paulo. An ethnographic approach guided by interpretative anthropology was used to search for the description of singular and expressive situations of the pain clinic's dynamics (considered as a service, established within Biomedicine, intended for care of chronic pain). Such situations express tensions and solutions created from the confrontation of the chronic pain as a complex object that imposes flexibility to all. This ethnography focuses on four therapeutic spaces: the waiting-room, the hall, the medical consultation and the clinical case discussion. The resulting description enlightens the multiple voices on pain and interdisciplinary collaboration in the clinic's daily routines. The directions of circulation within therapeutic spaces guided this reflection around the limits and possibilities of the establishment and operation of this service.

Holistic management of DSD.

Disorder of sex development (DSD) presents a unique challenge, both diagnostically and in terms of acute and longer-term management. These are relatively rare conditions usually requiring a multidisciplinary approach from the outset and the involvement of a tertiary centre for assessment and management recommendations. This article describes the structure of the multidisciplinary team (MDT) at our centre, with contributions from key members of the team regarding their individual roles. The focus is on the newborn referred for assessment of ambiguous genitalia, rather than on individuals who present in the adolescent period or at other times, although the same MDT involvement is likely to be required. The approach to the initial assessment and management is discussed and the subsequent diagnosis and follow-up presented, with emphasis on the importance of careful transition and long-term support.

Progress in ethical decision making in the care of the dying.

Practitioners in critical care have made a significant progress in caring for dying patients in critical care by taking advantage of the suggestions from their professional groups. Progress has been made in responding to and controlling patients' pain. Major initiatives from the Joint Commission and the American Pain Society have helped direct this improvement. Palliative care consultations as well as ethics consultations have improved symptom control in the critically ill. Issues of consent have been problematic for dying patients in critical care especially in the area of discontinuing therapies. But, better policies related to advance directives have been developed to ensure good care. Spiritual care has received more attention, and now chaplains are recognized by the Society for Critical Care Medicine as integral to the critical care team. The American Association of Critical-Care Nurses has been a leader in improving end-of-life issues and continues to spearhead many projects to improve end-of-life 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.

O dilema dos cuidadores da saúde: reflexões sobre distanásia diante do paciente fora de possibilidades terapêuticas / The health carers’ dilemma: reflections on disthanasia in face to patient out of therapeutics possibilities

Este estudo analisa o tema da "Distanásia" na realidade brasileira especificamente na Unidade de Cuidado Intensivo. A maioria dos profissionais da saúde, especificamente os médicos, tem dilemas éticos sobre o cuidado do paciente terminal fora de possibilidades terapêuticas. Continuar a terapêutica sempre? Parar? Quando e em que base? A lei é rígida e pribitiva em termos de eutanásia e estimula os tratamentos fúteis por defender a vida biológica. Esta situação resulta em morte dolorosa para o paciente, sofrimento inútil na família e eleva o custo do tratamento, em um cenário de recursos de saúde escassos. Os médicos têm medo de tomar decis~es para interromper o tratamento em face à morte iminente, porque a lei proíbe e define este ato como eutanásia. Consequentemente eles podem ser processados. Distanásia quer dizer uma morte lenta, medicamente prolongada e acompanhada de sofrimento. Embora o assunto eutanásia esteja frequentemente sendo discutido em nossa realidade.

[Clinical ethics consultation - an integrative model for practice and reflection]. / Ethikberatung in der Klinik - ein integratives Modell für die Praxis und ihre Reflexion.

Broad evidence exists that health care professionals are facing ethical difficulties in patient care demanding a spectrum of useful ethics support services. Clinical ethics consultation is one of these forms of ethics support being effective in the acute setting. An authentic case is presented as an illustration. We introduce an integrative model covering the activities being characteristic for ethics consultation and going beyond "school"-specific approaches. Finally, we formulate some do's and don'ts of ethics consultation that are considered to be key issues for successful practice.

Confidentiality in the age of HIPAA: a challenge for psychosomatic medicine.

This review, a work project of The Standards and Ethics Committee of The Academy of Psychosomatic Medicine, examines the challenges posed for consultation-liaison psychiatrists as they struggle to maintain the trust between patient and physician while balancing compliance with the increasing complexities of confidentiality with the provision of enough information to our medical colleagues for good clinical care. The authors discuss the moral, legal, and ethical issues that arise from the many-layered state and federal regulations, especially the impact of the Health Information Portability and Accountability Act (HIPPA) and make recommendations for practical application in the clinical setting.