Interprofessional perceptions of emotional, social, and ethical effects of multidrug-resistant organisms: A qualitative study.

INTRODUCTION: Multi-drug-resistant organisms (MDRO) are usually managed by separating the infected patients to protect others from colonization and infection. Isolation precautions are associated with negative experiences by patients and their relatives, while hospital staff experience a heavier workload and their own emotional reactions. METHODS: In 2018, 35 participants (nurses, physicians, pharmacists) in an antimicrobial-stewardship program participated in facilitated discussion groups working on the emotional impact of MDRO. Deductive codings were done by four coders focusing on the five basic emotions described by Paul Ekmans. RESULTS: All five emotions revealed four to 11 codes forming several subthemes: Anger is expressed because of incompetence, workflow-impairment and lack of knowledge. Anxiety is provoked by inadequate knowledge, guilt, isolation, bad prognoses, and media-related effects. Enjoyment is seldom. Sadness is experienced in terms of helplessness and second-victim effects. Disgust is attributed to shame and bad associations, but on the other hand MDROs seem to be part of everyday life. Deductive coding yielded additional codes for bioethics and the Calgary Family Assessment Method. CONCLUSION: MDRO are perceived to have severe impact on emotions and may affect bioethical and family psychological issues. Thus, further work should concentrate on these findings to generate a holistic view of MDRO on human life and social systems.

Spiritual care performed in a drug user clinic.

OBJECTIVE: To know the spiritual care practices of health workers in the context of an inpatient unit for the treatment of addictive disorders, aiming to incorporate an expanded care practice. METHOD: Qualitative study considering the Convergent Care Research theoretical framework. The data collection occurred using semi-structured interviews, with three rounds of conversations and informal chats with 14 health professionals, from July to November 2017. The analysis followed the steps of apprehension, synthesis, theorization and transference. RESULTS: Four categories emerged: respect for user ethical values; addressing the beliefs and values of professionals; the health professional-user relationship; and collective spiritual care. The main actions highlighted were individual (relaxation and prayer) and collective (meditation, spirituality and the 12 steps). CONCLUSION: The rounds of conversations carried out in this research allowed workers to talk about spiritual care in addiction, to better understand its relevance to meet the needs of the patient.

Spiritual care performed in a drug user clinic / El cuidado espiritual realizado en una unidad de internación en adición / O cuidado espiritual realizado em uma unidade de internação em adição

ABSTRACT Objective: To know the spiritual care practices of health workers in the context of an inpatient unit for the treatment of addictive disorders, aiming to incorporate an expanded care practice. Method: Qualitative study considering the Convergent Care Research theoretical framework. The data collection occurred using semi-structured interviews, with three rounds of conversations and informal chats with 14 health professionals, from July to November 2017. The analysis followed the steps of apprehension, synthesis, theorization and transference. Results: Four categories emerged: respect for user ethical values; addressing the beliefs and values of professionals; the health professional-user relationship; and collective spiritual care. The main actions highlighted were individual (relaxation and prayer) and collective (meditation, spirituality and the 12 steps). Conclusion: The rounds of conversations carried out in this research allowed workers to talk about spiritual care in addiction, to better understand its relevance to meet the needs of the patient.

RESUMEN Objetivo: Conocer las prácticas de cuidado espiritual de los trabajadores de la salud en el contexto de una unidad de hospitalización para el tratamiento de trastornos adictivos, con el objetivo de incorporar una práctica de atención ampliada. Método: Estudio cualitativo con referencial metodológico de la Investigación Convergente Asistencial. Se realizaron entrevistas semiestructuradas, tres rondas de conversaciones y conversaciones informales con 14 trabajadores de salud en una internación por adición de julio a noviembre de 2017. El análisis de las informaciones siguió las etapas de aprehensión, síntesis, teorización y transferencia. Resultados: Surgieron cuatro categorías: respeto de los valores éticos de los usuarios; creencias y valores de la persona; relaciones profesional de salud-usuario; y cuidado espiritual en grupo. Las principales acciones destacadas fueron individuales (relajación y oración) y colectivas (meditación, espiritualidad y 12 pasos). Conclusión: Las rondas de conversaciones, realizadas en esta investigación, permitieron a los trabajadores conversar sobre el cuidado espiritual en la adición, comprendiendo mejor su relevancia asistencial para atender las necesidades del paciente.

RESUMO Objetivo: Conhecer as práticas de cuidado espiritual de trabalhadores de saúde no contexto de uma unidade de internação para o tratamento de transtornos aditivos, visando incorporar uma prática assistencial ampliada. Método: Estudo qualitativo com referencial metodológico da Pesquisa Convergente Assistencial. Foram realizadas entrevistas semiestruturadas, três rodadas de conversas e conversas informais com 14 trabalhadores de saúde em uma unidade de internação em adição de julho a novembro de 2017. A análise das informações seguiu as etapas apreensão, síntese, teorização e transferência. Resultados: Emergiram quatro categorias: evocação dos valores éticos dos trabalhadores; respeito às crenças e valores do usuário; encontro trabalhador de saúde-usuário e cuidado espiritual em grupo. As principais ações destacadas foram individuais (relaxamento e oração) e coletivas (meditação, espiritualidade e 12 passos). Conclusão: As rodadas de conversas, realizadas nesta pesquisa, permitiram aos trabalhadores conversarem sobre o cuidado espiritual na adição, compreendendo melhor a sua relevância assistencial para atender às necessidades do paciente.

Healthcare professionals' moral distress in adult palliative care: a systematic review.

OBJECTIVES: Palliative care providers may be exposed to numerous detrimental psychological and existential challenges. Ethical issues in the healthcare arena are subject to continual debate, being fuelled with ongoing medical, technological and legal advancements. This work aims to systematically review studies addressing the moral distress experienced by healthcare professionals who provide adult palliative care. METHODS: A literature search was performed on PubMed, Scopus, Web of Science and PsycINFO databases, searching for the terms 'moral distress' AND 'palliative care'. The review process has followed the international PRISMA statement guidelines. RESULTS: The initial search identified 248 papers and 10 of them were considered eligible. Four main areas were identified: (1) personal factors, (2) patients and caregivers, (3) colleagues and superiors and (4) environment and organisation. Managing emotions of self and others, witnessing sufferance and disability, caring for highly demanding patients and caregivers, as well as poor communication were identified as distressing. Moreover, the relationship with colleagues and superiors, and organisational constraints often led to actions which contravened personal values invoking moral distress. The authors also summarised some supportive and preventive recommendations including self-empowerment, communication improvement, management of emotions and specific educational programmes for palliative care providers. A holistic model of moral distress in adult palliative care (integrating emotional, cognitive, behavioural and organisational factors) was also proposed. CONCLUSIONS: Cognisance of risk and protective factors associated with the moral distress phenomenon may help reframe palliative healthcare systems, enabling effective and tailored actions that safeguard the well-being of providers, and consequently enhance patient care.

Health Professionals Perceived Concerns and Challenges in Providing Palliative and End-of-Life Care: A Qualitative Analysis.

BACKGROUND:: The Institute of Medicine identifies that quality palliative/end-of-life (EOL) care should be provided to patients with serious, life-limiting illnesses and their families by competently prepared health professionals. PURPOSE:: This study assessed perceived concerns of health professionals pertaining to the delivery of palliative/EOL care in the hospital setting. The specific aim was to determine thematic concerns in the delivery of palliative/EOL care which emerged from respondents' impressions of a memorable palliative/EOL patient experience. METHODS:: Interdisciplinary health professionals at a large academic health system in the Midwest were surveyed to reflect upon a memorable palliative/EOL life care patient situation (positive or negative). A Thematic Analysis approach was used to code qualitative responses to 4 open-ended questions and then extract themes and subthemes from the coded data. RESULTS:: Concerns identified by participants (N = 425) emerged around 7 themes including communication (97%), decision-making/care planning (75%), education needs (60%), EOL care (48%), ethics (24%), satisfaction with care (9%), and spiritual/cultural sensitivity (6%). CONCLUSION:: Challenges exist in the delivery of quality palliative/EOL care in the hospital setting which may be addressed through educational initiatives that focus on recognition of cultural influences on care preferences, improving communication between patients/families and providers, education about the differences between palliative and EOL care, and increased competency of health providers in having EOL/goals-of-care discussions. Health professionals must recognize the benefit of collaborative palliative care in order to meet patient and family needs holistically and comprehensively.

Exploring the vagueness of Religion & Spirituality in complex pediatric decision-making: a qualitative study.

BACKGROUND: Medical advances have led to new challenges in decision-making for parents of seriously ill children. Many parents say religion and spirituality (R&S) influence their decisions, but the mechanism and outcomes of this influence are unknown. Health care providers (HCPs) often feel unprepared to discuss R&S with parents or address conflicts between R&S beliefs and clinical recommendations. Our study sought to illuminate the influence of R&S on parental decision-making and explore how HCPs interact with parents for whom R&S are important. METHODS: A longitudinal, qualitative, descriptive design was used to (1) identify R&S factors affecting parental decision-making, (2) observe changes in R&S themes over time, and (3) learn about HCP perspectives on parental R&S. The study sample included 16 cases featuring children with complex life-threatening conditions. The length of study for each case varied, ranging in duration from 8 to 531 days (median = 380, mean = 324, SD = 174). Data from each case included medical records and sets of interviews conducted at least monthly with mothers (n = 16), fathers (n = 12), and HCPs (n = 108). Thematic analysis was performed on 363 narrative interviews to identify R&S themes and content related to decision-making. RESULTS: Parents from 13 cases reported R&S directly influenced decision-making. Most HCPs were unaware of this influence. Fifteen R&S themes appeared in parent and HCP transcripts. Themes most often associated with decision-making were Hope & Faith, God is in Control, Miracles, and Prayer. Despite instability in the child's condition, these themes remained consistently relevant across the trajectory of illness. R&S influenced decisions about treatment initiation, procedures, and life-sustaining therapy, but the variance in effect of R&S on parents' choices ultimately depended upon other medical & non-medical factors. CONCLUSIONS: Parents consider R&S fundamental to decision-making, but apply R&S concepts in vague ways, suggesting R&S impact how decisions are made more than what decisions are made. Lack of clarity in parental expressions of R&S does not necessarily indicate insincerity or underestimation of the seriousness of the child's prognosis; R&S can be applied to decision-making in both functional and dysfunctional ways. We present three models of how religious and spiritual vagueness functions in parental decision-making and suggest clinical applications.

Aspectos bioéticos desde la visión personalista de la espiritualidad en el manejo de las personas en el área de la salud / Bioethical aspects from the personalist vision of spirituality in the management of people in the health area

Introducción: Por regla general todos los trabajadores de la salud han sido modelados por el paradigma científico de la modernidad que ha hecho una separación drástica entre cuerpo y mente y entre ser humano y naturaleza. Pero porque no se ha considerado en el abordaje de la espiritualidad en paciente sanos o con patologías que no necesariamente amenazan la vida? Esta interrogante debe darse respuesta tanto desde el punto de vista holístico y como parte de la ética del cuidado. No se puede separar al ser humano al cuidarlo solo en lo biológico o psicológico, el aspecto espiritual ha de ser abordado. Objetivos: Determinar qué aspectos de la Bioética están relacionados con la espiritualidad en el manejo de los pacientes. Paciente y Métodos: estudio cualitativo mediante Revisión sistemática de la literatura médica publicada en los siguientes buscadores: scielo, HINARI, pubmed, revisión de artículos publicados y manuales de Bioética y Espiritualidad, revisión de publicaciones en congreso, conferencias sobre Bioética y Espiritualidad. Resultados: El número total de artículos identificados fue de 101 (MEDLINE) y 135 (CINAHL). Después de tamizar, la recopilación de otros artículos que hablan sobre un aspecto de la espiritualidad, pero no el término en sí mismo (por ejemplo, la esperanza); la realización de búsquedas manuales en bibliografías o referido por sus compañeros que no se encuentran en la búsqueda de la literatura original, 58 artículos se consideraron pertinentes y se discuten aquí en el análisis temático. Los investigadores, que se sitúan en este campo, inevitablemente sugieren estudiar la espiritualidad desde una perspectiva más cualitativa, con el argumento de que porque la espiritualidad ha de ser experimentado que no se puede medir. Las palabras de McGrath encarnan la idea central de esta perspectiva, "conceptualmente, la espiritualidad no puede ser entendido como una entidad independiente que se mide y se registra. Los investigadores tienen que estar abiertos a la gran cantidad de formas en que los individuos construyen significado". Las necesidades espirituales de los pacientes de cuidados paliativos la naturaleza de la esperanza en los cuidados paliativos; herramientas y terapias relacionadas con la espiritualidad; efectos de la religión en los cuidados paliativos; y la espiritualidad y los profesionales de cuidados paliativos. En otros estudios se han informado que la espiritualidad y aspectos relacionados (por ejemplo, la oración, la meditación) han tenido un efecto positivo en: dolor crónico; psoriasis en pacientes que reciben fototerapia; función inmune; menos efectos adversos en pacientes cardíacos; mayor apoyo social y menos síntomas depresivos entre los pacientes geriátricos; aumento de la salud física y mental. Conclusión: existen evidencias para nada despreciables de que la espiritualidad tiene relación con el estado de salud y calidad de vida de las personas, que explorarlas, trabajarlas produce un bien en el ser persona del paciente, visto en su totalidad como ser digno en cualquier circunstancia, por tanto es ético tener que abordarlo adecuadamente

Introduction: As a general rule all health workers have been modeled by the scientific paradigm of modernity that has made a drastic separation between body and mind and between human and nature. But because it has not been considered in the approach of spirituality in healthy patients or with pathologies that do not necessarily threaten life? This question must be answered both holistically and as part of the ethics of care. It is not possible to separate the human being by taking care of it only in the biological or psychological, the spiritual aspect has to be approached. Objectives: To determine which aspects of bioethics are related to spirituality in the management of patients. Patient and Methods: qualitative study through Systematic Review of medical literature published in the following search engines: scielo, HINARI, pubmed, review of published articles and manuals Of Bioethics and Spirituality, review of publications in congress, conferences on Bioethics and Spirituality. Results: The total number of articles identified was 101 (MEDLINE) and 135 (CINAHL). After sifting, the compilation of other articles that speak about an aspect of spirituality, but not the term itself (eg, hope); The accomplishment of manual searches in bibliographies or referred by his companions that are not in the search of the original literature, 58 articles were considered pertinent and are discussed here in the thematic analysis. Researchers, who are in this field, inevitably suggest studying spirituality from a more qualitative perspective, arguing that because spirituality has to be experienced it can not be measured. McGrath's words embody the central idea of this perspective, "conceptually, spirituality can not be understood as an independent entity that is measured and recorded "Researchers have to be open to the myriad ways in which individuals construct meaning" the spiritual needs of palliative care patients the nature of hope in palliative care; Tools and therapies related to spirituality; Effects of religion on palliative care; And spirituality and palliative care professionals. Other studies have reported that spirituality and related aspects (eg, prayer, meditation) have had a positive effect on: chronic pain; Psoriasis in patients receiving phototherapy; Immune function; Fewer adverse effects in cardiac patients; Greater social support and fewer depressive symptoms among geriatric patients; Increased physical and mental health. Conclusion: there is no evidence that spirituality is related to the health and quality of life of people, to explore them, to work them produces a good in the person of the patient, seen in its totality as being worthy in any circumstance, So it is ethical to have to address it properly.

The impact of Professional Boundaries for Health Professionals (PBHP) training on knowledge, comfort, experience, and ethical decision-making: a longitudinal randomized controlled trial.

PURPOSE: A randomized controlled trial was conducted to evaluate the impact of Professional Boundaries for Health Professionals (PBHP) training program on the knowledge, comfort, experience, and ethical decision-making of multidisciplinary practitioners facing client-practitioner boundary dilemmas. METHODS: In all, 36 rehabilitation practitioners from an Australian state-wide spinal cord injuries service were assigned to experimental and control groups. The Boundaries in Practice (BIP) Scale measured outcomes at four points: pre, post, 3 months, and 1 year. The control group received the training after 3 months. Nonparametric Friedman's two-way analysis of variance was used to examine the trajectories over time. RESULTS: Analysis was conducted using the data of 10 experimental and 13 control group participants who responded at four data collection points. The experimental group showed significant improvement in knowledge (χ2 = 10.673, p = 0.014) and comfort (χ2 = 9.727, p = 0.021) managing professional boundaries post-training. The control group showed no significant change in knowledge or comfort. No significant change was seen in experience across either experimental (χ2 = 3.609, p = 0.307) or control group (χ2 = 7.800, p = 0.050). Ethical decision-making improved in the control group (χ2 = 13.188, p = 0.004) following training, however remained unchanged in the experimental group. CONCLUSIONS: The findings do not definitively support this training approach. Ethical decision-making may improve more substantially within the practice context and organizational culture change. Multifaceted approaches are indicated. Implications for Rehabilitation Ethical dilemmas related to boundaries between clients and practitioners are a frequent occurrence in the rehabilitation setting. In a relatively small sample, the current randomized trial provided inconclusive evidence on the benefit of a 1-day needs-oriented training program to improve knowledge, comfort, and ethical decision-making. Randomized trials of education and training for rehabilitation practitioners are fraught with challenges in the clinical environment of the rehabilitation setting. Multifaceted training approaches, management support and training as well as changes to policy and organizational context in the rehabilitation setting may be needed to more holistically address the issues surrounding professional boundaries in the rehabilitation setting.

Emotions, narratives, and ethical mindfulness.

Clinical care is laden with emotions, from the perspectives of both clinicians and patients. It is important that emotions are addressed in health professions curricula to ensure that clinicians are humane healers as well as technical experts. Emotions have a valuable and generative role in health professional ethics education.The authors have previously described a narrative ethics pedagogy, the aim of which is to develop ethical mindfulness. Ethical mindfulness is a state of being that acknowledges everyday ethics and ethically important moments as significant in clinical care, with the aim of enabling ethical clinical practice. Using a sample narrative, the authors extend this concept to examine five features of ethical mindfulness as they relate to emotions: (1) being sensitized to emotions in everyday practice, (2) acknowledging and understanding the ways in which emotions are significant in practice, (3) being able to articulate the emotions at play during ethically important moments, (4) being reflexive and acknowledging both the generative aspects and the limitations of emotions, and (5) being courageous.The process of writing and engaging with narratives can lead to ethical mindfulness, including the capacity to understand and work with emotions. Strategies for productively incorporating emotions in narrative ethics teaching are described. This can be a challenging domain within medical education for both educators and health care students and thus needs to be addressed sensitively and responsibly. The potential benefit of educating health professionals in a way which addresses emotionality in an ethical framework makes the challenges worthwhile.

Should health care providers be forced to apologise after things go wrong?

The issue of apologising to patients harmed by adverse events has been a subject of interest and debate within medicine, politics, and the law since the early 1980s. Although apology serves several important social roles, including recognising the victims of harm, providing an opportunity for redress, and repairing relationships, compelled apologies ring hollow and ultimately undermine these goals. Apologies that stem from external authorities' edicts rather than an offender's own self-criticism and moral reflection are inauthentic and contribute to a "moral flabbiness" that stunts the moral development of both individual providers and the medical profession. Following a discussion of a recent case from New Zealand in which a midwife was required to apologise not only to the parents but also to the baby, it is argued that rather than requiring health care providers to apologise, authorities should instead train, foster, and support the capacity of providers to apologise voluntarily.

[Healthcare occupations are "different"]. / Gesundheitsberufe sind "anders"

Healthcare requires careful coordination of several occupations. In order to attain the best possible result, including effectiveness and cost-efficiency, the specific expertise of each of these occupations must be clearly defined. Healthcare occupations, physicians and nurses, are indeed professions as opposed to mere "jobs". They are concerned with living but ill human beings and not with things. Reliance on a personal capacity of judgment is a decisive aspect of professions. Healthcare professionals perform best if they are granted specific independence relative to their work.

When should conscientious objection be accepted?

This paper makes two main claims: first, that the need to protect health professionals' moral integrity is what grounds the right to conscientious objection in health care; and second, that for a given claim of conscientious objection to be acceptable to society, a certain set of criteria should be fulfilled. The importance of moral integrity for individuals and society, including its special role in health care, is advocated. Criteria for evaluating the acceptability of claims to conscientious objection are outlined. The precise content of the criteria is dictated by the two main interests that are at stake in the dilemma of conscientious objection: the patient's interests and the health professional's moral integrity. Alternative criteria proposed by other authors are challenged. The bold claim is made that conscientious objection should be recognised by society as acceptable whenever the five main criteria of the proposed set are met.

Los derechos humanos y los cuidados paliativos: autoevaluación sobre la formación en cuidados paliativos en un grupo de residentes de medicina / Human rights and palliative care: self-assessment training in palliative care in a group of medical residents

La demanda social por los aspectos paliativos de la Medicina se ha incrementado notablemente en los últimos años debido, entre otros factores, al envejecimiento de la población y al aumento de los enfermos con cáncer y otras enfermedades crónicas con mal pronóstico de vida. Todo paciente con enfermedad terminal tiene el derecho a una asistencia integral, que le posibilite calidad de vida y una muerte digna. El discurso médico que enfoca sólo lo patológico se ve reflejado en la práctica médica en el corte entre la enfermedad y el hombre que la padece. La relación médico-paciente con enfermedad avanzada no puede reducirse al control de síntomas físicos, sino que demanda una atención integral, abarcativa de los aspectos bio-psico-sociales y espirituales. Hay estudios que señalan que los médicos recién egresados no están preparados suficientemente para asistir a estos pacientes. El ejercicio de la profesión en sí, no los capacita para enfrentar el sufrimiento y la muerte. Uno de los retos actuales de la Medicina es mejorar la atención de los enfermos incurables en su fase avanzada. A tal fin, las Facultades de Medicina, entre otras, deberían incorporar en sus planes de estudio, conocimientos, estrategias y habilidades que capaciten a estudiantes y residentes en el manejo óptimo de los síntomas, brindando información adecuada, proporcionando soporte emocional y trabajando en equipo interdisciplinario. El objetivo de este trabajo es determinar que proporción de un grupo de residentes de Medicina, han tenido formación en Cuidados Paliativos durante los estudios de pre y post-grado y cómo valoran esa formación.

The social demand for the palliative aspects of Medicine has increased significantly in the last years, among other reasons, as a result of an ageing population and an increase in cancer patients as well as other chronic diseases with poor life prognosis. Every terminally ill patient is entitled to an overall assistance that grants them a better quality of life and a dignified death. The physician’s speech, which only focuses on the pathological, is reflected on the medical practice in the breach between the illness and the person suffering it. The relationship doctor-patient with advanced disease cannot be confined to controlling physical symptoms only, it also calls for an overall, holistic assistance that contemplates bio-psycho-social and spiritual aspects. Current research stresses the fact that recent graduate doctors are not sufficiently trained to assist these patients. The profession as such does not prepare them to cope with suffering and death. One of the present challenges of Medicine is to improve the assistance to the terminally ill in their advanced stages. For that reason, the Medical Schools among others, should include knowledge, strategies and skills in their curricula with a view to training students and residents to deal with symptoms, to deliver information, to provide emotional support and to work as an interdisciplinary team in the best possible way.

A dimensão religiosa dos usuários na prática do atendimento à saúde: percepção dos profissionais da saúde / La dimensión religiosa de los usuarios en la práctica del atendimiento a la salud: percepción de los profesionales de la salud / The religious dimension of users in the practice of health assistance: perception of health professionals

Pesquisa de abordagem qualitativa com o objetivo de conhecer a opinião dos profissionais da saúde sobre a influência da espiritualidade/religiosidade dos usuários no processo saúde-doença. Foi usada a discussão focal com profissionais do Serviço de Saúde Comunitária do Grupo Hospitalar Conceição do município de Porto alegre, RS, no período de setembro de 2009. A amostra tentou abarcar a diversidade de áreas de atuação. O tema da discussão foi a relação entre saúde e espiritualidade dos usuários no trabalho dos profissionais. Para a interpretação dos dados foi utilizada a análise de conteúdo a partir de duas categorias: influência da espiritualidade/religiosidade sobre a saúde e respeito como imparcialidade. Os achados mostram que os profissionais possuem concepções ambíguas sobre a influência da espiritualidade/religiosidade dos usuários na saúde. Respeitam esta dimensão, mas não a utilizam na terapêutica.

Investigation of a qualitative nature aiming at knowing the opinion of health professionals on the influence of spirituality of users in the process health-disease. We used the focal discussion with professionals of the Serviço de Saúde Comunitária do Grupo Hospitalar Conceição [Service of Communitarian Health of Conceição Hospital Group of Porto Alegre, R.S., in the period of September 2009. The sample has tried to include the diversity of action areas. The subject of the discussion has been the relationship between health and spirituality of users in the work of professionals. For data interpretation content analysis was used according to two categories: the influence of spirituality on health and respect as impartiality. Results show that professionals have ambiguous conceptions about the influence of the spirituality of users on their health. Professionals respect that dimension, but they do not use it in treatments.

Investigación de abordaje cualitativo con el objetivo de conocer la opinión de los profesionales de la salud sobre la influencia de la espiritualidad/religiosidad de los usuarios en el proceso salud-enfermedad. Ha sido usada la discusión focal con profesionales del Serviço de Saúde Comunitária del Grupo Hospitalar Conceição [Servicio de Salud Comunitaria del Grupo Hospitalar Conceição] del municipio de Porto Alegre, R.S., en el período de septiembre de 2009. La muestra ha intentado abarcar la diversidad de áreas de actuación. El tema de la discusión ha sido la relación entre salud y espiritualidad de los usuarios en el trabajo de los profesionales. Para la interpretación de los datos se utilizó el análisis de contenido desde dos categorías: influencia de la espiritualidad/religiosidad sobre la salud y el respeto como imparcialidad. Los hallazgos muestran que los profesionales poseen concepciones ambiguas acerca de la influencia de la espiritualidad/religiosidad de los usuarios en la salud. Los profesionales respetan esa dimensión, pero no hacen uso de ella en la terapéutica.

Cultural, ethical, and spiritual competencies of health care providers responding to a catastrophic event.

Compassion is a language that is understood across cultures, religions, and nations. Being compassionate and empathetic is a basic responsibility of health care providers responding to disasters. Compassion and empathy cannot be operationalized unless providers show culturally competent, ethically right, and spiritually caring behavior. In addition to being accepting of cultures other than their own, providers must read literature and familiarize themselves with the predominant cultures of the affected population. Ethically right decision making is essentially an act of balancing the risks and benefits to the entire society. Spiritual care is an important dimension of total health, and therefore recognition and resolution of the spiritual needs of disaster victims is an essential role of health care providers. Disaster management is teamwork and therefore requires that health care providers draw on the expertise and support of other team members; coordinating efforts with local religious, social governmental organizations, and NGOs to deal with the intangible effects of the cultural and spiritual impact of a disaster and to prevent further demoralization of the affected community is imperative. Disasters occur, and the only thing that can ameliorate their devastating effects is to improve disaster preparedness and respond collectively and courageously to every catastrophic event.

Development of ethical rules for boundaries of touch in complementary medicine--outcomes of a Delphi process.

The practice of complementary medicine (CAM) often involves touch. The unique philosophy of many CAM therapies, and the setting in which treatments are provided create a therapeutic space which may be less clearly defined than in conventional settings - a space in which the boundaries between professional touch and personal/intimate touch may become easily obscured. Thus, complementary therapists need clear definitions and firm boundaries in order to maintain therapeutic efficacy and commitment. The aim of the process described in this article, was to develop ethical guidelines for boundaries of touch that will promote the safety and protection of the public which use CAM. Through a modified Delphi process, a diverse group of CAM practitioners, physicians, ethicists, legal consultants, health policy specialists, and representatives from the public, developed Ethical Rules for Boundaries of Touch in CAM. These guidelines may be implemented in ethical codes of professional CAM organizations, and also serve as a foundation for curriculums in ethics in CAM schools.

Frontline ethical issues in pediatric clinical research: ethical and regulatory aspects of seven current bottlenecks in pediatric clinical research.

In the course of the past decades, considerable effort has been expended on the ethical guidance and legal regulation of pediatric clinical trials in Europe. Nonetheless, the conduct of clinical research in the population of minors continues to generate myriad ethical and regulatory issues. This paper explores seven bottlenecks in the ethical guidance and legal regulation that currently govern pediatric clinical research: (1) the integration of research in therapy, (2) the education of clinicians, (3) the empowerment of families, (4) the harmonization of protocol review, (5) the assessment non-clinical research objectives, (6) the control of placebo use, and (7) the provision of fair incentives for pediatric research conduct. For all of these issues, a clear view on the way forward is largely lacking, either because these issues have not been discussed in depth to date or because the existing debates have failed to generate a generally supported consensus.

Recruiting palliative patients for a large qualitative study: some ethical considerations and staff dilemmas.

This article reports on the processes of staff members in referring patients to a study that explored the experience of palliative patients, family members, and health professionals with the implementation of a family meeting model as an instrument of spiritual care. The reported qualitative study was undertaken in two large metropolitan Australian hospitals. Criteria other than those set by the study protocol were employed by staff members referring patients. These included subjective opinions of who was suitable to refer and perceptions of patients' attitudes to religion or spirituality. Such practices raise ethical issues and may compromise studies that have received ethics approval.

Palliative care, public health and justice: setting priorities in resource poor countries.

Many countries have not considered palliative care a public health problem. With limited resources, disease-oriented therapies and prevention measures take priority. In this paper, I intend to describe the moral framework for considering palliative care as a public health priority in resource-poor countries. A distributive theory of justice for health care should consider integrative palliative care as morally required as it contributes to improving normal functioning and preserving opportunities for the individual. For patients requiring terminal care, we are guided less by principles of justice and more by the duty to relieve suffering and society's commitment to protecting the professional's obligation to uphold principles of beneficence, compassion and non-abandonment. A fair deliberation process is necessary to allow these strong moral commitments to serve as reasons when setting priorities in resource poor countries.