COVID 19: prioritise autonomy, beneficence and conversations before score-based triage.

At the start of the COVID-19 pandemic, mounting demand overwhelmed critical care surge capacities, triggering implementation of triage protocols to determine ventilator allocation. Relying on triage scores to ration care, while relieving clinicians from making morally distressing decisions under high situational pressure, distracts clinicians from what is essentially deeply humanistic issues entrenched in this protracted public health crisis. Such an approach will become increasingly untenable as countries flatten their epidemic curves. Decisions regarding intensive care unit admission are particularly challenging in older people, who are most likely to require critical care, but for whom benefits are most uncertain. Before applying score-based triage, physicians must first discern if older people will benefit from critical care (beneficence) and second, if he wants critical care (autonomy). When deliberating beneficence, physicians should steer away from solely using age-stratified survival probabilities from epidemiological data. Instead, decisions must be based on individualised risk-stratification that encompasses evidence-based predictors of adverse outcomes specific to older adults. Survival will also need to be weighed against burden of treatment, as well as longer term functional deficits and quality-of-life. By identifying the robust older people who may benefit from critical care, clinicians should proceed to elicit his values and preferences that would determine the treatment most aligned with his best interest. During these dialogues, physicians must truthfully convey the emergent clinical reality, discern the older person's therapeutic goals and discuss the feasibility of achieving them. Given that COVID-19 is here to stay, these conversations aimed at achieving goal-cordant care must become a new clinical norm.

La tecnología como amenaza creciente a la relación médico-paciente y al método clínico / Technology as a growing threat to the doctor-patient relationship and the clinical method

RESUMEN El avance de las ciencias médicas en la segunda mitad del siglo XX se ha debido a progresos de la terapéutica, las ciencias básicas y la tecnología aplicada al diagnóstico. El objetivo del estudio es ofrecer una valoración del papel que juega el método clínico en la práctica médica. El método científico y clínico, son una unidad inseparable y funcionan en plena armonía. El método clínico es una guía de trabajo aplicable al trabajo médico, con el objetivo de llegar a un diagnóstico contextualizado de la enfermedad que afecta a un individuo. La tecnología no sustituye al método clínico y el deterioro de la relación médico-paciente, la subvaloración del interrogatorio, del examen físico y la sobrevaloración de la tecnología son los aspectos que más afectan su uso y correcta aplicación en la práctica médica(AU)

ABSTRACT The advancement of medical sciences in the second half of the 20th century has been due to advances in therapeutics, basic sciences, and technology applied to diagnosis. The objective of the study is to offer an assessment of the role that the clinical method plays in medical practice. The scientific and clinical method are an inseparable unit and work in full harmony. The clinical method is a work guide applicable to medical work, with the aim of reaching a contextualized diagnosis of the disease that affects an individual. Technology does not replace the clinical method and the deterioration of the doctor-patient relationship, the undervaluation of interrogation, physical examination and the overvaluation of technology are the aspects that most affect its use and correct application in medical practice(AU)

Beecher Dépassé: Fifty Years of Determining Death, Legally.

Five decades ago, Henry Knowles Beecher, a renowned professor of research anesthesiology, sought to solve a problem created by modern medicine. The solution proposed by Beecher and his colleagues on the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death proved very influential.1 Indeed, other contemporaneous medical developments magnified its significance yet also made the solution it offered somewhat problematic. As we mark this fiftieth anniversary, at a time when concerns about the conceptual model on which its recommendations rested are being voiced by critics from medicine as well as philosophy, it is worthwhile to view the committee's report in relation to the problem that prompted its existence as well as the one to which it was quickly applied.

A Path Not Taken: Beecher, Brain Death, and the Aims of Medicine.

It has been fifty years since a report by an ad hoc committee of Harvard Medical School ushered in the widespread adoption of brain death as a definition of death. Yet brain death remains disputed as an acceptable definition within bioethics. The continuous debate among bioethicists has had three key recurring features: first and foremost, argument over alleged flaws in the conceptual logic and consistency of the "whole-brain" approach as a description of the meaning of death; second, efforts to fix perceived limitations of brain death-based practices to optimize transplantation, especially given that transplantation was the presumed original intended purpose of the definition; and third, a basic unease provoked by the experience of using the criteria and managing a body in this state of "irreversible coma." The third feature is the one I find the most compelling, though it is less explored, and it persists because of the failures of the prior two. Brain death remains strange-to medical personnel, families, philosophers. That is not because it hasn't yet been logically argued well enough or conceptually framed adequately, but because those things don't matter as much to resolving this strangeness as the bioethical approach to brain death over the last fifty years has assumed it does. It is necessary to look to other things that can anchor the aims of medicine in the midst of this strangeness.

A Conceptual Justification for Brain Death.

Among the old and new controversies over brain death, none is more fundamental than whether brain death is equivalent to the biological phenomenon of human death. Here, I defend this equivalency by offering a brief conceptual justification for this view of brain death, a subject that Andrew Huang and I recently analyzed elsewhere in greater detail. My defense of the concept of brain death has evolved since Bernard Gert, Charles Culver, and I first addressed it in 1981, a development that paralleled advances in intensive care unit treatment. The century-old concept of the organism as a whole provides the fundamental justification for the equivalency of brain death and human death. In our technological age, in which increasing numbers of components and systems of an organism can be kept alive, and for longer intervals, the permanent cessation of functioning of the organism as a whole is the phenomenon that best corresponds to its death.

Certeza diagnóstica mediante interrogatorio y examen físico en estudiantes de medicina interna / Diagnostic certainty through interrogatory and physical examination in internal medicine students

Introducción: el análisis de los errores cometidos durante el proceso diagnóstico al aplicar el método clínico por los estudiantes de medicina interna, en dos momentos de su rotación, permite mejorar la calidad de la atención médica. Objetivo: analizar si existe relación entre el diagnóstico al ingreso y egreso, y los errores detectados durante el interrogatorio y examen físico en los estudiantes de tercer año al iniciar y finalizar la rotación de medicina interna. Métodos: se realizó un estudio descriptivo de los alumnos de tercer año del Hospital Militar Dr. Carlos J. Finlay en el curso académico 2015-2016. Resultados: los errores son más frecuentes en el interrogatorio, tanto en el primero como en el segundo encuentro médico. La concordancia entre el diagnóstico al ingreso y al egreso, mejoró en un 21,7 por ciento entre el primer y el segundo. Conclusiones: la realización de diagnósticos certeros implica mejoramiento de la atención médica con ahorro de recursos económicos(AU)

Introduction: the analysis of the errors made during the diagnostic process when applying the clinical method by the students of internal medicine, in two moments of its rotation, allows to improve the quality of the medical attention. Objective: to analyze if there is a relationship between the diagnosis at admission and discharge and the errors detected during the interrogation and physical examination in the third year students at the beginning and end of the Internal Medicine rotation. Methods: a descriptive study of the third year students of the Military Hospital Dr. Carlos J. Finlay in the academic year 2015 - 2016. Results: errors are more frequent in the interrogation, both in the first and in the second medical encounter. The agreement between the diagnosis on admission and discharge, improved by 21.7 percent between the first and second medical encounter. Conclusions: the realization of accurate diagnoses implies improvement of medical care with savings of economic resources(AU)

Using best interests meetings for people in a prolonged disorder of consciousness to improve clinical and ethical management.

Current management of people with prolonged disorders of consciousness is failing patients, families and society. The causes include a general lack of concern, knowledge and expertise; a legal and professional framework which impedes timely and appropriate decision-making and/or enactment of the decision; and the exclusive focus on the patient, with no legitimate means to consider the broader consequences of healthcare decisions. This article argues that a clinical pathway based on the principles of (a) the English Mental Capacity Act 2005 and (b) using time-limited treatment trials could greatly improve patient management and reduce stress on families. There needs to be early and continuing use of formal best interests meetings, starting between 7 and 21 days after onset of unconsciousness (from any cause, including progressive disorders). The treatment options need to evolve as the clinical state and prognosis becomes more certain. A formal discussion of treatment withdrawal should occur when the upper bound of predicted recovery falls below a level the patient would have considered acceptable, and it should always be discussed when the condition is considered permanent. Any decision to stop treatment should be contingent on a formal second opinion from an independent expert who should review the clinical situation and expected prognosis, but not the best interests decision. The article also asks how, if at all, the adverse effects on the family and the resource implications of long-term care of people left in a prolonged state of unconsciousness should be incorporated in the process.

Demise of the LCP: villain or scapegoat?

The winding down and withdrawal of the Liverpool Care Pathway (LCP) following the Neuberger Report has been met with mixed reviews. It appears that responsibility for failures of clinical care has been laid at the feet of a care pathway rather than the practitioners who used it, a rather curious outcome given that the LCP was primarily a system of documentation, a tool with no intrinsic therapeutic properties. The Neuberger inquiry was the result of persistent and repeated reports of poor-quality end-of-life care associated with the use of the LCP. There were indeed problems with the LCP regarding the process of diagnosing dying and its approach to supportive care, particularly artificial nutrition and hydration. Some of the problems were the product of personal or professional ideology influencing goals of care rather than patient-centred considerations. These problems were not insurmountable, however, and were being addressed by the organisation responsible for the LCP. With the removal of the LCP, we are left with no bench mark for end-of-life care, only aspirational goals for individualised care plans. It seems unlikely that practitioners who could not provide appropriate care with the LCP will do so without it.

Ethics and end of life care: the Liverpool Care Pathway and the Neuberger Review.

The Liverpool Care Pathway for the Dying has recently been the topic of substantial media interest and also been subject to the independent Neuberger Review. This review has identified clear failings in some areas of care and recommended the Liverpool Care Pathway be phased out. I argue that while the evidence gathered of poor incidences of practice by the Review is of genuine concern for end of life care, the inferences drawn from this evidence are inconsistent with the causes for the concern. Seeking to end an approach that is widely seen as best practice and which can genuinely deliver high quality care because of negative impressions that have been formed from failing to implement it properly is not a good basis for radically overhauling our approach to end of life care. I conclude that improvements in training, communication and ethical decision-making, without the added demand to end the Liverpool Care Pathway, would have resulted in a genuine advance in end of life care.