Living ethics: a stance and its implications in health ethics.

Moral or ethical questions are vital because they affect our daily lives: what is the best choice we can make, the best action to take in a given situation, and ultimately, the best way to live our lives? Health ethics has contributed to moving ethics toward a more experience-based and user-oriented theoretical and methodological stance but remains in our practice an incomplete lever for human development and flourishing. This context led us to envision and develop the stance of a "living ethics", described in this inaugural collective and programmatic paper as an effort to consolidate creative collaboration between a wide array of stakeholders. We engaged in a participatory discussion and collective writing process known as instrumentalist concept analysis. This process included initial local consultations, an exploratory literature review, the constitution of a working group of 21 co-authors, and 8 workshops supporting a collaborative thinking and writing process. First, a living ethics designates a stance attentive to human experience and the role played by morality in human existence. Second, a living ethics represents an ongoing effort to interrogate and scrutinize our moral experiences to facilitate adaptation of people and contexts. It promotes the active and inclusive engagement of both individuals and communities in envisioning and enacting scenarios which correspond to their flourishing as authentic ethical agents. Living ethics encourages meaningful participation of stakeholders because moral questions touch deeply upon who we are and who we want to be. We explain various aspects of a living ethics stance, including its theoretical, methodological, and practical implications as well as some barriers to its enactment based on the reflections resulting from the collaborative thinking and writing process.

[An assessment of an orhthogeriatrics unit 5 years after its creation]. / Bilan 5 ans après la création d'une unité d'orthogériatrie.

On January 1st, 2018, we established an orthogeriatrics (OG) unit for patients aged ≥ 70 years old with hip fracture, based on a purely geriatric management 24-hours post-operation. In this article we discuss the results of the implemented measures (geriatric follow-up with standardized protocols) on mortality after 6 weeks, operative delay, and complications. Among the 607 treated patients, the mortality rate was 6.75 %, which was unaffected by the average operative delay of 35 hours. Age, male gender, dependency status, cognitive disorder and malnutrition all significantly increased the mortality rate. Presenting at least one complication multiplied the mortality rate by 4.79, a cardiac complication by 3.92, and severe malnutrition by 4.95.

Le 1er janvier 2018, nous avons créé une unité d'orthogériatrie (OG) pour les sujets âgés de ≥ 70 ans avec fracture de hanche, reposant sur une prise en charge purement gériatrique après 24 heures postopératoires. Dans cet article, nous présentons le bilan des mesures appliquées (suivi gériatrique, avec protocoles standardisés) sur la mortalité après 6 semaines, le délai opératoire et les complications. La mortalité des 607 patients pris en charge était de 6,75 %, non influencée par le délai opératoire moyen de 35 heures. L'âge, le sexe masculin, l'état de dépendance, les troubles cognitifs et la malnutrition ont significativement augmenté la mortalité. Présenter au moins une complication a multiplié le risque de mortalité par 4,79, une complication cardiaque par 3,92 et une malnutrition sévère par 4,95.

[Management of pneumonia in advanced stage dementia]. / Prise en charge de la pneumonie au stade avancé d'une démence.

Alzheimer's dementia is a leading cause of morbidity and mortality with devastating consequences for the affected individuals and their family. Pneumonia is a common complication in patients with advanced dementia that is frequently the direct cause of death. Despite the relatively well-established progressive and non-reversible trajectory of Alzheimer's disease, these patients still frequently receive curative treatments during the last months of their lives and access to palliative care is often delayed. The approach and therapeutic options to manage pneumonia at the advanced stage of Alzheimer's disease are discussed in this article.

La maladie d'Alzheimer est une cause importante de morbidité et de mortalité avec des conséquences importantes pour l'individu affecté et sa famille. Les pneumonies sont des complications fréquentes au stade avancé de la maladie et souvent la cause directe du décès. Malgré l'évolution progressive et non réversible de la démence d'Alzheimer, les patients déments reçoivent des traitements à visée curative durant les derniers mois de leur vie et le recours à une approche palliative est souvent tardif. Cet article propose une approche de ces situations et discute les options thérapeutiques en cas de pneumonie au stade avancé de la maladie.

Long-Term Mortality in Very Old Survivors of COVID-19.

OBJECTIVES: This report aimed to describe mortality at 18 months in older survivors of the first wave of COVID-19. DESIGN: Observational cohort study. SETTING AND PARTICIPANTS: Patients aged ≥65 years hospitalized for COVID-19 in the acute geriatric wards of 2 centers. METHODS: Characteristics of deceased and survivors were compared by Fisher exact, Mann-Whitney U, or 2-tailed t tests. Survival rates were analysed by Cox proportional hazards regression models. RESULTS: Of a total of 323 patients admitted during the first wave, 196 survived the acute phase, with 34 patients who died in the 18 months after hospital discharge (17.3%). Higher mortality was observed in patients living in nursing homes (P = .033) and in those who were hospitalized after discharge during the follow-up period (97.1% vs 72.8%, P = .001). There was no difference in survival curves according to age, sex, presence of dyspnea, and dementia. Living in a nursing home significantly increased the mortality rates in the multivariate model adjusted for age and sex (hazard ratio 3.07, 95% CI 1.47-6.40; P = .007). CONCLUSIONS AND IMPLICATIONS: No excess mortality was observed during 18 months in older survivors of COVID-19. Living in a nursing home was associated with decreased survival rates.

Does prior exposure to clinical critical events influence stress reactions to simulation session in nursing students: A case-control study.

BACKGROUND: Simulation is a pedagogical method known to be a generator of stress, that could be influenced by previous stressful experiences. OBJECTIVES: The purpose of this study was to determine the impact of previous experience with a clinical critical event on the stress experienced by nursing students during simulation session of critical events, and on the stress experienced during clinical critical events subsequent to the training. DESIGN: Observational case-control study. SETTINGS: Four critical event scenarios were created using full-scale simulation. PARTICIPANTS: Two hundred and fifteen undergraduate nursing students of semester four. The control group (n = 112) consisted of learners who had not previously experienced a critical event. The prior exposure group (n = 103) consisted of learners who had experienced a critical event prior to the course. METHODS: Stress levels were assessed using the self-report stress numerical rating scale-11. RESULTS: There was no significant difference in the level of stress between the prior exposure group and the control group before, during or expected after the simulation session. A significant decrease in stress was observed in both groups from before the course to during the session (p < 0.05) and expected after the session (p < 0.05). There was no significant difference between the expected post-session stress level and the stress levels reported four months after the training (p = 0.966). At four months, there was no significant difference in stress levels between the groups (p = 0.212). CONCLUSIONS: The prior experience of a clinical critical event before a simulation course did not influence their reported stress level during the simulation session. Conversely, simulation-based training of critical situations appears to reduce the level of self-assessed stress during critical events in clinical practice after the training.

Effect of combined individual-collective debriefing of participants in interprofessional simulation courses on crisis resource management: a randomized controlled multicenter trial. / Efecto de un debriefing (reunión informativa) combinado en los participantes en cursos de simulación interprofesional para la gestión de recursos de crisis: un estudio aleatorio, controlado y multicéntrico.

OBJECTIVES: Interprofessional simulation (IPS) training is an effective way to learn crisis resource management. The type of debriefing used in IPS training may affect participants' performance and their level of psychological safety. We aimed to assess and compare performance after standard collective debriefing versus a combination of individual and collective debriefing ("combined" approach). MATERIAL AND METHODS: Randomized, controlled multicenter trial. IPS sessions were randomized to have either standard or combined debriefing. Each team's performance in the IPS session was assessed with the Team Emergency Assessment Measure. The participants assessed the debriefing quality with the Debriefing Assessment for Simulation in Healthcare. RESULTS: Forty IPS sessions were randomized, and 30 were analyzed, 15 using standard collective debriefing and 15 the combined individual-collective method. Teams' performance improved with both types of debriefing, based on pre-post testing (P<.01), and there were no significant differences in overall performance scores between the 2 types of debriefing (P=.64). However, the combined approach was associated with higher scores for leadership skills (P<.05) and psychological safety, and the participants' learning experience was better (P<.05). CONCLUSION: During IPS courses on crisis resource management, debriefing improves participants' performance, but similar overall results can be obtained with both debriefing methods. Combined debriefing might be more effective for improving participants' leadership skills and psychological safety and also provide a better learning experience.

OBJETIVO: La simulación interprofesional (SIP) es eficaz para aprender gestión de recursos de crisis. La modalidad de debriefing utilizada en la SIP puede influir en el rendimiento de los participantes y en su integridad psicológica. Se evalúa y compara el rendimiento de un debriefing estándar (DE) ­colectivo­ con un debriefing combinado (DC) ­individual y colectivo­ en cursos de SIP en escenarios que simulan pacientes con patología aguda y grave. METODO: Ensayo controlado, aleatorizado y multicéntrico. Se aleatorizó el tipo de debriefing realizado (DE o DC) en las sesiones de SIP. El rendimiento del debriefing se evaluó con la escala TEAM (Team Emergency Assessment Measure). La calidad de la SIP fue valorada por los participantes con la escala DASH (Debriefing Assessment for Simulation in Healthcare©). RESULTADOS: Se aleatorizaron 40 cursos de SIP de los que se analizaron 30. Quince realizaron DE y 15 DC. Ambos grupos mejoraron entre la pre y la posprueba (p < 0,01), pero no hubo diferencias en el rendimiento global entre ambas modalidades de debriefing (p = 0,64). El DC obtuvo mejores resultados que el DE en la capacidad de liderazgo (p < 0,05), en la percepción de seguridad psicológica y en la experiencia de aprendizaje eficaz (p < 0,05). CONCLUSIONES: Durante la SIP en situaciones de crisis, el debriefing mejora el rendimiento de los participantes, sin diferencias entre un DE y un DC. El DC podría ser más efectivo para mejorar la capacidad de liderazgo, la seguridad psicológica y la experiencia del aprendizaje.

[Simulation-based interprofessional education for critical care teams: Concept, implementation and assessment]. / L'éducation interprofessionnelle des équipes de soins critiques par la simulation : concept, mise en œuvre et évaluation.

Interprofessional simulation-based education is effective for learning non-technical critical care skills and strengthening interprofessional team collaboration to optimize quality of care and patient outcome. Implementation of interprofessional simulation sessions in initial and continuing education is facilitated by a team of "champions" from each discipline/profession to ensure educational quality and logistics. Interprofessional simulation training must be integrated into a broader interprofessional curriculum supported by managers, administrators and clinical colleagues from different professional programs. When conducting interprofessional simulation training, it is essential to account for sociological factors (hierarchy, power, authority, interprofessional conflicts, gender, access to information, professional identity) both in scenario design and debriefing. Teamwork assessment tools in interprofessional simulation training may be used to guide debriefing. The interprofessional simulation setting (in-situ or simulation centre) will be chosen according to the learning objectives and the logistics.

Justice and Neurodevelopmental Disability: Moral-Political Philosophies, Policies, and Their Outcomes.

Neurodevelopmental disabilities, such as cerebral palsy and autism, touch a population which has been dubbed to be "doubly vulnerable." Individuals with neurodevelopmental disability have conditions that impair their cognition, communication, mobility, or social interactions, and they also rely on others to make decisions on their behalf. Accordingly, these children-as described in other contributions of this special issue-are particularly prone to suffer from systemic (ie, social, economic, and political) conditions that give or prevent access to quality and timely health care and social services as well as economic opportunities. In this article, we expose 2 different views on the principle of justice (justice as equality and justice as fairness). We then examine policy approaches and general outcomes of 3 countries (Sweden, the United States of America, and the United Kingdom), which have opted for different policy orientations. The United Kingdom's targeted approach to neurodevelopmental disability seems to be generating interesting results while the more general Swedish approach is not without merits, although perhaps more difficult to apply to other countries. Given knowledge gaps, there is great need to compare different policy approaches to neurodevelopmental disability and their real-world implications on the life of individuals and their families.

Efecto de un debriefing (reunión informativa) combinado en los participantes en cursos de simulación interprofesional para la gestión de recursos de crisis: un estudio aleatorio, controlado y multicéntrico / Effect of combined individual–collective debriefing of participants in interprofessional simulation courses on crisis resource management: a randomized controlled multicenter trial

Objetivo: La simulación interprofesional (SIP) es eficaz para aprender gestión de recursos de crisis. La modalidad de debriefing utilizada en la SIP puede influir en el rendimiento de los participantes y en su integridad psicológica. Se evalúa y compara el rendimiento de un debriefing estándar (DE) –colectivo– con un debriefing combinado (DC) –individual y colectivo– en cursos de SIP en escenarios que simulan pacientes con patología aguda y grave. Método: Ensayo controlado, aleatorizado y multicéntrico. Se aleatorizó el tipo de debriefing realizado (DE o DC) en las sesiones de SIP. El rendimiento del debriefing se evaluó con la escala TEAM (Team Emergency Assessment Measure). La calidad de la SIP fue valorada por los participantes con la escala DASH (Debriefing Assessment for Simulation in Healthcare©). Resultados. Se aleatorizaron 40 cursos de SIP de los que se analizaron 30. Quince realizaron DE y 15 DC. Ambos grupos mejoraron entre la pre y la posprueba (p < 0,01), pero no hubo diferencias en el rendimiento global entre ambas modalidades de debriefing (p = 0,64). El DC obtuvo mejores resultados que el DE en la capacidad de liderazgo (p < 0,05), en la percepción de seguridad psicológica y en la experiencia de aprendizaje eficaz (p < 0,05). Conclusiones: Durante la SIP en situaciones de crisis, el debriefing mejora el rendimiento de los participantes, sin diferencias entre un DE y un DC. El DC podría ser más efectivo para mejorar la capacidad de liderazgo, la seguridad psicológica y la experiencia del aprendizaje

Objective: Interprofessional simulation (IPS) training is an effective way to learn crisis resource management. The type of debriefing used in IPS training may affect participants' performance and their level of psychological safety. We aimed to assess and compare performance after standard collective debriefing versus a combination of individual and collective debriefing ("combined" approach). Methods: Randomized, controlled multicenter trial. IPS sessions were randomized to have either standard or combined debriefing. Each team's performance in the IPS session was assessed with the Team Emergency Assessment Measure. The participants assessed the debriefing quality with the Debriefing Assessment for Simulation in Healthcare. Results: Forty IPS sessions were randomized, and 30 were analyzed, 15 using standard collective debriefing and 15 the combined individual–collective method. Teams' performance improved with both types of debriefing, based on pre-post testing (P<.01), and there were no significant differences in overall performance scores between the 2 types of debriefing (P=.64). However, the combined approach was associated with higher scores for leadership skills (P<.05) and psychological safety, and the participants' learning experience was better (P<.05). Conclusions: During IPS courses on crisis resource management, debriefing improves participants' performance, but similar overall results can be obtained with both debriefing methods. Combined debriefing might be more effective for improving participants' leadership skills and psychological safety and also provide a better learning experience