RESUMO
BACKGROUND: Even in countries with an opt-out or presumed consent system, relatives have a considerable influence on the post-mortem organ harvesting decision. However, their reflection capacity may be compromised by grief, and they are, therefore, often prone to choose refusal as default option. Quite often, it results in late remorse and dissatisfaction. So, a high-quality reflection support seems critical to enable them to gain a stable position and a long-term peace of mind, and also avoid undue loss of potential grafts. In practice, recent studies have shown that the ethical aspects of reflection are rarely and often poorly discussed with relatives and that no or incomplete guidance is offered. No review of the literature is available to date, although it could be of value to improve the quality of the daily practice. OBJECTIVES: The objective was to review and synthesize the main concepts and approaches, theories and practices of ethical reflection support of the relatives or surrogates of potential post-mortem organ donors. RESEARCH DESIGN: A narrative review was performed in the medical, psychological and ethical fields using PubMed, PsycArticles and Web of Science databases (1980-2020). RESULTS: Out of 150 papers, 25 were finally retained. Four themes were drawn: the moral status of the potential post-mortem organ donor, the principlistic approach with its limits and critics, the narrative approach and the transcendental approach. DISCUSSION: This review suggests an extension of psychological support towards ethical reflection support. The process of helping relatives in their ethical exploration of post-mortem organ donation is psychologically and morally characterized. The need for specialized professionals educated and experienced both in clinical psychology and in health ethics to carry out this task is discussed. PRACTICAL IMPACT: This review could contribute to optimize the quality of the ethical reflection support by initiating an evolution from an empirical, partial and individual-dependent support to a more systematized, professionalized and exhaustive support.
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Obtenção de Tecidos e Órgãos , Emoções , Humanos , Princípios Morais , Consentimento Presumido , Doadores de TecidosRESUMO
CONTEXT: “Analytical frameworks” and “practical tools” referring extensively to values and principles have been developed since the 1990’s to provide guidance for public health decision makers and practitioners in ethical reasoning. OBJECTIVE: This study aimed at identifying the values and principles in public health ethics “frameworks” and “tools”, at classifying them by theme, and at characterizing them by questioning their meanings and articulations. METHOD: We conducted a systematic review according to PRISMA-S guidelines. It used 3 databases and gathered documents published during the last thirty years. This corpus was analyzed following a multidisciplinarily defined interpretive framework. RESULTS: We included 51 publications. More than a half was issued by North American organizations and 7 by European organizations. We identified 110 values and 153 principles referring to the themes of justice, autonomy, beneficence and non-maleficence, governance and evaluation of actions. LIMITATIONS: There are likely other unpublished frameworks and tools used by public health actors and decision makers. CONCLUSION: Although the most cited values and principles appear to correspond to several fundamental characteristics of public health, it is still early to talk about an ethics specific to public health.
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Saúde Pública , Justiça Social , Beneficência , HumanosRESUMO
Limited research is available on parental decision-making regarding their children's participation in pediatric phase I oncology trials compared with the adult population. The objectives of this review were to describe: (1) the process of parental decision-making in this situation; (2) the optimal communication features physicians need when proposing inclusion in such trials; and (3) the place of the child/adolescent in the assent process. Thirty relevant studies meeting inclusion criteria were identified by searching five computerized databases (PubMed, Web of Science, Cairn, Psychinfo, EM Premium). Parental decision-making is a complex process based on hopeful expectations, multiple family considerations and the child's previous cancer experience. It is highly impacted by the quality of physicians' communication. A therapeutic alliance along with an empathetic attitude and a timely delivery of accurate information is essential. Due weight should be given to the voice of children or adolescents and their optimal level of involvement may be discussed depending on their age and maturity. They should be given age-adapted information in order to empower them to be rightfully and meaningfully involved in early-phase research. This review highlights the main gaps and necessary remedial actions to support an optimal patient care management in this situation. Physicians' training in communication, structured interdisciplinary teamwork and early integration of palliative care are three key challenges which need to be implemented to actively engage in optimization strategies which would improve patient care and family support when offering enrollment in a phase I trial.
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Tomada de Decisões , Neoplasias/terapia , Pais , Relações Médico-Paciente , Adolescente , Adulto , Criança , Ensaios Clínicos Fase I como Assunto , Feminino , Humanos , MasculinoRESUMO
PURPOSE: Giving advice about antibiotic prescription through dedicated consultations is a cornerstone of antibiotic stewardship programmes. Our objective was to explore practices, organisation, and regulatory requirements related to antibiotic advising. METHODS: We performed an international, exploratory, Internet-based, cross-sectional survey targeting infectious diseases and clinical microbiology specialists. It was disseminated through ESCMID and ESGAP networks. RESULTS: Answers from 830 participants (74 countries, 77% of participants from Europe) were collected. Consultations were mostly given on demand (81%, 619/764), while unsolicited consultations targeting specific conditions (e.g., positive blood culture) were less frequent (66%, 501/764). Consultations usually included indications on diagnostic work-up and follow-up (> 79%). Curbside consultations (i.e., without examining the patient) were reported by 82% (598/733) of respondents, mainly by phone (89%, 531/598). The referring physician was considered authorised not to follow the advice by 57% (383/676). Direct consultations (i.e., after examining the patient) were recorded in the medical file more frequently than curbside consultations (69%, 472/689 vs 35%, 206/592). Concerning legal liability, the majority of respondents considered that it is shared between the adviser and the referring physician, who, however, is considered primarily responsible. The advisers' liability was considered to be lower in cases of curbside and unrecorded consultations. Significant inter-countries and intra-country variability were identified, suggesting that the setting markedly influenced practices. CONCLUSION: Significant variability exists in the practice of antibiotic advising. This concerns both the organisation of care and how advisers perceive regulatory requirements. These elements must be taken into account when implementing antibiotic stewardship programmes and when training stewards.
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Gestão de Antimicrobianos/legislação & jurisprudência , Gestão de Antimicrobianos/organização & administração , Padrões de Prática Médica , Encaminhamento e Consulta , Estudos Transversais , Feminino , Hospitais , Humanos , Internacionalidade , Internet , Masculino , Inquéritos e QuestionáriosRESUMO
INTRODUCTION: Public health tries to modify existing social norms by setting up strategies to promote the emergence of norms that are more adapted to the objectives of good health and well-being. Prevention policies and the corresponding interventions concern health behaviours and are designed to modify the individual's habits, and contribute to defining new ways of being, acting and living. Prevention therefore involves numerous personal, cultural, social and collective values. An ethical reflection concerning the meaning, rationale and justice of these actions is therefore essential. The objective of this study is to characterize the ethical reflection at the time of creation of public health norms. METHODS: A narrative review, based on the Web of Science database covering journals of the various disciplines concerned, was conducted to address this issue. RESULTS: Thirty-four publications were selected, illustrating the numerous definitions and types of norms used in public health intervention strategies. Many stakeholders are involved in the creation of public health norms specialists, opinion leaders, and social stakeholders. Finally, although some publications stress that the use of prevention norms raises a number of ethical issues, no publication refers to the presence of a structured ethical reflection as part of this process. CONCLUSION: Ethical reflection is an essential part of prevention interventions and tools. What is the best way of achieving the best results? How to resolve conflicts of interests? These issues must be addressed when developing policies or programmes and can more effectively guide public health strategies and help to improve their acceptability and efficacy in populations.
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Política de Saúde , Prevenção Primária/ética , Saúde Pública/ética , Saúde Pública/normas , HumanosRESUMO
Introduction: Since 2000, the notion of "complex interventions" has been emerging in the health research field. "Complex interventions" and "complexity" are commonly used terms, but they are generally not defined. Conceptual ambiguities persist concerning the notion of complexity. The objective of this exploratory review is to characterize the notion of complexity: What is complexity? Where does this notion come from and what does it cover? What are the consequences of complexity in the health field?Methods: To clarify the concept of complexity, a narrative review was conducted in the fields of humanities and social science, managerial economics, psychology and healthcare.Results: The concept of complexity, that can be attributed to Edgar Morin, has been the subject of appropriations, adaptations, and operations in multiple areas. Complexity consists of understanding the factors influencing individual decisions. In the field of healthcare, the concept of complexity is used more pragmatically and is defined by objective characteristics of interventions (defined as complex) or their contexts for the practical purposes of evaluation.Discussion: The notions of complexity and complex interventions have implications for researchers and users of the results of research. In particular, the notion of complexity is designed to provide a better understanding of the mechanism of effectiveness of interventions, support transferability and use by actors and decision-makers.
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Atenção à Saúde , Saúde PúblicaRESUMO
BACKGROUND: Therapeutic patient education, which advocates a change of behaviour, may affect the patient's and the patient's family's lifestyles. The aim of this survey was to describe the perception of heart failure patients and their families concerning the impact of TPE on their lifestyles. METHODS: A national self-administered questionnaire survey b was performed from january to May 2013 with patients and their relatives. A total of 2,153 questionnaires were sent to all patients registered in the Heart Failure Observatory registry (Odin), who forwarded them to a relative of their choice. Only relatives of educated patients were included. A total of 2,397 questionnaires were sent to patients. RESULTS: We obtained 149 responses from patient's families (7%). One half of them (50.3%) met our inclusion criteria. We obtained 257 responses from patients (11 %). Respondents noted a change in the patient's daily lifestyle after TPE (85.8% of the total population) and said that the patient had a more positive approach to his/her illness (70.7% of the total population). According to respondents, relatives had changed their lifestyle after their participation of TPE (67.8% of the total population). CONCLUSION: This study shows that patients and their relatives report a positive change in their lifestyle due to TPE. The patient's relatives appear to comply with the recommendations of health professionals, initially designed for the patient.
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Saúde da Família , Insuficiência Cardíaca/terapia , Estilo de Vida , Educação de Pacientes como Assunto/métodos , Adulto , Idoso , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Percepção , Inquéritos e QuestionáriosRESUMO
The chronic worldwide lack of organs for transplantation and the continuing improvement of strategies for in situ organ preservation have led to renewed interest in elective non-therapeutic ventilation of potential organ donors. Two types of situation may be eligible for elective intensive care: patients definitely evolving towards brain death and patients suitable as controlled non-heart beating organ donors after life-supporting therapies have been assessed as futile and withdrawn. Assessment of the ethical acceptability and the risks of these strategies is essential. We here offer such an ethical assessment using the four principles of medical ethics of Beauchamp and Childress applying them in their broadest sense so as to include patients and their families, their caregivers, other potential recipients of intensive care, and indeed society as a whole. The main ethical problems emerging are the definition of beneficence for the potential organ donor, the dilemma between the duty to respect a dying patient's autonomy and the duty not to harm him/her, and the possible psychological and social harm for families, caregivers other potential recipients of therapeutic intensive care, and society more generally. Caution is expressed about the ethical acceptability of elective non-therapeutic ventilation, along with some proposals for precautionary measures to be taken if it is to be implemented.
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Beneficência , Morte Encefálica , Cuidados Críticos/ética , Parada Cardíaca , Autonomia Pessoal , Respiração Artificial/ética , Justiça Social , Doadores de Tecidos/provisão & distribuição , Obtenção de Tecidos e Órgãos/ética , Teoria Ética , Ética Médica , Humanos , Cuidados para Prolongar a Vida/ética , Futilidade Médica , Ética Baseada em Princípios , Suspensão de Tratamento/éticaAssuntos
Anestesiologia/ética , Tomada de Decisões/ética , Parto/psicologia , Autonomia Pessoal , Termos de Consentimento/ética , Cultura , Parto Obstétrico , Feminino , Humanos , Consentimento Livre e Esclarecido/ética , Troca Materno-Fetal , Parto/etnologia , Educação de Pacientes como Assunto/ética , GravidezRESUMO
OBJECTIVE: To describe the reasons that lead judges to qualify malpractice as a lack of information, then rule in favour or not of the health professional (HP). METHODS: We conducted a systematic review of case law relating to the breach of disclosure obligations over a ten-year period from 2010 to 2020. We used 3 legal databases: Légifrance, Dalloz and Lexis 360, all identified as the most exhaustive. RESULTS: Of the 514 law cases included: judges found malpractice owing to lack of information in 377 (73.3%) cases. Among the latter, malpractices were lack of risk information (N = 257, 68.2%), lack of proof of information (N = 243, 64.5%) and/or lack of information on therapeutic alternatives (N = 49, 13.0%). These malpractices resulted in a conviction of the HP in 268 (71.1%) of the cases. CONCLUSION: Case law is an important source of information for improving the quality of HP, lawyers, and judges' practices. PRACTICE IMPLICATIONS: This review suggests that.
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Consentimento Livre e Esclarecido , Imperícia , HumanosRESUMO
OBJECTIVES: The primary objective of the study was to assess the agreement between the perceived and objectified comprehension levels of oral information received by patients during their preoperative consultation. METHODS: We conducted a prospective study in a surgical consultation service with patients who had scheduled prosthetic surgery. The study included 2 measurement phases, each of which involved an evaluation of the patient's perceived understanding and an evaluation of the understanding by a health professional (i.e., objective understanding). RESULTS: The study included 98 patients. Median (min-max) age was 67 (29-90) years. Depending on the item considered, the weighted kappa coefficient for agreement between perceived patient understanding and professional-objectified levels of understanding ranged from 0.05 to 0.42, suggesting low to moderate levels of agreement. In situations of disagreement, patients had higher self-ratings of understanding than practitioners' ratings for most items. CONCLUSION: Self and hetero-measurement permits the HP to see "how much the patient understands" and to clear up any important element of management both from the point of view of the patient's legal autonomy (self-determination and choice) and of his or her power to act (management of his or her illness). PRACTICE IMPLICATIONS: Asking patients if they have understood the information given is insufficient not only from both a medical care but also from a medico-legal point of view.
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Consentimento Livre e Esclarecido , Autoavaliação (Psicologia) , Idoso , Idoso de 80 Anos ou mais , Retroalimentação , Feminino , Humanos , Masculino , Autonomia Pessoal , Estudos ProspectivosRESUMO
BACKGROUND: Our objectives were to describe Human Papillomavirus vaccination coverage rates (HPV-VCR), policies, and practical steps for programme implementation that may be linked to high uptake in the population targeted by routine programmes across 30 European Union/European Economic Area Member States and Switzerland. METHODS: Information from institutional websites and from articles indexed in Medline between 01/2006 and 01/2017 was reviewed and extracted using a standardised form. In 12/2017, a cross-sectional survey was administered to national experts, in order to update the compiled information. RESULTS: Data were available in 31 countries, and validated by national experts in 28 of them. National vaccination programmes targeted girls 9-15 years of age in 30 countries and boys in 11 countries. HPV-VCR in girls was monitored in 25 countries: VCR was reported ≥71%(high) in ten countries, 51-70% in seven, 31-50% in four, and ≤30%(very low) in four. In high VCR countries, HPV vaccination was mainly delivered through school health services, and invitation and reminders to attend for vaccination were used. In areas with very low VCR, vaccination tended to be opportunistic and no reminders were used. CONCLUSION: According to our findings, school delivery within structured vaccination programmes and the use of reminders tended to be associated with highest HPV-VCR.
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Infecções por Papillomavirus , Vacinas contra Papillomavirus/administração & dosagem , Cobertura Vacinal/estatística & dados numéricos , Adolescente , Criança , Estudos Transversais , Europa (Continente) , União Europeia , Feminino , Humanos , Programas de Imunização , Masculino , Infecções por Papillomavirus/prevenção & controle , Políticas , Sistemas de Alerta , Serviços de Saúde Escolar , SuíçaRESUMO
French law 2005-370 of April 22, 2005 (Leonetti's law) brings new rights to patients and clarifies medical practices regarding end of life care. This new law prohibits unreasonable obstinacy in investigations or therapeutics and authorizes the withholding or withdrawal of treatments when they appear "useless, disproportionate or having no other effect than solely the artificial preservation of life". Relief from pain is a fundamental right of patients. With regard to pain control, the law also allows doctors to dispense to patients "in an advanced or final phase of a serious and incurable affliction" anti-pain treatments as needed, even if these treatments, as a side effect, hasten their death. The drafting of advance directives regarding end of life constitutes a new right of patients. The decision to withdraw or withhold a treatment from a patient unable to express their will has to take into account the wishes they might have expressed through advance directives, and/or the wishes of a trusted person or, lastly, of the family. Before making any decision, physicians should respect a collegial medical procedure. Euthanasia defined as the act of terminating one's life on a patient's explicit request remains illegal.
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Direito a Morrer/ética , Direito a Morrer/legislação & jurisprudência , Diretivas Antecipadas/ética , Diretivas Antecipadas/legislação & jurisprudência , Atitude Frente a Morte , França , Humanos , Direitos do Paciente/ética , Direitos do Paciente/legislação & jurisprudência , Assistência Terminal/ética , Assistência Terminal/legislação & jurisprudência , Suspensão de Tratamento/ética , Suspensão de Tratamento/legislação & jurisprudênciaRESUMO
The exercise test is performed routinely in cardiology; its main indication is the diagnosis of myocardial ischemia, evaluated along with the subject's pretest probability and cardiovascular risk level. Other criteria, such as analysis of repolarization, must be taken into consideration during the interpretation of an exercise test, to improve its predictive value. An exercise test is also indicated for many other cardiac diseases (e.g. rhythm and conduction disorders, severe asymptomatic aortic stenosis, hypertrophic cardiomyopathy, peripheral artery disease, hypertension). Moreover, an exercise test may be indicated for specific populations (women, the elderly, patients with diabetes mellitus, patients in a preoperative context, asymptomatic patients and patients with congenital heart defects). Some cardiac diseases (such as chronic heart failure or arterial pulmonary hypertension) require a cardiopulmonary exercise test. Finally, an exercise test or a cardiopulmonary exercise test is indicated to prescribe a cardiac rehabilitation programme, adapted to the patient.
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Cardiologia/normas , Aptidão Cardiorrespiratória , Teste de Esforço/normas , Cardiopatias/diagnóstico , Reabilitação Cardíaca , Tomada de Decisão Clínica , Consenso , Tolerância ao Exercício , França , Cardiopatias/fisiopatologia , Cardiopatias/terapia , Humanos , Valor Preditivo dos Testes , Prognóstico , Reprodutibilidade dos TestesRESUMO
OBJECTIVE: The objective of this study was to identify changes in the decision-making criteria of general practitioners (GPs) concerning the care of elderly cancer patients after 1 year of corrective measures for care practices in the Lorraine region, France. MATERIALS AND METHODS: In 2014, a postal mail questionnaire was sent to all GPs in the Lorraine region. This questionnaire was designed to identify GPs' decision-making criteria. It was based on the results of a literature review and on existing guidelines. During 1 year, corrective measures were implemented to improve practices, especially training sessions for physicians and production of specific tools, including a guide to the accepted ideas in geriatric oncology. In 2015, the same questionnaire was resent to all GPs to compare the answers. RESULTS: In 2014, 430 questionnaires were returned out of 2,048 sent, and in 2015, 378 questionnaires were returned out of 2,066 sent. Our results show for the first time that there exists a significant difference in the overall decision criteria between the two survey periods. This difference mainly concerns criteria related to the cancerous diseases. Physicians tend to consider the principal decision criteria to be less important after the training period. GPs express the importance of accessibility to specialists for additional advice in both 2014 and 2015; the distance between the patient's home and an adapted care facility and the interval before care begins are viewed as similarly important. CONCLUSION: Training and information sessions for physicians remain the most important tool for improving care practices. Such training strategies are more effective when carried out at the geographical scale at which the cancer professionals practice, allowing them to exploit their local organizational structure. The analysis of our data makes it possible to further integrate the patient into the care path, which remains a public health issue in terms of cost and organization.
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Tomada de Decisões , Clínicos Gerais , Enfermagem Geriátrica , Neoplasias , Idoso , Atitude do Pessoal de Saúde , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos e QuestionáriosRESUMO
The exercise test is still a key examination in cardiology, used for the diagnosis of myocardial ischemia, as well as for the clinical evaluation of other heart diseases. The cardiopulmonary exercise test can further define functional capacity and prognosis for any given cardiac pathology. These new guidelines focus on methods, interpretation and indications for an exercise test or cardiopulmonary exercise test, as summarized below. The safety rules associated with the exercise test must be strictly observed. Interpretation of exercise tests and cardiopulmonary exercise tests must be multivariable. Functional capacity is a strong predictor of all-cause mortality and cardiovascular events. Chest pain, ST-segment changes and an abnormal ST/heart rate index constitute the first findings in favor of myocardial ischemia, mostly related to significant coronary artery disease. Chronotropic incompetence, abnormal heart rate recovery, QRS changes (such as enlargement or axial deviations) and the use of scores (based on the presence of various risk factors) must also be considered in exercise test interpretation for a coronary artery disease diagnosis. Arrhythmias or conduction disorders arising during the exercise test must be considered in the assessment of prognosis, in addition to a decrease or low increase in blood pressure during the exercise phase. When performing a cardiopulmonary exercise test, peak oxygen uptake and the volume of expired gas/carbon dioxide output slope are the two main variables used to evaluate prognosis.
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Cardiologia/normas , Doenças Cardiovasculares/diagnóstico , Teste de Esforço/normas , Doenças Cardiovasculares/fisiopatologia , Doenças Cardiovasculares/terapia , Consenso , Teste de Esforço/efeitos adversos , Tolerância ao Exercício , França , Hemodinâmica , Humanos , Valor Preditivo dos Testes , Prognóstico , Reprodutibilidade dos Testes , RespiraçãoRESUMO
The main objective of this study is to identify the decision criteria of general practitioners and oncologists in the management of older patients with cancer in Lorraine. The secondary objectives are to identify the difficulties encountered and to propose solutions to improve health path of these patients. 2,995 post mail questionnaires were sent to all general practitioners and oncologists in Lorraine. Some decision criteria differ between general practitioners and oncologists: civilian age and accessibility to a specialized advice for general practitioners; type of cancer, nutritional status, application of best practice recommendations, and multidisciplinary discussion for oncologists. The main difficulties reported are organizational and relate to time interval before specific care beginning, accessibility to a medical specialist, and post-diagnosis such link between primary care and hospital. General practitioners and oncologists mainly agree with the difficulties encountered and the solutions to find, even if some decision criteria differences are highlighted. The training of professionals remains the major lever for improvement of medical practices.