Cuestiones bioéticas involucradas en los Cuidados Paliativos: desde la perspectiva de los profesionales de la salud / Bioethical issues involved in Palliative Care: from the perspective of health professionals

Las cuestiones inherentes al final de la vida constituyen un inmenso desafío para los médicos, debido a la falta de educación formal en lo inherente a cuidados paliativos, y a que se entrelazan conceptos médicos, religiosos, legales y bioéticos en su abordaje. El objetivo de este estudio es identificar, desde la perspectiva de los profesionales de la salud, las cuestiones éticas involucradas en el proceso de atención de pacientes incluidos en cuidados paliativos. Para ello se llevó a cabo de una revisión de 10 artículos, en los cuales se observa la carencia de formación bioética y la aplicación inadecuada (o falta) en lo inherente a manejo adecuado de la información y la dificultad en su comunicación, toma de decisiones compartidas, respeto de la autonomía del paciente, verdad médica, limitación de esfuerzos terapéuticos (AU)

End-of-life issues constitute an immense challenge for physicians, due to the lack of formal education regarding palliative care, and the intertwining of medical, religious, legal, and bioethical concepts in their approach. The objective of this study is to identify, from the perspective of health professionals, the ethical issues involved in the care process for patients included in palliative care. For this, a review of 10 articles was carried out, in which the lack of bioethical training and the inadequate application (or lack) is observed in terms of the proper management of information and the difficulty in its communication, decision making shared, respect for patient autonomy, medical truth, limitation of therapeutic efforts (AU)

Ética médica y atención a pacientes en estadio terminal en el nivel primario de atención / Medical Ethics and End-stage Patient Care at the Primary Care Level

Introducción: El artículo reflexiona sobre la naturaleza multidimensional y compleja de la ética y su relación con las ciencias médicas. Objetivo: Reflexionar sobre la atención a pacientes en estadio terminal desde el punto de vista de la ética médica para una atención médica integral en el primer nivel de atención. Métodos: estudio cualitativo; se emplearon análisis documental, sistematización, análisis y síntesis de publicaciones sobre la temática estudiada como métodos teóricos, para ello se valoran los criterios de autores y resultados que se expresan en artículos publicados. Se realizaron búsquedas, tanto en bases de datos estudiadas como en las plataformas de productos del Nacional Council for Biotechnology Information de la Nacional Library of Medicine of United States of America; y de Elsevier, esta última productora de Embase y Scopus, a través del motor de búsqueda Google Académico, en español e inglés, y sin límite de tiempo. Se emplearon los términos: ética médica, deontología médica, relación médico-paciente, paciente terminal y cuidados paliativos. Se excluyeron aquellos artículos que no habían sido revisados por pares o no mostraban el texto completo. Se revisó la información suministrada por cada fuente y se sintetizó. Conclusiones: En Cuba, la bioética avanza en la medida que lo permite la estrategia de Atención Primaria de Salud, con un Programa del Médico y Enfermera de la Familia resiliente y de valores humanos demostrados nacional e internacionalmente. Como reto se plantea estimular el debate entre saberes para generar cambios a favor de los pacientes, las familias, las comunidades y la sociedad(AU)

Introduction: The article reflects on the multidimensional and complex nature of ethics and its relationship to the medical sciences. Objective: To reflect on the care of terminally ill patients from the point of view of medical ethics for comprehensive medical care at the primary level of care. Methods: A qualitative study was carried out using documentary analysis, systematization, analysis and synthesis of publications on the subject studied as theoretical methods. For this purpose, the criteria of authors and results expressed in published articles were evaluated. Searches were carried out in Spanish and English through Google Scholar, and without time limit, both in the databases studied and in the product platforms of the National Council for Biotechnology Information of the National Library of Medicine of the United States of America and Elsevier. The terms: medical ethics, medical deontolog, physician-patient relationship, terminal patient and palliative care were used. Articles that were not peer-reviewed and those that did not show the full text were excluded. The information provided by each source was reviewed and synthesized. Conclusions: In Cuba, bioethics advances to the extent allowed by the Primary Health Care strategy, with a resilient Family Physician and Nurse Practitioner Program and human values demonstrated nationally and internationally. The challenge is to stimulate the debate between knowledge to generate changes in favor of patients, families, communities and society(AU)

Chapitre 1. La télémédecine et ses implications sur la relation médecin/patient.

The practice of telemedicine is likely to raise ethical and legal problems that affect the doctor-patient relationship. Therefore, the respect of ethical principles is necessary, in addition to the involvement of the legislator, who must enact specific instruments capable of identifying all the problems caused by telemedicine and contributing to a certain humanization of the doctor-patient relationship.

Telemedicina e tecnologia assistiva / Telemedicina i tecnologia d'assistència / Telemedicina y tecnología de asistencia / Telemedicine and assistive technology

Busca-se analisar os desafios da aproximação entre médico e paciente numa relação intermediada pela telemedicina e como a tecnologia assistiva pode (e deve) contribuir para um atendimento satisfatório, com respeito a todas as dimensões do paciente, sua individualidade e autodeterminação. Considera-se verdadeiro retrocesso aos ideais paternalistas o ato de delegar o destino do paciente à tecnologia, sem a devida atenção e respeito às suas limitações e características individuais. E entende-se que a tecnologia assistiva pode ser uma possível solução aos problemas derivados do uso de tecnologias de informação e comunicação. Conclui-se que a integralidade dos serviços de saúde somente é atingida se houver atenção à realidade social dos pacientes e às suas características individuais, para o alcance da igualdade e da equidade; e que o uso puro e simples dos meios tecnológicos não é suficiente para que a integralidade dos serviços de saúde seja alcançada. Foi utilizada a metodologia exploratória, levantamento de dados e informações doutrinárias sobre o objeto de estudo, seguindo-se a respectiva sistematização em caráter triplo (coleta, organização e conservação de documentos), para a sua fundamentação.(AU)

Busca analitzar els desafiaments de l'acostamentmèdic i pacient en una relació intervinguda per la telemedicina i com les tecnologies asistives poden (i han de) contribuir a una atenció satisfactòria, respectant totes les dimensions del pacient, la seva individualitat i autodeterminació. L'acte de delegar el destí del pacient a la tecnologia, sense la deguda atenció i respecte a les seves limitacions i característiques individuals, és considerat un veritable retrocés als ideals paternalistes. I s'entén que la tecnologia asistiva pot ser una solució possible als problemes derivats de l'ús de les tecnologies de la informació i la comunicació. Es conclou que la integralitat dels serveis de salut només s'aconsegueix si s'atenen la realitat social dels pacients i les seves característiques individuals, a fi d'aconseguir la igualtat i l'equitat; i que l'ús pur i simple dels mitjans tecnològics no és suficient per assolir la integralitat dels serveis de salut. Es va utilitzar metodologia exploratòria, recol·lecció de dades i informació doctrinal sobre l'objecte d'estudi, seguida de la respectiva sistematització en un triple caràcter (recopilació, organització i conservació de documents), per justificar-la.(AU)

Busca analizar los desafíos del acercamiento médico y paciente en una relación mediada por la telemedicina y cómo las tecnologías asistivas pueden (y deben) contribuir a una atención satisfactoria, respetando todas las dimensiones del paciente, su individualidad y autodeterminación. El acto de delegar el destino del paciente a la tecnología, sin la debida atención y respeto a sus limitaciones y características individuales, es considerado un verdadero retroceso a los ideales paternalistas. Y se entiende quela tecnología asistiva puede ser una posible solución a los problemas derivados del uso de las tecnologías de la información y la comunicación. Se concluye que la integralidad de los servicios de salud solo se logra si se atiende a la realidad social de los pacientes y sus características individuales, con el fin de lograr la igualdad y la equidad; y que el uso puro y simple de los medios tecnológicos no es suficiente para lograr la integralidad de los servicios de salud. Se utilizó metodología exploratoria, recolección de datos e información doctrinal sobre el objeto de estudio, seguida de la respectiva sistematización en un triple carácter (recopilación, organización y conservación de documentos), para su justificación.(AU)

It seeks to analyze the challenges of approaching doctor and patient in a relationship mediated by telemedicine and how assistive technology can (and should) contribute to satisfactory care, with respect to all dimensions of the patient, their individuality and self-determination. The act of delegating the fate of the patient to technology, without due attention and respect to their limitations and individual characteristics, is considered a true setback to paternalistic ideals. And it is understood that assistive technology can be a possible solution to problems arising from the use of information and communication technologies. It is concluded that the integrality of healthservices is only achieved if there is attention to the social reality of patients and their individual characteristics, in order to achieve equality and equity; and that the pure and simple use of technological means is not enough for the integrality of health services to be achieved. Exploratory methodology was used, data collection and doctrinal information about the object of study, followed by the respective systematization in a triple character (collection, organization and conservation of documents),for its justification.(AU)

El modelo de las decisiones compartidas en la atención médica de la COVID-19 y las enfermedades crónicas en México / The model of shared decisions in Covid-19 and chronic disease care in Mexico

Estimado Editor: Consciente o inconscientemente los profesionales de la salud actúan de acuerdo a un modelo de relación atención de la salud-usuarios de los servicios de salud. Se opta por este término sobre el de relación médico-paciente, pues contempla la complejidad de la relación y de las dos realidades que interactúan.1 Generalmente, adoptan el modelo que han aprendido a lo largo de su formación, habitualmente el modelo biomédico que, además, consideran más vanguardista. El problema del enfoque biomédico de la atención radica en su simplificación de los problemas de salud, promoviendo una forma de relación con los usuarios fría e incompleta. A manera de ejemplo, en 2007 en México, el entonces presidente de la Republica Felipe de Jesús Calderón Hinojosa declara la guerra al narcotráfico. Desde su perspectiva la solución era clara, muerto el perro, terminada la rabia. No obstante, esta es una respuesta sencilla para un problema complejo. Si no se entienden los determinantes estructurales responsables del narcotráfico en México, lo único que se logra con esta estrategia es inaugurar una fábrica de muertes prevenibles, principalmente de hombres jóvenes.2 Con esto, se pretende ilustrar el riesgo de simplificar los problemas, al tiempo que se resalta la importancia de entender los fenómenos en toda su extensión para poder proponer soluciones complejas y correctas a problemas complejos. Ciertamente, la pandemia...(AU)

Evaluation of psychiatrist's communication with psychosis patients / Evaluación de la comunicación de psiquiatras con pacientes psicóticos / Avaliação da comunicação de psiquiatras com pacientes psicóticos

Abstract: Evaluation of the physician-patient relationship is very important in determining priorities in medical practice and medicine. For this purpose, in this study the psychiatrist's communication with psychotic patients as a sensitive group was evaluated. A questionnaire was administered to 210 patients in a psychiatric clinic of Inonu University Hospital in Turkey to determine how the examination is performed in the facility for outpatients in the psychosis unit. According to the study conducted, it was observed that the evaluation score of the psychiatrist's communication with psychotic patients increased positively with increasing consultation duration. Our work is particularly noteworthy because it deals with a sensitive area, such as a group of psychiatric patients. The scores were obtained based on data from the evaluation of the questionnaires, which showed that the communication between the psychiatrist and the psychotic patient was conducted in a sensitive and careful manner, and without ethical problems.

Resumen: La evaluación de la relación médico-paciente es muy importante para determinar las prioridades en la práctica médica y la medicina. Para este propósito, en este estudio se evaluó la comunicación del médico psiquiatra con los pacientes psicóticos como grupo sensible. Se administró un cuestionario a 210 pacientes de una clínica psiquiátrica del Hospital de la Universidad de Inonu en Turquía, para determinar cómo se realiza el examen en el establecimiento para los pacientes externos de la unidad de psicosis. De acuerdo con el estudio realizado, se observó que el puntaje de evaluación de la comunicación del psiquiatra con los pacientes psicóticos se incrementó positivamente al aumentar la duración de la consulta. Nuestro trabajo se destaca particularmente por tratarse de un área sensible, como es un grupo de pacientes psiquiátricos. Los puntajes se obtuvieron basándose en datos de la evaluación de los cuestionarios, que mostraron que la comunicación entre el psiquiatra y el paciente psicótico se realizó de una forma sensible y cuidadosa, y sin problemas éticos.

Resumo: A avaliação da relação médico-paciente é muito importante para determinar as prioridades na prática médica e na medicina. Para este fim, neste estudo foi avaliada a comunicação do psiquiatra com pacientes psicóticos como um grupo sensível. Um questionário foi aplicado a 210 pacientes em uma clínica psiquiátrica do Hospital Universitário Inonu na Turquia para determinar como o exame é conduzido nas instalações para pacientes ambulatoriais da unidade de psicose. De acordo com o estudo realizado, observou-se que a pontuação da avaliação da comunicação do psiquiatra com pacientes psicóticos aumentou positivamente à medida que a duração da consulta aumentava. Nosso trabalho é particularmente notável porque trata de uma área sensível, tal como um grupo de pacientes psiquiátricos. Os resultados foram obtidos com base nos dados da avaliação dos questionários, que mostraram que a comunicação entre psiquiatra e paciente psicótico foi realizada de forma sensível e cuidadosa, e sem problemas éticos.

Violentar el pensamiento médico: la revolución de la bioética en la medicina / TO VIOLENT THE MEDICAL THINKING: THE REVOLUTION OF BIOETHICS IN MEDICINE

En el presente trabajo presentamos otra mirada del acontecer del hombre en el mundo de las Ciencias Biológicas, especialmente, en el mundo de la Medicina. Trazamosun paralelismo entre el pensamiento de Martín Heidegger con respecto a la diferencia ontológica entre el ser y ente y lo ocurrido dentro del mundo médico a partir del olvido del ser en el hombre padeciente. En este camino, nos proponemos realizar una reflexión antropológica desde el origen de la Medicina hasta nuestros días y exponer el devenir que sufrió la figura del ser y su enteque derivó en un privilegio a este último en detrimento del primero. Para ello, describimos un brevísimo bosquejo de la Medicina Hipocrática y de su visión del médico que se enfocaba a la atención tanto del ser como del ente del hombre. Luego analizamos el estudio de la etapa médica posterior en la cual aparece el olvido del ser del ente/hombre/enfermo. Desde allí surge un movimiento iniciado en los años 70 del siglo pasado, el movimiento bioético, que despierta un nuevo acontecer del hombre en el mundo de las Ciencias Biológicas respetando su autonomía

In the present work I take another look at the way man happens in the world of Biological Sciences, especially in the world of Medicine. I draw a parallel between the thought of Martín Heidegger regarding the ontological difference between being and being and what happened within the medical world from the forgetting of being in the suffering man. Along this path, I propose to carry out an anthropological reflection from the origin of Medicine to the present day and expose the evolution suffered by the figure of the being and the entity of it that resulted in a privilege to the latter to the detriment of the former. To do this, I describe a very brief sketch of Hippocratic Medicine and its vision of the doctor that focused on the attention of both the being and the being of man. Ten I analyze the study of the later medical stage, in which, the forgetfulness of the being of the entity / man / sick appears. From there arises a movement started in the 70s of the last century, called the bioethical movement, which awakens a new happening of man in the world of Biological Sciences while respecting his autonomy

College complaints against resident physicians in Canada: a retrospective analysis of Canadian Medical Protective Association data from 2013 to 2017.

BACKGROUND: An understanding of regulatory complaints against resident physicians is important for practice improvement. We describe regulatory college complaints against resident physicians using data from the Canadian Medical Protective Association (CMPA). METHODS: We conducted a retrospective analysis of college complaint cases involving resident doctors closed by the CMPA, a mutual medicolegal defence organization for more than 100 000 physicians, representing an estimated 95% of Canadian physicians. Eligible cases were those closed between 2008 and 2017 (for time trends) or between 2013 and 2017 (for descriptive analyses). To explore the characteristics of college cases, we extracted the reason for complaint, the case outcome, whether the complaint involved a procedure, and whether the complaint stemmed from a single episode or multiple episodes of care. We also conducted a 10-year trend analysis of cases closed from 2008 to 2017, comparing cases involving resident doctors with cases involving only nonresident physicians. RESULTS: Our analysis included 142 cases that involved 145 patients. Over the 10-year period, college complaints involving residents increased significantly (p = 0.003) from 5.4 per 1000 residents in 2008 to 7.9 per 1000 in 2017. While college complaints increased for both resident and nonresident physicians over the study period, the increase in complaints involving residents was significantly lower than the increase across all nonresident CMPA members (p < 0.001). For cases from the descriptive analysis (2013-2017), the top complaint was deficient patient assessment (69/142, 48.6%). Some patients (22/145, 15.2%) experienced severe outcomes. Most cases (135/142, 97.9%) did not result in severe physician sanctions. Our classification of complaints found 106 of 163 (65.0%) involved clinical problems, 95 of 163 (58.3%) relationship problems (e.g., communication) and 67 of 163 (41.1%) professionalism problems. In college decisions, 36 of 163 (22.1%) had a classification of clinical problem, 66 of 163 (40.5%) a patient-physician relationship problem and 63 of 163 (38.7%) a professionalism problem. In 63 of 163 (38.7%) college decisions, the college had no criticism. INTERPRETATION: Problems with communication and professionalism feature prominently in resident college complaints, and we note the potential for mismatch between patient and health care provider perceptions of care. These results may direct medical education to areas of potential practice improvement.

Bioética y virtualidad en la relación médico-paciente / Bioethics and virtuality in the doctor-patient relationship

The paper proposes, as the topic of analysis, the emergence of telemedicine, a tool that has been intensively used by doctors and other professionals during the covid pandemic. The essay, divided into two parts, first describes the current situation of telemedicine and afterwards proposes a few precautionary theses, related to telemedicine and the doctor-patient relationship according to the undestanding that the latter has been inherited and transmitted by medical anthropology and the medical humanities. (AU)

Ética médica en la práctica clínica / Medical ethics in clinical practice

La actividad médica se puede ver en dos contextos diferentes, tanto en la práctica clínica como en la investigación científica. El concepto de práctica clínica es todo acto realizado sobre un paciente con el objetivo de diagnosticar o tratar enfermedades. Por otro lado, la investigación clínica cuestiona diferentes aspectos relacionados con la salud humana. Este estudio busca inicialmente esclarecer los aspectos y componentes que orientan la relación y comunicación médico-paciente, definiendo los valores éticos de esta práctica, donde el profesional médico modela su carácter, mediante una relación entre los principios abordados en el ámbito de la ética de los profesionales de la salud. La demostración de una adecuada y sana relación de los profesionales médicos con sus pacientes es necesaria y fundamental a través del respeto y principalmente a través del principio de autonomía, ya que todo ser humano debe ser reconocido como fin y dueño de sí mismo, donde las actividades médicas comprenden procesos que involucran vida, salud e integridad física. Así, el presente trabajo abordará los diversos aspectos de la ética médica, en relación con el contexto de la práctica clínica del médico.

The medical activity can be seen in different contexts, both in clinical practice and in scientific research. The concept of clinical practice is every act performed on a patient with the objective of diagnosing or treating illnesses. On the other hand, clinical research questions different aspects related to human health. This study initially seeks to clarify the aspects and components that guide the doctor-patient relationship and communication, defining the ethical values of this practice, from which the medical professional models its character, through a relationship between the principles addressed in the scope of their ethics. health professionals. The demonstration of an adequate and healthy relationship between medical professionals and their patients is necessary and fundamental through respect and mainly through the principle of autonomy, since every human being must be recognized as an end and duen of symbolism, hence medical activities include processes that involve life, health and physical integrity. Thus, this work will address the various aspects of medical ethics, in relation to the context of the clinical practice of the doctor.

Examining patient trust towards physicians between clinical departments in a Chinese hospital.

The purpose of this cross-sectional survey study is to quantitatively examine the differences in patient trust towards physicians between four different clinical departments in a Chinese hospital. Using a validated modified Chinese version of the Wake Forest Physician Trust Scale, we measured patient trust in each department, and also collected data on patient demographics. A total of 436 patients or family members were surveyed in the departments of emergency medicine, pediatrics, cardiology, and orthopedic surgery. Significant differences were found between the departments, especially between pediatrics (trust score 43.23, range 11-50) and emergency medicine and cardiology (trust scores 45.29 and 45.79, respectively with range of 11-50). The average total score across all four departments was 44.72. There are indications that specifically comparing departments, such as patient demographics or department structure, could be helpful in tailoring patient care to improve physician-patient relationships.

Remote medico-legal assessment by telephone during COVID-19: Monitoring safety and quality when documenting evidence of torture for UK asylum applicants.

INTRODUCTION: Due to the COVID-19 pandemic, Freedom from Torture developed remote telephone assessments to provide interim medico-legal reports, ensuring people could obtain medical evidence to support their asylum claim. METHOD: To audit this new way of working, feedback was collected from the doctors, interpreters, individuals being assessed, and senior medical and legal staff who reviewed the reports. This paper presents findings from the first 20 assessments. RESULTS: Individuals assessed reported that the doctor developed good rapport, but in 35% of assessments reported that there were some experiences they felt unable to disclose. In 70% of assessments, doctors felt that rapport was not as good compared to face-to-face. In the majority of assessments, doctors were unable to gain a full account of the torture or its impact. They reported feeling cautious about pressing for more information on the telephone, mindful of individuals' vulnerability and the difficulty of providing support remotely. Nevertheless, in 85% of assessments doctors felt able to assess the consistency of the account of torture with the psychological findings, in accordance with the Istanbul Protocol (United Nations, 2004). Factors that hindered the assessment included the inability to observe body language, the person's ill health, and confidentiality concerns. CONCLUSION: This research indicates that psychological medico-legal reports can safely be produced by telephone assessment, but are more likely to be incomplete in terms of both full disclosure of torture experiences and psychological assessment. The limitations underline the need for a follow-up face-to-face assessment to expand the psychological assessment as well as undertake a physical assessment.

Is physician implicit bias associated with differences in care by patient race for metastatic cancer-related pain?

RATIONALE: Implicit racial bias affects many human interactions including patient-physician encounters. Its impact, however, varies between studies. We assessed the effects of physician implicit, racial bias on their management of cancer-related pain using a randomized field experiment. METHODS: We conducted an analysis of a randomized field experiment between 2012 and 2016 with 96 primary care physicians and oncologists using unannounced, Black and White standardized patients (SPs)who reported uncontrolled bone pain from metastatic lung cancer. We assessed implicit bias using a pain-adaptation of the race Implicit Association Test. We assessed clinical care by reviewing medical records and prescriptions, and we assessed communication from coded transcripts and covert audiotapes of the unannounced standardized patient office visits. We assessed effects of interactions of physicians' implicit bias and SP race with clinical care and communication outcomes. We conducted a slopes analysis to examine the nature of significant interactions. RESULTS: As hypothesized, physicians with greater implicit bias provided lower quality care to Black SPs, including fewer renewals for an indicated opioid prescription and less patient-centered pain communication, but similar routine pain assessment. In contrast to our other hypotheses, physician implicit bias did not interact with SP race for prognostic communication or verbal dominance. Analysis of the slopes for the cross-over interactions showed that greater physician bias was manifested by more frequent opioid prescribing and greater discussion of pain for White SPs and slightly less frequent prescribing and pain talk for Black SPs with the opposite effect among physicians with lower implicit bias. Findings are limited by use of an unvalidated, pain-adapted IAT. CONCLUSION: Using SP methodology, physicians' implicit bias was associated with clinically meaningful, racial differences in management of uncontrolled pain related to metastatic lung cancer. There is favorable treatment of White or Black SPs, depending on the level of implicit bias.