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2.
Health Res Policy Syst ; 19(1): 47, 2021 Mar 31.
Artículo en Inglés | MEDLINE | ID: mdl-33789671

RESUMEN

BACKGROUND: At the height of the COVID-19 pandemic, Thailand had almost depleted its critical care resources, particularly intensive care unit (ICU) beds and ventilators. This prompted the necessity to develop a national guideline for resource allocation. This paper describes the development process of a national guideline for critical resource allocation in Thailand during the COVID-19 pandemic. METHODS: The guideline development process consisted of three steps: (1) rapid review of existing rationing guidelines and literature; (2) interviews of Thai clinicians experienced in caring for COVID-19 cases; and (3) multi-stakeholder consultations. At steps 1 and 2, data was synthesized and categorized using a thematic and content analysis approach, and this guided the formulation of the draft guideline. Within step 3, the draft Thai critical care allocation guideline was debated and finalized before entering the policy-decision stage. RESULTS: Three-order prioritization criteria consisting of (1) clinical prognosis using four tools (Charlson Comorbidity Index, Sequential Organ Failure Assessment, frailty assessment and cognitive impairment assessment), (2) number of life-years saved and (3) social usefulness were proposed by the research team based on literature reviews and interviews. At consultations, stakeholders rejected using life-years as a criterion due to potential age and gender discrimination, as well as social utility due to a concern it would foster public distrust, as this judgement can be arbitrary. It was agreed that the attending physician is required to be the decision-maker in the Thai medico-legal context, while a patient review committee would play an advisory role. Allocation decisions are to be documented for transparency, and no appealing mechanism is to be applied. This guideline will be triggered only when demand exceeds supply after the utmost efforts to mobilize surge capacity. Once implemented, it is applicable to all patients, COVID-19 and non-COVID-19, requiring critical care resources prior to ICU admission and during ICU stay. CONCLUSIONS: The guideline development process for the allocation of critical care resources in the context of the COVID-19 outbreak in Thailand was informed by scientific evidence, medico-legal context, existing norms and societal values to reduce risk of public distrust given the sensitive nature of the issue and ethical dilemmas of the guiding principle, though it was conducted at record speed. Our lessons can provide an insight for the development of similar prioritization guidelines, especially in other low- and middle-income countries.


Asunto(s)
Cuidados Críticos , Enfermedad Crítica , Asignación de Recursos para la Atención de Salud , Accesibilidad a los Servicios de Salud , Pandemias , Guías de Práctica Clínica como Asunto , Toma de Decisiones , Revelación , Ética Médica , Recursos en Salud , Hospitalización , Humanos , Unidades de Cuidados Intensivos , Pronóstico , Discriminación Social , Valores Sociales , Participación de los Interesados , Tailandia , Confianza
3.
J Med Internet Res ; 23(3): e25698, 2021 03 30.
Artículo en Inglés | MEDLINE | ID: mdl-33783366

RESUMEN

BACKGROUND: As the use of technology to deliver health services is increasing rapidly and has further intensified during the COVID-19 pandemic, these initiatives may fail if ethical impacts are not fully identified and acted upon by practitioners. Ignoring the ethical impacts of information and communication technology health service delivery creates an unintended risk for patients and can lead to reduced effectiveness, noncompliance, and harm, undermining the best intentions of governments and clinicians. OBJECTIVE: Our aim was to explore how ethical considerations or impacts may be different, greater, or more variable in information and communication technology methods versus face-to-face health care delivery models, and how they may be applied in practice. METHODS: We undertook a systemic literature review to provide a critical overview of existing research into the incorporation of ethical principles into telehealth practice. Six databases were searched between March 2016 to May 2016 and again in December 2020 to provide the benefit of currency. A combination of broad terms ("ethics," "ethical," "health," and "care") with the restrictive terms of "telehealth" and "telemedicine" was used in keyword searches. Thematic analysis and synthesis of each paper was conducted, aligned to the framework developed by Beauchamp and Childress. RESULTS: From the 49 papers reviewed, authors identified or discussed the following ethical principles in relation to telehealth practice: autonomy (69% of authors, 34/49), professional-patient relationship (53% of authors, 26/49), nonmaleficence (41% of authors, 20/49), beneficence (39%, of authors, 19/49), and justice (39% of authors, 19/49). CONCLUSIONS: Although a small number of studies identified ethical issues associated with telehealth practice and discussed their potential impact on service quality and effectiveness, there is limited research on how ethical principles are incorporated into clinical practice. Several studies proposed frameworks, codes of conduct, or guidelines, but there was little discussion or evidence of how these recommendations are being used to improve ethical telehealth practice.


Asunto(s)
Prestación de Atención de Salud , Brotes de Enfermedades , Telemedicina/ética , Ética Médica , Humanos
4.
BMC Med Ethics ; 22(1): 28, 2021 03 22.
Artículo en Inglés | MEDLINE | ID: mdl-33752662

RESUMEN

BACKGROUND: The worsening COVID-19 pandemic in South Africa poses multiple challenges for clinical decision making in the context of already-scarce ICU resources. Data from national government and the last published national audit of ICU resources indicate gross shortages. While the Critical Care Society of Southern Africa (CCSSA) guidelines provide a comprehensive guideline for triage in the face of overwhelmed ICU resources, such decisions present massive ethical and moral dilemmas for triage teams. It is therefore important for the health system to provide clinicians and critical care facilities with as much support and resources as possible in the face of impending pandemic demand. Following a discussion of the ethical considerations and potential challenges in applying the CCSSA guidelines, the authors propose a framework for regional triage committees adapted to the South African context. DISCUSSION: Beyond the national CCSSA guidelines, the clinician has many additional ethical and clinical considerations. No single ethical approach to decision-making is sufficient, instead one which considers multiple contextual factors is necessary. Scores such as the Clinical Frailty Score and Sequential Organ Failure Assessment are of limited use in patients with COVID-19. Furthermore, the clinician is fully justified in withdrawing ICU care based on medical futility decisions and to reallocate this resource to a patient with a better prognosis. However, these decisions bear heavy emotional and moral burden compounded by the volume of clinical work and a fear of litigation. CONCLUSION: We propose the formation of Provincial multi-disciplinary Critical Care Triage Committees to alleviate the emotional, moral and legal burden on individual ICU teams and co-ordinate inter-facility collaboration using an adapted framework. The committee would provide an impartial, broader and ethically-sound viewpoint which has time to consider broader contextual factors such as adjusting rationing criteria according to different levels of pandemic demand and the latest clinical evidence. Their functioning will be strengthened by direct feedback to national level and accountability to a national monitoring committee. The potential applications of these committees are far-reaching and have the potential to enable a more effective COVID-19 health systems response in South Africa.


Asunto(s)
Cuidados Críticos/ética , Toma de Decisiones/ética , Asignación de Recursos para la Atención de Salud/ética , Unidades de Cuidados Intensivos , Pandemias , Triaje/métodos , Conducta Cooperativa , Emociones , Ética Médica , Recursos en Salud , Humanos , Inutilidad Médica , Pronóstico , Sudáfrica , Triaje/ética
7.
Artículo en Ruso | MEDLINE | ID: mdl-33591678

RESUMEN

The authors of this study discovered in annals of history the "Oath" of the Portuguese physician Amatus Lusitanus (1511-1568) and translated it into Russian for the first time. The mentioned historical document represents a sort of Code of Honor of European physician of XVI century that both took in ethical norms of Hippocrates and determined one's own rules of doctoring. The ethical principles of Amatus are akin Hippocrates' ones and they are in parallel on seven positions. However, the "Oath" of A. Lusitanus also includes other aspects of medical ethics that are completely organic to the very personality of author and distinguish themselves by courage and novelty for its time. To mention reward of physician for one's labor, difficulties and hardships falling on representatives of medical profession, theme of glorification and exaltation of physician and and medical tolerance. Amatus Lusitanus can be considered as a precursor of initiation of tolerance in European medical ethics that he anticipated with his "Oath".


Asunto(s)
Medicina , Médicos , Ética Médica , Humanos , Principios Morales , Federación de Rusia
9.
Curr Opin Anaesthesiol ; 34(2): 141-144, 2021 Apr 01.
Artículo en Inglés | MEDLINE | ID: mdl-33630773

RESUMEN

PURPOSE OF REVIEW: Addressing patients' Do Not Resuscitate (DNR) status in the perioperative setting is important for shared patient decision-making. Although the inherently resuscitative nature of anesthesia and surgery may pose an ethical quandary for clinicians tasked with caring for the patient, anesthesiologist-led efforts need to evaluate all aspects of the DNR order and operative procedures. RECENT FINDINGS: Approximately 15% of patients undergoing surgical procedures have a preexisting DNR order (Margolis et al., 1995) [1]. American Society of Anesthesiologists (ASA) and the American College of Surgeons (ACS) do not support automatic reversal of the DNR order in the perioperative setting. Citing patient self-determination and autonomy, these societies advocate for a thoughtful discussion where a patient or legal designee may make an informed decision regarding resuscitation in the perioperative setting. Although studies have suggested increased perioperative mortality among patients with a preexisting DNR order, this data remains largely inconclusive. SUMMARY: Efforts must be made to address the DNR order in the perioperative setting. The fundamental tenets of medical ethics, nonmaleficence, beneficence, and patient autonomy can help to guide this oftentimes challenging discussion.


Asunto(s)
Órdenes de Resucitación , Anestesia , Anestesiología , Ética Médica , Humanos
10.
Med Educ Online ; 26(1): 1891610, 2021 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-33618631

RESUMEN

Multiple mini-interview (MMI) is a 'multiple sample-based' approach comprising multiple focused encounters intended to access and assess a range of attributes in order to gain more objectively multiple impressions of an applicant's interpersonal skills, thoughtfulness and general demeanour. It is designed to focus on four domains that are not considered to be comprehensive, but are considered to be vital for a successful career in the health sciences: critical thinking, ethical decision making, communication and knowledge of the healthcare system. Traditionally, the MMI is conducted face-to-face, but with COVID-19 pandemic and the implementation of social distancing measures, no onsite or campus teaching, banning of mass gatherings and cancellation of face-to-face interviews, Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah Institute of Health Sciences at Universiti Brunei Darussalam explored the feasibility of conducting MMI through virtual means. This report provides an account of our experience in conducting internet-MMI for the selection of new applicants into the August 2020 cohort of the Medicine programme. We also aimed to determine whether the scores derived from internet-MMI were reliable and equivalent to the scores derived from traditional MMI.


Asunto(s)
/epidemiología , Entrevistas como Asunto/métodos , Criterios de Admisión Escolar , Facultades de Medicina/organización & administración , Comunicación , Toma de Decisiones , Ética Médica , Conocimientos, Actitudes y Práctica en Salud , Humanos , Pandemias , Pensamiento
13.
Int J Law Psychiatry ; 74: 101649, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-33418151

RESUMEN

This article investigates the lawfulness of isolating residents of care and group homes during the COVID-19 pandemic. Many residents are mobile, and their freedom to move is a central ethical tenet and human right. It is not however an absolute right and trade-offs between autonomy, liberty and health need to be made since COVID-19 is highly infectious and poses serious risks of critical illness and death. People living in care and group homes may be particularly vulnerable because recommended hygiene practices are difficult for them and many residents are elderly, and/or have co-morbidities. In some circumstances, the trade-offs can be made easily with the agreement of the resident and for short periods of time. However challenging cases arise, in particular for residents and occupants with dementia who 'wander', meaning they have a strong need to walk, sometimes due to agitation, as may also be the case for some people with developmental disability (e.g. autism), or as a consequence of mental illness. This article addresses three central questions: (1) in what circumstances is it lawful to isolate residents of social care homes to prevent transmission of COVID-19, in particular where the resident has a strong compulsion to walk and will not, or cannot, remain still and isolated? (2) what types of strategies are lawful to curtail walking and achieve isolation and social distancing? (3) is law reform required to ensure any action to restrict freedoms is lawful and not excessive? These questions emerged during the first wave of the COVID-19 pandemic and are still relevant. Although focussed on COVID-19, the results are also relevant to other future outbreaks of infectious diseases in care and group homes. Likewise, while we concentrate on the law in England and Wales, the analysis and implications have international significance.


Asunto(s)
/epidemiología , Hogares para Grupos/ética , Hogares para Grupos/legislación & jurisprudencia , Casas de Salud/ética , Casas de Salud/legislación & jurisprudencia , Aislamiento de Pacientes/ética , Aislamiento de Pacientes/legislación & jurisprudencia , Inglaterra/epidemiología , Ética Médica , Humanos , Pandemias , Gales/epidemiología
15.
Acta Neurochir (Wien) ; 163(3): 593-598, 2021 03.
Artículo en Inglés | MEDLINE | ID: mdl-33469692

RESUMEN

The COVID-19 pandemic has resulted in a widespread shortage of personal protective equipment (PPE). Many healthcare workers, including neurosurgeons, have expressed concern about how to safely and adequately perform their medical responsibilities in these challenging circumstances. One of these concerns revolves around the pressing question: should providers continue to work in the absence of adequate PPE? Although the first peak of the COVID-19 crisis seems to have subsided and supply of PPE has increased, concerns about insufficient PPE availability remain. Inconsistent supply, limited efficacy, and continued high demand for PPE, combined with the continued threat of a second COVID-19 wave, mean that the issues surrounding PPE availability remain unresolved, including a duty to work. This paper offers an ethical investigation of whether neurosurgeons should perform their professional responsibilities with limited availability of PPE. We evaluate ethical considerations and conflicting duties and thereby hope to facilitate providers in making a well-considered personal and moral decision about this challenging issue.


Asunto(s)
/prevención & control , Neurocirujanos/ética , Salud Laboral/ética , Equipo de Protección Personal/provisión & distribución , Ética Médica , Personal de Salud , Humanos , Obligaciones Morales , Pandemias , Medición de Riesgo
18.
Am J Bioeth ; 21(1): 4-13, 2021 01.
Artículo en Inglés | MEDLINE | ID: mdl-33373555

RESUMEN

Statements of the core ethical and professional responsibilities of medical professionals are incomplete in ways that threaten fundamental goals of medicine. First, in the absence of explicit guidance for responding to cases in which there is significant uncertainty or disagreement about the relative therapeutic, prophylactic or diagnostic merits of available interventions they perpetuate self-defeating practices. Second, without addressing the role of advertising in shaping patient and community preferences they risk creating moral loopholes that bypass and undermine professional duties of fidelity, honesty and transparency. In both cases, these flaws are exacerbated by an individualism that ignores the critical role of health systems in managing and reducing uncertainty and conflict over best practices, and in communicating with and shaping the expectations of the public. These points are illustrated with examples from the response to COVID-19 and suggestions for reform are proposed.


Asunto(s)
Códigos de Ética , Ética Médica , Humanos , Principios Morales
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