Dificultades de las enfermeras de atención primaria en los procesos de planificación anticipada de las decisiones: un estudio cualitativo / Primary care nurses’ difficulties in advance care planning processes: a qualitative study

OBJETIVO: Conocer las dificultades que encuentran las enfermeras de atención primaria para promover procesos de planificación anticipada de las decisiones con personas en el final de la vida. DISEÑO: Estudio cualitativo fenomenológico. EMPLAZAMIENTO: Área de Gestión Sanitaria Norte de Jaén. PARTICIPANTES: Enfermeras de atención primaria. MÉTODO: Muestreo intencional. Realización de 14 entrevistas en profundidad hasta la saturación de los discursos. Análisis de contenido en 4 etapas: transcripción de datos, codificación, obtención de resultados y verificación de conclusiones. Uso de N-Vivo como apoyo al análisis. Triangulación de resultados entre investigadores. RESULTADOS: Dificultades referidas a los profesionales: falta de conocimiento sobre el tema, falta de habilidades de comunicación o de experiencia y presencia de emociones negativas. En la institución sanitaria, la falta de tiempo y las interferencias con otros profesionales suponen una barrera. También la actitud del propio paciente o su familia es vista como una traba ya que pocos hablan sobre el final de la vida. Finalmente, nuestra sociedad evita las conversaciones abiertas sobre temas relacionados con la muerte. CONCLUSIONES: Es necesario el aprendizaje de los profesionales sobre planificación anticipada de decisiones, su entrenamiento en habilidades comunicativas y su educación afectiva. Los gestores sanitarios han de tener en cuenta el hecho de que las intervenciones para planificar anticipadamente decisiones sanitarias precisan formación, tiempo y atención continuada. En tanto no acontezca un cambio cultural, persistirá un modelo evasivo para afrontar el final de la vida

OBJECTIVE: To know the primary care nurses' difficulties to promote advance care planning process with patients in the end of life. DESIGN: Phenomenological qualitative methodology. LOCATION: Health Management Area North of Jaén. PARTICIPANTS: Primary care nurses. METHOD: Purposive sampling. Fourteen in-depth interviews were conducted until the speeches saturation. Content analysis in four steps: transcription, coding, obtaining results and conclusions verification. Supported whit the software Nvivo 8. Triangulation of results between researchers. RESULTS: Professionals' difficulties: Lack of knowledge about the topic, lack of communication skills, lack of experience and presence of negative emotions. In the health institution lack of time and interference with other professionals is a barrier. Also the patient's attitude and the family are identified as an obstacle because few people speak about the end of life. Finally, our society prevents open discussion about issues related to death. CONCLUSIONS: Professional learning about advanced care planning, training in communication skills and emotional education are necessary. Health managers should consider the fact that early interventions for planning health decisions require training, time and continued attention. If a cultural change does not happen, an evasive way to face the end of life will persist

[Primary care nurses' difficulties in advance care planning processes: A qualitative study]. / Dificultades de las enfermeras de atención primaria en los procesos de planificación anticipada de las decisiones: un estudio cualitativo.

OBJECTIVE: To know the primary care nurses' difficulties to promote advance care planning process with patients in the end of life. DESIGN: Phenomenological qualitative methodology. LOCATION: Health Management Area North of Jaén. PARTICIPANTS: Primary care nurses. METHOD: Purposive sampling. Fourteen in-depth interviews were conducted until the speeches saturation. Content analysis in four steps: transcription, coding, obtaining results and conclusions verification. Supported whit the software Nvivo 8. Triangulation of results between researchers. RESULTS: Professionals' difficulties: Lack of knowledge about the topic, lack of communication skills, lack of experience and presence of negative emotions. In the health institution lack of time and interference with other professionals is a barrier. Also the patient's attitude and the family are identified as an obstacle because few people speak about the end of life. Finally, our society prevents open discussion about issues related to death. CONCLUSIONS: Professional learning about advanced care planning, training in communication skills and emotional education are necessary. Health managers should consider the fact that early interventions for planning health decisions require training, time and continued attention. If a cultural change does not happen, an evasive way to face the end of life will persist.

Content of Public Health Ethics Postgraduate Courses in the United States.

UNLABELLED: This paper evaluates the content of the syllabi of postgraduate courses on public health ethics (PHE) within accredited schools and programs of public health (PH) in the United States in order to gain an awareness of the topics addressed within these courses. METHODS: Data was gathered via the analysis of syllabi of courses on PHE. In 2012, information was requested by e-mail from the 48 schools and 86 PH programs accredited by the U.S. Council on Education for Public Health for 2012. The "Epidemiology and PHE Syllabi" project of the University of Miami also was consulted. A table of topics was drawn up in order to carry out content analysis of the documents. RESULTS: Data was obtained from 25 schools (52%) and 36 accredited programs (42%); 36 syllabi were gathered and 75 different topics were found. Of these, 38 topics were addressed in six or more syllabi and can be grouped as follows: foundations of PHE; autonomy and its limits; infectious disease control; justice; research ethics; health education and promotion; environmental and occupational health; screening; genetics; privacy and confidentiality; and community-based practice and vulnerable populations. CONCLUSIONS: The analyzed syllabi show high variability in curricular content. The debate with regard to whether a core curriculum on PHE should be established is ongoing. The results of this work might be of interest for schools and programs of PH in other countries or regions of the world in order to develop or ameliorate their own PHE syllabi.

Stability over time in the preferences of older persons for life-sustaining treatment.

OBJECTIVE: To measure the stability of life-sustaining treatment preferences amongst older people and analyse the factors that influence stability. DESIGN: Longitudinal cohort study. SETTING: Primary care centres, Granada (Spain). Eighty-five persons age 65 years or older. Participants filled out a questionnaire with six contexts of illness (LSPQ-e). They had to decide whether or not to receive treatment. Participants completed the questionnaire at baseline and 18 months later. RESULTS: 86 percent of the patients did not change preferences. Sex, age, marital status, hospitalisation, and self-perception of health and pain did not affect preferences. Morbidity and the death of a relative did. CONCLUSION: Stability of preferences of older persons in relation to end-of-life decisions seems to be more probable than instability. Some factors, such as the death of a relative or the increase in morbidity, can change preferences. These findings have implications for advance directives (ADs) and advance care planning.

[Euthanasia in Belgium]. / La eutanasia en Bélgica.

The experience of the Netherlands in relation with the legalization and practice of euthanasia is better known in Spain than the Belgian experience in this matter. But the historical process of social debate in Belgium has many specific details which should be known by Spanish healthcare professionals, bioethicists, politicians and lawyers. This paper begins with a comparative analysis of both countries: Spain and Belgium and follows with a description of the milestones of the historical process of debating and, finally, passing the Belgian Law on Euthanasia in 2002. The next chapter consists of a description of the main contents of this important Law. The paper continues then with an approach to the epidemiology of the practice of euthanasia in Belgium and finishes with a description of the different positions of the actors of the process. Two positions are described more in depth: the opinion of the specialists in palliative care, and the opinion of the Catholic Church. The paper ends underlining the reason for the incorporation of the Belgian experience on euthanasia to the debate about the possibility of legalizing euthanasia in Spain.

End-of-life healthcare decisions, ethics and law: the debate in Spain.

The debate on euthanasia in Spain has been ongoing from the beginning of the 20th century and remains extant. Three periods can be identified: prior to 1978, 1978-2002, and after 2002. The debate increased significantly after the Ramon Sampedro case (1995-1998), and was fuelled with new, although very different cases, such as those of Leganés (2005-2008), Jorge Leon (2006) or Inmaculada Echevarria (2006-2007). As a consequence of these cases in 2008 the Regional Government of Andalusia started a legal process to pass a law regulating end-of-life decisions, excluding euthanasia and assisted-suicide, which was finally enacted in 2010. Two other Spanish regions (Navarra and Aragón) passed similar laws. The central government also initiated a legal process to approve a national law, excluding euthanasia and assisted-suicide. The project failed because of the dissolution of the Parliament in June 2011. The new government will have to decide how to continue the process.

La eutanasia en Bélgica / Euthanasia in Belgium

La experiencia holandesa en relación con la legalización y la práctica de la eutanasia es más conocida en España que la experiencia belga. Sin embargo, el proceso histórico de debate social en Bélgica en torno a la eutanasia tiene una riqueza en matices que debería ser conocida por los profesionales sanitarios, bioeticistas, políticos y juristas. El presente trabajo se inaugura con un análisis sobre las similitudes y diferencias que existen entre España y Bélgica, lo que permite encuadrar el desarrollo posterior. Después se describe la historia del proceso de debate realizado en Bélgica que tiene su punto álgido en la aprobación de la ley de eutanasia en el año 2002. En el apartado siguiente se analiza de forma detallada el contenido de esta disposición legislativa, señalando los aspectos más relevantes. A continuación se exponen algunos datos epidemiológicos sobre la práctica de la eutanasia en Bélgica y se finaliza con un relato sobre la manera en que diversos grupos de población han afrontado el tema de la eutanasia. En este último apartado el trabajo se detiene en las posiciones de dos grupos especialmente relevantes: los especialistas en Cuidados Paliativos y la Iglesia Católica. Se finaliza con una exposición de los motivos por los que resulta conveniente incorporar la perspectiva y experiencia belga en futuros debates sobre la posible legalización de la eutanasia en España(AU)

The experience of the Netherlands in relation with the legalization and practice of euthanasia is better known in Spain than the Belgian experience in this matter. But the historical process of social debate in Belgium has many specific details which should be known by Spanish healthcare professionals, bioethicists, politicians and lawyers. This paper begins with a comparative analysis of both countries: Spain and Belgium and follows with a description of the milestones of the historical process of debating and, finally, passing the Belgian Law on Euthanasia in 2002. The next chapter consists of a description of themain contents of this important Law. The paper continues then with an approach to the epidemiology of the practice of euthanasia in Belgium and finishes with a description of the different positions of the actors of the process. Two positions are described more in depth: the opinion of the specialists in palliative care, and the opinion of the Catholic Church. The paper ends underlining the reason for the incorporation of the Belgian experience on euthanasia to the debate about the possibility of legalizing euthanasia in Spain(AU)

El culto a los números y el factor de impacto / The cult of numbers and impact factor

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Are the health messages in schoolbooks based on scientific evidence? A descriptive study.

BACKGROUND: Most textbooks contains messages relating to health. This profuse information requires analysis with regards to the quality of such information. The objective was to identify the scientific evidence on which the health messages in textbooks are based. METHODS: The degree of evidence on which such messages are based was identified and the messages were subsequently classified into three categories: Messages with high, medium or low levels of evidence; Messages with an unknown level of evidence; and Messages with no known evidence. RESULTS: 844 messages were studied. Of this total, 61% were classified as messages with an unknown level of evidence. Less than 15% fell into the category where the level of evidence was known and less than 6% were classified as possessing high levels of evidence. More than 70% of the messages relating to "Balanced Diets and Malnutrition", "Food Hygiene", "Tobacco", "Sexual behaviour and AIDS" and "Rest and ergonomics" are based on an unknown level of evidence. "Oral health" registered the highest percentage of messages based on a high level of evidence (37.5%), followed by "Pregnancy and newly born infants" (35%). Of the total, 24.6% are not based on any known evidence. Two of the messages appeared to contravene known evidence. CONCLUSION: Many of the messages included in school textbooks are not based on scientific evidence. Standards must be established to facilitate the production of texts that include messages that are based on the best available evidence and which can improve children's health more effectively.

[Life support treatment preferences in critical health situations]. / Preferencias de tratamiento de soporte vital en condiciones críticas de salud.

OBJECTIVE: To explore citizens' treatment preferences in critical health situations. METHOD: We performed a cross-sectional study through a questionnaire administered to 306 participants, randomly selected from nursing consultations, cultural centers, nursing homes and the university. Treatment preferences in critical health situations were measured through the Life Support Preferences Questionnaire (LSPQ). A descriptive bivariate and multivariate analysis was performed. RESULTS: The mean age of participants was 39.28 years (SD: 24.52), 37% had primary school or no education, and 29.1% were male. Age was inversely correlated with accepting treatments; thus acceptance of life support measures was lower among participants older than 55 years than among the youngest participants and was also lower among those with a lower educational level than those with a higher educational level. No differences were found between men and women. In serious diseases with no possibility of recovery, all age groups rejected treatment. When there was the potential for recovery or for non-invasive treatments, participants aged 21 years old or older would prefer to be treated. CONCLUSION: There is wide variability among the population when accepting or rejecting life support treatment. The view that treatment should be accepted at all costs is inappropriate. Disseminating knowledge of advance directives and the use of these documents is recommended as the most effective way to respect patients' wishes when they are unable to express themselves.

Opinión de los pacientes sobre la legibilidad de los folletos de Educación para la Salud / Opinion of the patients about legible health education leaflets

Antecedentes: los Servicios de salud normalmente proporcionan a los pacientes folletos u otros documentos relacionados con tratamientos. Este material no está escrito con mucha legibilidad y los pacientes tienen dificultad en entenderlos. Objetivos: determinar la opinión de los lectores en relación a los requisitos que deberían ser encontrados en este material para asegurar la legibilidad. Metodología: metodología cualitativa de entrevistas semiestructuradas. 24 participantes fueron entrevistados con preguntas abiertas. Los participantes tenían un bajo nivel académico. Resultados: ocho categorías fueron identificadas en los folletos que debían encontrarse para aumentar la legibilidad: escribir como se habla, interés por el tema, estilo directo, ordenar las ideas, mensajes afirmativos, imágenes, amplios márgenes, letra grande y clara. Conclusiones: los profesionales sanitarios y los escritores de folletos educativos deberían involucrar a los pacientes en el proceso de diseño del material educativo (AU)

Introduction: Healthcare Service usually provides patients with leaflets relating to treatment. Often, this material is written not very legible and patients have difficulty understanding it. Aims: This study aims to determine the opinion of readers in relation to the requisites that should be met by this material in order to ensure legibility. Design: Qualitative method of semi-structured interviews. Method: Twelve interviews were conducted. Open-ended questions were asked in each interview. Participants had a low academic level, poor reading habits, but they usually were capable of read. Finding: Eight categories were identified that describe the opinion of the participants in relation to the requisites that the leaflets must meet in order to improve legibility: Writing like speaking, interest in the subject, direct style, order of the ideas, affirmative messages, images and clear fonts. Conclusions: Health professionals and writers of educational leaflets should involve patients in the process of designing educational material (AU)

[Grammatical readability of the package leaflets of the medicinal products most widely consumed and generating the highest expense in Spain during 2005]. / Legibilidad gramatical de los prospectos de los medicamentos de más consumo y facturación en España en 2005.

BACKGROUND: The manufacturers of medicinal products are responsible for providing consumers proper information on the use of such products. This information is set out in the package leaflets which, according to current legislation, must be easy for patients to read and understand. The purpose of this study is to analyse the linguistic/grammatical readability of the package leaflets of medicinal products through application of the Flesch formula. METHODS: The 30 medicinal products most widely consumed and the 30 which generated the highest expenditure during 2005 in Spain were selected. In line with the recommendations of the relevant literature, documents with a Flesch Index value of > or = 10 were considered readable. The grammatical readability was calculated by using the Flesch Index accessible through the Microsoft Office 2000 programme. RESULTS: Only 5 documents obtained an acceptable Flesch Index score (= 10), while 18 scored 0. Half of the values were under 2; 25% were 0 and 25% scored 6 or more. CONCLUSIONS: The data obtained reveal a low level of linguistic and grammatical readability in the package leaflets analysed. The syntax used on drafting the texts tends to use long words.

Legibilidad gramatical de los prospectos de los medicamentos de más consumo y facturación en España en 2005 / Grammatical readability of the package leaflets of the medicinal products most widely consumed and generating the highest expense in Spain during 2005

Fundamento. Los fabricantes de medicamentos tienen el deber de proporcionar a los consumidores información correcta sobre su uso. Esta información está recogida en el prospecto que, según la normativa vigente, debe ser legible y comprensible para el paciente. El objetivo de este estudio es analizar la legibilidad lingüística gramatical de los prospectos de medicamentos mediante la aplicación de la fórmula de Flesch. Métodos. Se seleccionan las 30 medicamentos más consumidos y los 30 que más gasto han generado durante el año 2005 en España. Siguiendo las recomendaciones de la literatura, se han considerado legibles aquellos documentos cuyo Índice de Flesch fuese ≥ 10. Se ha calculado la legibilidad gramatical a través del Índice de Flesch accesible en el programa Microsoft Office 2000. Resultados. Sólo 5 documentos alcanzan un índice de Flesch aceptable (= 10) y 18 tienen una puntuación de 0. La mitad de los valores si sitúan por debajo de 2; 25% de los valores tienen valor 0 y 25% tiene valores de 6 ó más. Conclusiones. Los datos obtenidos revelan una baja legibilidad lingüística y gramatical de los prospectos analizados. La sintaxis empleada al redactarlos tiende a usar frases y palabras largas, lo que incumple claramente las indicaciones de la normativa vigente (AU)

Background. The manufacturers of medicinal products are responsible for providing consumers proper information on the use of such products. This information is set out in the package leaflets which, according to current legislation, must be easy for patients to read and understand. The purpose of this study is to analyse the linguistic/grammatical readability of the package leaflets of medicinal products through application of the Flesch formula. Methods. The 30 medicinal products most widely consumed and the 30 which generated the highest expenditure during 2005 in Spain were selected. In line with the recommendations of the relevant literature, documents with a Flesch Index value of ≥ 10 were considered readable. The grammatical readability was calculated by using the Flesch Index accessible through the Microsoft Office 2000 programme. Results. Only 5 documents obtained an acceptable Flesch Index score (= 10), while 18 scored 0. Half of the values were under 2; 25% were 0 and 25% scored 6 or more. Conclusions. The data obtained reveal a low level of linguistic and grammatical readability in the package leaflets analysed. The syntax used on drafting the texts tends to use long words (AU)

[Presence of current child and adolescent health priorities in school textbooks]. / Presencia de las actuales prioridades de salud infantil y adolescente en los libros de texto escolares.

BACKGROUND: Textbooks are an educational tool for learning health habits. The aim of this study was to determine how these textbooks present the health priorities defined by health organizations to children and teenagers. METHOD: We performed a descriptive study in 3 steps: a) the priorities defined by health organizations were identified; b) the messages on health in the textbooks used in the schools of a municipality were identified, and c) the extent to which these messages fitted the priorities established was analyzed. RESULTS: The World Health Organization, the European Union, the Spanish Ministry of Health and Consumption, and the Spanish Society of Public Health and Healthcare Administration define 24 priorities. One hundred textbooks were collected, with 663 health messages. The priorities most frequently covered in the textbooks were diet, physical exercise and the impact of environmental contamination. The least frequently covered topics was bullying, child maltreatment, poverty, self harm, and obesity. The latter topic was especially lacking in kindergartens and elementary schools. CONCLUSIONS: The health messages contained in school textbooks are not well adapted to the priorities defined by health organizations.

Revisión de la literatura sobre el uso del testamento vital por la población mayor / Review of literature about the use of living bill by elderly population

El Testamento Vital (TV) recoge las preferencias detratamiento de una persona para cuando sea incapazde tomar decisiones por sí misma. Nuestro país estádando los primeros pasos para su implantación. Paraque el TV sea accesible y útil para las personas mayores,conviene conocer cómo se ha desarrollado en otrospaíses. En EE.UU., el TV ha pasado de una concepciónformal y burocrática a otra integral, denominadade Planificación Anticipada de Decisiones Sanitarias.La población mayor española tiene una opinión favorablesobre el TV si se incluye en una estrategia de comunicacióncon la familia y los profesionales. Teneren cuenta los hallazgos de la literatura facilitará eldesarrollo de un modelo organizativo efectivo que normaliceen España el uso del testamento vital por partede los mayores(AU)

The Living Will (LW) gathers the treatment preferencesof a person. Spain is starting the LW’ implantation.In order to the TV will be accessible and usefulfor the older people, we have to know how it has beendeveloped in other countries. In United States, TV hashappened through different stages: from a formal andbureaucratic conception to an integral concept, denominatedAdvance Care Planning. Spanish oldadults have a favourable opinion about TV, but it isnecessary to include it in a strategy of communicationand dialogue with its family and its professionals caregivers.Review literature findings will facilitate the developmentof an effective organizational model thatstandardizes in Spain the use of the TV by the oldadults(AU)

Presencia de las actuales prioridades de salud infantil y adolescente en los libros de texto escolares / Presence of current child and adolescent health priorities in school textbooks

Introducción: Los libros de texto escolares son una herramienta didáctica para aprender hábitos saludables. El objetivo de este estudio es conocer cómo se recogen en los libros las prioridades de salud infantil y adolescente definidas por las autoridades sanitarias.Métodos: Estudio descriptivo en 3 fases: a) identificación de las prioridades según las autoridades sanitarias; b) identificación de los mensajes sobre salud de los textos usados en los colegios de un distrito municipal, y c) observación de cómose adecuan estos mensajes a las prioridades.Resultados: La Organización Mundial de la Salud, la UniónEuropea, el Ministerio de Sanidad y Consumo, y la Sociedad Española de Salud Pública y Administración Sanitaria definen 24 prioridades. Se recogieron 100 libros de texto y 663 mensajes sobre salud. Las prioridades tratadas con más frecuencia son la alimentación, el ejercicio físico y el impacto de la contaminación medioambiental. Las menos tratadas son elacoso escolar, el maltrato infantil, la pobreza, la autolesión y la obesidad, esta última especialmente en educación infantil y primaria.Conclusiones: Los mensajes sobre salud de los libros no se ajustan suficientemente a las prioridades definidas por las autoridades

Background: Textbooks are an educational tool for learning health habits. The aim of this study was to determine how these textbooks present the health priorities defined by health organizationsto children and teenagers.Method: We performed a descriptive study in 3 steps: a) the priorities defined by health organizations were identified; b) the messages on health in the textbooks used in the schools of a municipality were identified, and c) the extent to which these messages fitted the priorities established was analyzed.Results: The World Health Organization, the European Union, the Spanish Ministry of Health and Consumption, and the Spanish Society of Public Health and Healthcare Administration define 24 priorities. One hundred textbooks were collected, with 663 health messages. The priorities most frequently covered in the textbooks were diet, physical exercise and the impact of environmental contamination. The least frequently covered topics was bullying, child maltreatment, poverty, self harm,and obesity. The latter topic was especially lacking in kindergartens and elementary schools.Conclusions: The health messages contained in school textbooks are not well adapted to the priorities defined by health organizations

Criterios éticos para las decisiones sanitarias al final de la vida de personas incapaces / Ethical criteria for substitute decision-making in people without capacity

Actualmente las relaciones sanitarias se apoyan en el reconocimientodel derecho de los pacientes a participar en las decisionessobre su salud. Esta idea es el fundamento del consentimiento informado.Sin embargo, problema surge cuando el paciente no puedeparticipar en estas decisiones porque se halla en una situación deincapacidad. Es otro, un representante, quien debe decidir por él. EnEspaña no existe claridad sobre qué criterios deben orientar las decisionesque ha de tomar el representante. El presente artículo presentalos criterios de decisión en pacientes incapaces desarrollados porla jurisprudencia norteamericana: el criterio subjetivo, el criterio deljuicio sustitutivo y el criterio del mejor interés o mayor beneficio. Elcriterio subjetivo consiste en seguir las directrices que el pacientedictó antes de perder la capacidad. El criterio del juicio sustitutivotrata de deducir la decisión que hubiese tomado el propio paciente sipudiera, a partir de lo que conocemos de él. El criterio del mayorbeneficio intenta proteger el bienestar del paciente. Tradicionalmenteel «mejor interés» ha sido defender la vida a toda costa, sin atendera otro tipo de consideraciones. Quizás sea el momento de buscar unconsenso sobre lo que socialmente hoy en día se considera «mejorinterés». Su significado no podrá derivarse exclusivamente del derechoa la vida, sino de la conjunción entre éste –en cantidad y calidadsuficientes– y la libertad, interpretados a la luz del respeto a la dignidadde la persona

Nowadays healthcare relationships rest on the recognition of theright of patients to take part in the decisions about their health. Thisidea is the foundation of the informed consent theory. Nevertheless,problem arises when the patient cannot take part in these decisionsbecause he hasn't enough capacity. Then, another person, a substitute,must decide for him. In Spain does not exist enough clarity aboutthe criteria that must guide the decisions of the proxy. The presentwork deals with the three criteria developed by the North Americanjurisprudence. These criteria are: the subjective criterion, the criterionof the substitute judgment and the best interest or major benefitcriterion. The subjective criterion is based on the statement of theown patient, usually written in an advance directive or living will.The criterion of the substitute judgment tries to rebuild the decisionthat the own patient had taken if he remained capable. The criterionof the major benefit tries to protect the well-being of the patient. Traditionallythe «better interest» has been to defend the life at anyexpense, without attending to another type of considerations. Probablyit is the moment to look for a new consensus on what today thesociety has to consider the «better interest» of a patient. Surely thisnew definition meaning would not stem exclusively from the right tolife, but from the conjunction between quantity and quality of lifeconsiderations and the freedom of patients, all interpreted in the lightof the respect person's dignity

Problemas éticos de la investigación cualitativa / Ethical problems of qualitative research

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