Protective factors of ethical conflict during a pandemic-Quali-Ethics-COVID-19 research part 2: An international qualitative study.

AIMS AND OBJECTIVES: To determine which factors can be considered protective of ethical conflicts in intensive care unit healthcare professionals during a pandemic. BACKGROUND: The COVID-19 pandemic gave rise to new ethical concerns in relation to the management of public health and the limitations on personal freedom. Continued exposure to ethical conflict can have a range of psychological consequences. DESIGN: A qualitative design based on phenomenological approach. METHODS: A total of 38 nurses and physicians who were regular staff members of Barcelona and Milan's public tertiary university hospitals and working in intensive care units during the first wave of the COVID-19 pandemic. Semi-structured online in-depth interviews were conducted. A thematic analysis was performed by two independent researchers following the seven steps of Colaizzi's methods. We adhere COREQ guidelines. RESULTS: One theme 'Protective factors of ethical conflict in sanitary crisis' and four subthemes emerged from the data: (1) knowledge of the infectious disease, (2) good communication environment, (3) psychological support and (4) keeping the same work team together. CONCLUSIONS: Four elements can be considered protective factors of ethical conflict for healthcare professionals during a sanitary crisis. While some of these factors have already been described, the joint identification of this set of four factors as a single element is, in itself, novel. This should help in ensuring the right mechanisms are in place to face future pandemics and should serve to improve institutional organisation and guarantee safe and high-quality patient care in times of healthcare crisis. RELEVANCE TO CLINICAL PRACTICE: Future strategies for the prevention of ethical conflict during sanitary crises, pandemics or other catastrophes need to consider a set of four factors as a single element. These factors are the knowledge of the infectious disease, a good communication environment, psychological support and keeping the same work team together into joint consideration.

COVID-19 pandemic experiences, ethical conflict and decision-making process in critical care professionals (Quali-Ethics-COVID-19 research part 1): An international qualitative study.

AIM AND OBJECTIVES: The aim of this study was to explore the sources of ethical conflict and the decision-making processes of ICU nurses and physicians during the first and subsequent waves of the COVID-19 pandemic. BACKGROUND: Depside several studies exploring ethical conflicts during COVID-19 pandemic, few studies have explored in depth the perceptions and experiences of critical care professionals regarding these conflicts, the decision-making process or which have analysed the complexity of actually implementing the recommendations of scientific societies and professional/healthcare institutions in interdisciplinary samples. DESIGN: A descriptive phenomenological study. METHODS: Thirty-eight in-depth interviews were conducted with critical care nurses and physicians from five hospitals in Spain and Italy between December 2020 and May 2021. A thematic content analysis of the interview transcripts was conducted by two researchers. Consolidated criteria for reporting qualitative research (COREQ) were employed to ensure the quality and transparency of this study. RESULTS: Two main themes emerged as sources of ethical conflict: the approach to end of life in exceptional circumstances and the lack of humanisation and care resources. The former comprised two subthemes: end-of-life care and withholding and withdrawal of life-sustaining treatment; the latter comprised three subthemes: the impossibility of guaranteeing the same opportunities to all, fear of contagion as a barrier to taking decisions and the need to humanise care. CONCLUSIONS: Professionals sought to take their decisions in line with professional ethics and bioethical principles, but, nevertheless, they experienced moral dilemmas and moral distress when not being able to care for, or to treat, their patients as they believed fit. RELEVANCE TO CLINICAL PRACTICE: Further education and training are recommended on the provision of end-of-life and post-mortem care, effective communication techniques via video calls, disclosure of bad news and bioethical models for decision-making in highly demanding situations of uncertainty, such as those experienced during the COVID-19 pandemic.

Barriers to Advance Care Planning Implementation in Health care: An Umbrella Review with Implications for Evidence-Based Practice.

BACKGROUND: Advance care planning (ACP) refers to a process of discussions between professionals, patients, and their families, which allows the patient to define and communicate their care and treatment preferences. Understanding the barriers to advance care planning is the first step on the way to overcoming them and to improving person-centred care and attention. AIMS: To identify the barriers perceived by professionals, patients, and family members when implementing ACP in a clinical context and to analyse the methodological quality of the evidence. METHODS: An umbrella review guided by the Joanna Briggs Institute and a systematic review in accordance with PRISMA 2015 were utilized. Data were obtained from MEDLINE, Cochrane Library, The Joanna Briggs Institute, CINAHL, Scopus, and EMBASE in November 2018. RESULTS: Fourteen systematic reviews were included. The main barriers reported by professionals were lack of knowledge and skills to carry out ACP, a certain fear of starting conversations about ACP, and a lack of time for discussions. Patients and family members considered that the main barriers were fear of discussing their relative's end of life, lack of ability to carry out ACP, and not knowing who was responsible for initiating conversations about ACP. LINKING EVIDENCE TO ACTION: This review has examined the barriers presented by health professionals, patients, and family members, so that future lines of research can develop preventive or decisive measures that encourage the implementation of ACP in health care.

Association between knowledge and attitudes towards advance directives in emergency services.

BACKGROUND: Implementing the routine consultation of patient advance directives in hospital emergency departments and emergency medical services has become essential, given that advance directives constitute the frame of reference for care personalisation and respect for patients' values and preferences related to healthcare. The aim of this study was to assess the levels and relationship of knowledge and attitudes of nursing and medical professionals towards advance directives in hospital emergency departments and emergency medical services, and to determine the correlated and predictor variables of favourable attitudes towards advance directives. METHODS: Observational, descriptive, and cross-sectional study. The study was conducted in the emergency department of a second-level hospital and in the emergency medical service. Data collection was performed from January 2019 to February 2020. The STROBE guidelines were followed for the preparation of the study. RESULTS: A total of 173 healthcare professionals responded to the questionnaire. Among them, 91.3% considered that they were not sufficiently informed about advance directives, and 74% acknowledged not having incorporated them into their usual practice. Multinomial analysis indicated a statistically significant relationship between the variable emergency medical service and having more favourable attitudes towards consulting the advance directives in their practical application (OR 2.49 [95% CI 1.06-5.88]; p = 0.037) and compliance in complex scenarios (OR 3.65 [95% CI 1.58 - 8.41]; p = 0.002). Working the afternoon and night shift was a predictor variable for obtaining a higher score with respect to attitudes in complex scenarios. CONCLUSION: There is an association between the level of knowledge that nursing and medical professionals have about advance directives and the scores obtained on the attitude scales at the time of practical implementation and in complex scenarios. This shows that the more knowledge professionals have, the more likely they are to consult patients' advance directives and to respect their wishes and preferences for care and/or treatment.

Managing ethical aspects of advance directives in emergency care services.

BACKGROUND: In Hospital Emergency Department and Emergency Medical Services professionals experience situations in which they face difficulties or barriers to know patient's advance directives and implement them. OBJECTIVES: To analyse the barriers, facilitators, and ethical conflicts perceived by health professionals derived from the management of advance directives in emergency services. RESEARCH DESIGN, PARTICIPANTS, AND CONTEXT: This is a qualitative phenomenological study conducted with purposive sampling including a population of nursing and medical professionals linked to Hospital Emergency Department and Emergency Medical Services. Three focus groups were formed, totalling 24 participants. We performed an inductive-type thematic discourse analysis. ETHICAL CONSIDERATIONS: This study was approved by ethical committees of Ethical Commitee of Clínic Hospital (Barcelona) and Comittee of Emergency Medical Services (Barcelona). The participants received information about the purpose of the study. Patients' anonymity and willingness to participate in the study were guaranteed. FINDINGS: There were four types of barriers that hindered the proper management of patients' advance directives in Hospital Emergency Department and Emergency Medical Services: personal and professional, family members, organisational and structural, and those derived from the health system. These barriers caused ethical conflicts and hindered professionals' decision-making. DISCUSSION: These results are in line with those of previous studies and indicate that factors such as gender, professional category, and years of experience, in addition to professionals' beliefs and the opinions of colleagues and family members, can also influence the professionals' final decisions. CONCLUSION: The different strategies described in this study can contribute to the development of health policies and action protocols to help reduce both the barriers that hinder the correct management and implementation of advance directives and the ethical conflicts generated.

La planificación de decisiones anticipadas como estrategia preventiva de conflictos éticos en urgencias y emergencias durante y después de la COVID-19 / Advance Care Planning as a preventive strategy for ethical conflicts in emergencies during and after COVID-19 / La Planificació de Decisions Anticipades com a estratègia preventiva de conflictes ètics a urgències I emergències durant I després de la COVID-19

La actual pandemia por la COVID-19 está ocasionado serias amenazas para la salud pública a nivel mundial, especialmente para los grupos de población más vulnerables. Los casos más graves de la enfermedad han sido primeramente atendidos por los profesionales de urgencias y emergencias, los cuales han tenido que tomar decisiones en contextos altamente complejos donde la priorización en la asignación de los recursos sanitarios disponibles les ha generado situaciones éticamente conflictivas. El objetivo del presente artículo es analizar la importancia de implantar la PDA en los servicios de urgencias y emergencias como herramienta de consulta en la resolución de los problemas éticos surgidos durante la pandemia por COVID-19, concretamente, en la atención al paciente crónico complejo o con enfermedad crónica avanzada

The events of the present CoVID-19 pandemic are causing serious threats to Public Health worldwide, specifically at the most vulnerable population groups. Emergency professionals have served as the first responders for the most serious cases of this disease. At the same time, they have made decisions in highly complex contexts where the prioritization of allocated care resources has generated ethically conflictive situations. The aim of this article is to analyze the importance of implementing the ACP as a tool in the emergency services to solve ethical problems that have arisen during the COVID-19 pandemic, particularly in the care of complex chronic patients or those with advanced chronic disease

L'actual pandèmia per la COVID-19 està ocasionat serioses amenaces a la salut pública a nivell mundial, especialment als grups de població més vulnerables. Els casos més greus de la malaltia han estat primerament atesos pels professionals d'urgències I emergències, els quals han hagut de prendre decisions en contextos altament complexos on la priorització en l'assignació dels recursos sanitaris disponibles els ha generat situacions èticament conflictives. L'objectiu d'aquest article va ser analitzar la importància d'implantar la PDA en els serveis d'urgències I emergències com a eina de consulta a la resolució dels problemes ètics sorgits durant la pandèmia per COVID-19, concretament, en l'atenció al pacient crònic complex o amb malaltia crònica avançada

Actitud y conocimiento de las enfermeras en relación al Documento de Voluntades / Attitude and knowledge of nurses in relation to the advance health care directive in urgent decisions

Objetivo. Analizar, con estudiantes del Máster en Enfermería Intensiva de la EUI-Sant Pau, la actitud y conocimiento de las enfermeras en relación al Documento de Voluntades Anticipadas (DVA) ante una situación de riesgo vital. Material y Métodos. Estudio observacional, descriptivo y transversal de carácter exploratorio, realizado a estudiantes del Máster de Enfermería Intensiva de la EUI-Sant Pau. Evaluación de los conocimientos y actitudes de los estudiantes en relación al DVA a partir de una adaptación del cuestionario validado por Eu-genio Contreras y otros. Resultados. La media de edad de los estudiantes es de 25,46 años (±5,7) y la media de años de experiencia como enfermera, de 3,38 años (±5,58). Un 91,9% de los estudiantes conoce el DVA y el 94,6% desconoce las leyes que lo regulan. Un 75,7% no sabría dónde consultarlo en su servicio y más del 50% opina que no es frecuente que se consulte la existencia de DVA en situación de urgencia vital. Existe una relación estadísticamente significativa (p=.029) entre la variable conocimiento del DVA y la variable frecuencia de consulta del DVA en situación de urgencia vital. Conclusiones. El desconocimiento del DVA y de los sistemas de registro influye en la consulta del DVA por parte de las enfermeras

Objective. Analyzing the attitude and knowledge of nursing professionals in relation to the Advance Health Care Directive (AHCD) in a life-threatening situation, using master’s degree students in Intensive Nursing at EUI-Sant Pau. Material and Methods. Descriptive, observational and transversal study of an exploratory nature, using master’s degree students in Intensive Nursing at EUI-Sant Pau. The knowledge and the attitudes of the students in relation to the AHCD were assessed by an adaptation of the questionnaire validated by Eugenio Contreras and others. Results. The average age of students is 25.46 years (±5.7) and the average number of years of experience as a nurse is 3.38 years (±5.58). 91.9% of the students are aware of the AHCD and 94.6% do not know which laws regulate it. 75.7% would not know where to consult AHCD documents in their service and more than 50% think that it is not common practice to check for the existence of an AHCD document in life threatening situations. There is a statistically significant relation (p=.029) between the variable of the knowledge of AHCD and the variable of search frequency in life threatening situations. Conclusions. The lack of awareness of the AHCD and of its registration systems has an influence on consulting AHCD documents by nursing professionals