La eficiencia no basta. Análisis ético y recomendaciones para la distribución de recursos escasos en situación de pandemia / Efficiency is not enough. Ethical analysis and recommendations for the allocation of scarce resources in a pandemic situation

Objetivo: Elaborar una herramienta de apoyo que ayude a tomar decisiones en el marco de la pandemia de COVID19. Método: Se parte de una búsqueda de diferentes recomendaciones éticas surgidas en España sobre priorización de recursos sanitarios escasos en la pandemia de COVID19, así como de una revisión narrativa de modelos teóricos sobre distribución en pandemias para definir una fundamentación ética. Finalmente, se extraen recomendaciones para su posible aplicación en distintos ámbitos asistenciales. Resultados: Se identifican tres principios, igualdad estricta, equidad y eficiencia, que se sustancian en criterios de distribución específicos. Conclusiones: Se propone un modelo de distribución de recursos sanitarios escasos en situación de pandemia que parte de un procedimiento de toma de decisiones y adapta los criterios de distribución a los escenarios de la atención sanitaria: atención primaria, residencias sociosanitarias y atención hospitalaria. (AU)

Objective: To develop a support tool to decision-making in the framework of the COVID19 pandemic. Method: Different ethical recommendations that emerged in Spain on prioritizing scarce health resources in the COVID19 pandemic first wave were searched; it was conducted a narrative review of theoretical models on distribution in pandemics to define an ethical foundation. Finally, recommendations are drawn to be applied in different healthcare settings. Results: Three principles are identified; strict equality, equity and efficiency, which are substantiated in specific distribution criteria. Conclusions: A model for the distribution of scarce health resources in a pandemic situation is proposed, starting with a decision-making procedure and adapting the distribution criteria to different healthcare scenarios: primary care settings, nursing homes and hospitals. (AU)

[Efficiency is not enough. Ethical analysis and recommendations for the allocation of scarce resources in a pandemic situation]. / La eficiencia no basta. Análisis ético y recomendaciones para la distribución de recursos escasos en situación de pandemia.

OBJECTIVE: To develop a support tool to decision-making in the framework of the COVID-19 pandemic. METHOD: Different ethical recommendations that emerged in Spain on prioritizing scarce health resources in the COVID-19 pandemic first wave were searched; it was conducted a narrative review of theoretical models on distribution in pandemics to define an ethical foundation. Finally, recommendations are drawn to be applied in different healthcare settings. RESULTS: Three principles are identified; strict equality, equity and efficiency, which are substantiated in specific distribution criteria. CONCLUSIONS: A model for the distribution of scarce health resources in a pandemic situation is proposed, starting with a decision-making procedure and adapting the distribution criteria to different healthcare scenarios: primary care settings, nursing homes and hospitals.

Planificación anticipada de decisiones en salud mental: modelos, utilidades y propuestas de aplicación / Advance care planning in mental health: models, utilities and proposals for application

Introducción: A lo largo de los últimos años, la Convención sobre los Derechos de las Personas con Discapacidad (CDPD) ha contribuido a una atención creciente a la detección y prevención de situaciones de vulneración de los derechos humanos en salud mental. Entre las estrategias de mejora se ha propuesto la introducción de modelos de Voluntades Anticipadas en Salud Mental (VVAA-SM) y Planificación Anticipada de Decisiones en Salud Mental (PAD-SM). Material y método: 1. Revisión bibliográfica. Análisis de conceptos, modelos, utilidades y limitaciones de documentos de Voluntades Anticipadas en Salud Mental y procesos de PAD-SM en diferentes países. 2. Debate, identificación y elaboración de estrategias para la adaptación al contexto andaluz, realizado por el Grupo Derechos Humanos y Salud Mental del Plan Integral de Salud Mental de Andalucía. Resultados: En el contexto internacional, se observa la existencia de modelos y terminologías diferenciadas. En los estudios revisados se identifican diferentes utilidades, entre ellas la protección de derechos, el aumento de la participación y empoderamiento, la mejora de la relación entre usuarios/as, profesionales sanitarios/as y familiares, así como aspectos relacionados con la utilidad clínica y la relación coste-eficacia. Entre las potenciales limitaciones destacan la escasez de apoyo institucional y la falta de formación profesional. Para el contexto andaluz, el Grupo propone la introducción de un proceso de PAD-SM como herramienta clínica enfocada en la información, el diálogo y la toma de decisiones, a la vez que trabajar hacia la creación de un modelo legalmente vinculante. Conclusiones: La introducción de la PAD-SM se identifica como una estrategia útil para proteger los derechos de personas usuarias de servicios de salud mental en coherencia con los principios establecidos en la CDPD (AU)

Introduction: Over the last years, the Convention on the Rights of Persons with Disabilities (CRPD) has contributed to increase attention to the detection and prevention of human rights violations in mental health services. Among different strategies for improvement, the introduction of models for Advance Directives in Mental Health (AD-MH) and Advance Care Planning in Mental Health (ACP-MH) has been proposed. Material and methods: 1. Literature review. Analysis of concepts, models, utilities and limitations of documents related AD-MH and ACP-MH processes in different countries. 2. Discussion, identification and elaboration of strategies for the adaptation in the Andalusian context conducted by the Human Rights and Mental Health Working Group of the Comprehensive Mental Health Plan of Andalusia. Results: In the international context, the existence of differentiated models and terminologies is observed. In the reviewed studies different utilities are identified, among them the protection of rights, an increased participation and empowerment, the improvement of the relation between users, health providers and relatives, as well as aspects related to clinical utility and cost-efficacy. Among the potential limitations, the lack of institutional support and professional training is highlighted. For the Andalusian context, the Working Group proposes the introduction of an ACP-MH process as a clinical tool focused on information, dialogue and decision making, at the same time as working towards the creation of a legally binding model. Conclusions: The introduction of ACP-MH is identified as a useful strategy to protect the rights of users of mental health services in coherence with the principles established in the CRPD (AU)

Preferences of caregivers and patients regarding opioid analgesic use in terminal care.

CONTEXT: Patients and caregivers participate in decision-taking, and their views should be considered in the preparation of Clinical Practice Guidelines (CPGs). We involved them in the development of a CPG on the safe use of major opioids. OBJECTIVE: To identify the values and preferences of patients and caregivers on the use of opioids and the desired outcomes, to investigate motives for the acceptance/rejection of opioid therapy, and to evaluate their beliefs and information about these drugs. METHODS: A qualitative study was conducted using semi-structured interviews in an Andalusian population of terminal patients and caregivers (N = 42). Study variables included the role, diagnosis, and adherence to treatment. Content and validity analyses were performed. RESULTS: Less than one-third of participants recognized the term opioid. Among these, false beliefs were held related to the addictive nature of these drugs, their exclusive use in terminal cases and at the end of life, and their association with premature death. The information received was very general: it was known that they are "useful for pain," and some were informed about the administration route, composition, and habituation. Participation in decision making was usually limited to reporting symptoms to the physician. CONCLUSION: These patients and caregivers demonstrated a preference for pain alleviation by opioid treatment and gave negative assessments on adverse digestive effects that can cause this treatment to be abandoned. They expressed interest in receiving more information and in participating in therapeutic decision making, and they reported erroneous beliefs and a lack of information about the effects of these drugs.

Euthanasia and physician-assisted suicide: knowledge, attitudes and experiences of nurses in Andalusia (Spain).

The aim of this study is to assess the knowledge, attitudes and experiences of Spanish nurses in relation to euthanasia and physician-assisted suicide. In an online questionnaire completed by 390 nurses from Andalusia, 59.1% adequately identified a euthanasia situation and 64.1% a situation involving physician-assisted suicide. Around 69% were aware that both practices were illegal in Spain, while 21.4% had received requests for euthanasia and a further 7.8% for assisted suicide. A total of 22.6% believed that cases of euthanasia had occurred in Spain and 11.4% believed the same for assisted suicide. There was greater support (70%) for legalisation of euthanasia than for assisted suicide (65%), combined with a greater predisposition towards carrying out euthanasia (54%), if it were to be legalised, than participating in assisted suicide (47.3%). Nurses in Andalusia should be offered more education about issues pertaining to the end of life, and extensive research into this area should be undertaken.

Interventions to promote the use of advance directives: an overview of systematic reviews.

OBJECTIVE: To identify, appraise and synthesise the results of systematic reviews of the literature (SRLs) that examines the effectiveness of interventions to increase advance directive (AD) completion rate. METHODS: Narrative review of the literature-an overview of SRLs focused on interventions to improve patients' AD completion rate. RESULTS: Seven SRLs were located. A wide range of interventions was identified in order to determine their influence on the AD completion rate. CONCLUSION: The most effective method of increasing the use of ADs is the combination of informative material and repeated conversations over clinical visits. The use of passive informative material in isolation does not significantly increase AD completion rates. However, when interactive informative interventions are employed, the AD completion rate increases and the majority of the studies identify multiple sessions as the most effective method for direct interaction between patients and health care professionals. PRACTICE IMPLICATIONS: The progressive ageing of the population and the provision of quality care during the process of ageing and dying, have given rise to the Governments' interest in developing moral autonomy and regulating tools as ADs. In order to put legislation into practice it is necessary to set up successful interventions to expand ADs use.

Advance directives in Spain. Perspectives from a medical bioethicist approach.

Spain is one of the most advanced European countries in terms of the legislative and administrative development of ADs. Article 11 of Law 41/2002, concerning Patient Autonomy, regulates 'advance directives' and has prompted various Autonomous Regions to develop legislation in this area. Nevertheless, whilst the variety of legislations in different territories presents advantages, the disparity of criteria also presents problems. Despite significant legislative development, only 23,000 Spanish citizens have filled in an AD. Clearly, AD use is confined to a minority. Several surveys, however, show that the Spanish population views these documents in a positive light. Thus, we must analyse this discrepancy between attitude and practice. A similar situation exists amongst health professionals. Whilst they generally feel that the use of ADs is positive and necessary, they are frequently unwilling to employ them. Bioethical literature and research on ADs has significantly increased in Spain over the last six years. It is likely that this trend will continue in the foreseeable future; but more resources and effort are required if ADs are to become consolidated.

[Knowledge and attitudes of medical staff in two health districts concerning living wills]. / Conocimientos y actitudes de los médicos en dos áreas sanitarias sobre las voluntades vitales anticipadas.

OBJECTIVES: To explore the knowledge and attitudes of physicians towards advance directives in 2 healthcare areas. To compare the outcomes of both areas. To compare the outcomes of primary healthcare and specialised healthcare. DESIGN: A cross sectional, descriptive study by means of a self-administered questionnaire. SETTING: North-Málaga and North-Almería healthcare areas, Spain. PARTICIPANTS: Physicians of primary and specialised healthcare. MEASUREMENTS AND MAIN RESULTS: Knowledge and attitudes towards advance directives. 194 (63.19%) questionnaires were filled out by the physicians from both healthcare districts. Mean age (standard deviation) 42.54 (80.85); 65.5% of participants were men and 33.5% were women; 51.55% from primary care and 48.45% from specialised healthcare. CONCLUSIONS: Polled physicians revealed a positive attitude towards the usefulness of advance directives for the patient's relatives and for healthcare professionals. They also show a positive attitude towards the use and respect of advance directives. They show a high predisposition to registry their advance directive, but a low predisposition to do so in a short term.

Conocimientos y actitudes de los médicos en dos áreas sanitarias sobre las voluntades vitales anticipadas / Knowledge and attitudes of medical staff in two health districts concerning living wills

Objetivos. Explorar los conocimientos y actitudes de los médicos acerca de las voluntades anticipadas en dos áreas de Andalucía. Comparar los resultados de ambas áreas sanitarias. Comparar los resultados de los médicos de atención primaria y atención especializada. Diseño. Estudio descriptivo, transversal, mediante cuestionario autocumplimentado. Emplazamiento. Área Sanitaria Norte de Málaga y Área Sanitaria Norte de Almería. Participantes. Médicos de atención primara y especializada. Mediciones y resultados principales. Conocimientos y actitudes acerca de las voluntades vitales anticipadas (testamentos vitales); 194 médicos respondieron al cuestionario (tasa de respuesta del 63,19%). Media de edad ± desviación típica, 42,54 ± 80,85 años; el 65,5%, varones, y el 33,5%, mujeres. El 51,55%, médicos de atención primaria, y el 48,45%, de especializada. Conclusiones. Hay una actitud favorable hacia la utilidad de las voluntades anticipadas tanto para los familiares del paciente como para los profesionales sanitarios; también hacia su utilización y respeto. Desean manifestar su propia voluntad anticipada aunque no en un futuro cercano. El personal de atención primaria muestra una actitud más favorable hacia las voluntades anticipadas en algunos ítems que el personal de especializada

Objectives. To explore the knowledge and attitudes of physicians towards advance directives in two healthcare areas. To compare the outcomes of both areas. To compare the outcomes of primary healthcare and specialised healthcare. Design. A cross sectional, descriptive study by means of a self-administered questionnaire. Setting. North-Málaga and North-Almería healthcare areas, Spain. Participants. Physicians of primary and specialised healthcare. Measurements and main results. Knowledge and attitudes towards advance directives. 194 (63.19%) questionnaires were filled out by the physicians from both healthcare districts. Mean age (standard deviation) 42.54 (80.85); 65.5% of participants were men and 33.5% were women; 51.55% from primary care and 48.45% from specialised healthcare. Conclusions. Polled physicians revealed a positive attitude towards the usefulness of advance directives for the patient's relatives and for healthcare professionals. They also show a positive attitude towards the use and respect of advance directives. They show a high predisposition to registry their advance directive, but a low predisposition to do so in a short term

[Knowledge and attitudes of nursing staff toward advance directives in 2 health areas in Andalusia (Spain)]. / Conocimientos y actitudes del personal de enfermería acerca de las voluntades anticipadas en 2 áreas sanitarias de Andalucía.

OBJECTIVES: To identify the knowledge and attitudes of nursing staff toward advance directives (AD) in 2 health areas, and to compare the results in both areas. METHOD: We performed a cross-sectional, descriptive study by means of a self-administered, validated, 12-item questionnaire carried out in 2 Andalusian health areas. Sampling was not carried out as the aim was to contact the whole population. RESULTS: A total of 298 (75.25%) questionnaires were completed. The nursing staff surveyed scored their knowledge with a mean of 4.47 points. Only 63.1% (188) knew about the legislation on AD, and only 32.3% (n= 96) had read the document. The nurses believed that planning and writing down one's wishes about the care to be received was advisable (mean: 8.36). The nursing professionals considered ADs to be a useful tool for health professionals (mean: 8.37) and for relatives (mean: 8.21). The nurses surveyed would register their own AD at some point in their lives (mean: 8.33). However, when the nurses were asked if they would do so in the next year the mean score dropped to 5.13. CONCLUSIONS: The nurses surveyed revealed a positive attitude toward the usefulness of ADs for patients' relatives and for health professionals, as well as a positive attitude toward the use of and respect for ADs. Among these nurses, willingness to register their own AD was high, but few intended to do so in the short term. Efforts should be made to improve nurses' knowledge of ADs and of the organizational process that allows these health professionals to introduce advance care planning as a specific task within nursing care.

Conocimientos y actitudes del personal de enfermería acerca de las voluntades anticipadas en 2 áreas sanitarias de Andalucía / Knowledge and attitudes of nursing staff toward advance directives in 2 health areas in Andalusia (Spain)

Objetivos. Describir los conocimientos y actitudes del personal de enfermería acerca de las voluntades anticipadas (VA) en 2 áreas sanitarias de Andalucía, y comparar los resultados de ambas áreas. Método. Estudio descriptivo transversal, mediante cuestionario autocumplimentado validado y compuesto por 12 ítems, realizado al personal de enfermería de 2 áreas sanitarias de Andalucía. No se realizó muestreo, intentando llegar a toda la población. Resultados. Se cumplimentaron 298 (75,25%) cuestionaros. El personal de enfermería encuestado puntuó sus conocimientos con una media de 4,47. Sólo el 63,1% (188) sabía que las VA están reguladas por la ley y tan sólo un 32,3% (96) había leído el documento. Creyeron conveniente planificar y escribir los deseos sanitarios una media de 8,36. Lo consideraron un instrumento útil para profesionales con una media de 8,37 y para familiares la media fue de 8,21. Cumplimentarían su VA en algún momento de sus vidas una media de 8,33, pero al preguntarles si lo harían durante el próximo año la media descendió a 5,13. Conclusiones. El personal de enfermería reveló una actitud favorable hacia la utilidad de las VA, tanto para los familiares del paciente como para los profesionales sanitarios. También fue positiva su actitud hacia la utilización y respeto de las VA. Manifestaron una alta predisposición a cumplimentar su propia VA pero no en un futuro cercano. Es necesario mejorar los conocimientos de estos profesionales acerca del tema y la forma organizativa que permita a la enfermería incorporar la planificación anticipada como un rol específico de los cuidados de enfermería

Objectives. To identify the knowledge and attitudes of nursing staff toward advance directives (AD) in 2 health areas, and to compare the results in both areas. Method. We performed a cross-sectional, descriptive study by means of a self-administered, validated, 12-item questionnaire carried out in 2 Andalusian health areas. Sampling was not carried out as the aim was to contact the whole population. Results. A total of 298 (75.25%) questionnaires were completed. The nursing staff surveyed scored their knowledge with a mean of 4.47 points. Only 63.1% (188) knew about the legislation on AD, and only 32.3% (n= 96) had read the document. The nurses believed that planning and writing down one's wishes about the care to be received was advisable (mean: 8.36). The nursing professionals considered ADs to be a useful tool for health professionals (mean: 8.37) and for relatives (mean: 8.21). The nurses surveyed would register their own AD at some point in their lives (mean: 8.33). However, when the nurses were asked if they would do so in the next year the mean score dropped to 5.13. Conclusions. The nurses surveyed revealed a positive attitude toward the usefulness of ADs for patients' relatives and for health professionals, as well as a positive attitude toward the use of and respect for ADs. Among these nurses, willingness to register their own AD was high, but few intended to do so in the short term. Efforts should be made to improve nurses' knowledge of ADs and of the organizational process that allows these health professionals to introduce advance care planning as a specific task within nursing care