Reflexiones éticas desde la experiencia práctica de la crisis COVID-19 / Ethical reflections from the practical experience of the COVID-19 crisis

El objetivo de este artículo es realizar una reflexión ética en base a documentos generados durante la pandemia por COVID-19, aportando conclusiones sobre lo aprendido y lo que nos falta por aprender. Se desarrollarán seis áreas de acción: priorización de los recursos, consulta presencial y telemedicina, la (des)protección de los profesionales, la atención en los centros de mayores, la respuesta social y la atención en los últimos días. Ante la falta de recursos, la autoridad pública puede establecer criterios que limiten, sin suprimirlo, el derecho a la protección de la salud de algunos. Se puede justificar la asignación según la capacidad de recuperación del paciente, sin discriminar por edad o discapacidad. Las consultas telemáticas ayudan a mantener la relación clínica, pero requieren de tiempo y entrenamiento. La relación clínica tiene exigencias deontológicas, y requiere mejorar la tecnología y las habilidades de relación telemática. La metáfora bélica y del heroísmo genera presión y confusión sobre el alcance del deber, ante la grave desprotección sufrida por los profesionales. Se debe realzar el valor de la interdependencia y la responsabilidad, no "romantizar" el riesgo, y compensar a los profesionales y sus familias. En las residencias de mayores predominan grandes centros, organizados por tareas, con poca autonomía y privacidad. Debemos decidir qué modelos queremos, y podemos pagar, y qué riesgos compartidos asumimos desde valores comunes. La sociedad civil puede responder a las crisis (democracia es "gobierno del pueblo", que debe protagonizar la vida pública, no los políticos). El acompañamiento al morir son derechos reconocidos. Su limitación excepcional no puede ser una privación total. La planificación anticipada requiere hablar de los miedos y los valores con los pacientes y sus familias. Es un proceso deliberativo que debemos recuperar en la era de la COVID-19

The aim of this article was to conduct an ethical reflection based on documents generated during the COVID-19 pandemic, providing conclusions about what has been learned and what we still have to learn. Six areas of action will be developed: prioritization of resources, face-to-face consultation and telemedicine, (un)protection of professionals, care in nursing homes, social response, and last days care. Facing lack of resources, public authority can establish criteria that limit the right to health protection. The allocation can be justified according to the patient's ability to recover, without discriminating by age or disability. Telematic consultation can keep patient-clinician relationship, but requires time and training. The clinical relationship has deontological requirements, and requires improving technology and telematic communication skills. The war metaphor generates pressure and confusion over the scope of duty in the face of the serious lack of protection suffered by professionals. The value of interdependence and responsibility must be enhanced, not "romanticizing" the risk, and compensating professionals and their families. Nursing homes in our country are predominantly large centers, organized by tasks, with little autonomy and privacy. We must decide which models we want and can afford, and which shared risks we assume from common values. Civil society can respond to crises (democracy is the "government of the people", which must begin in public life, not in politicians. Accompaniment at death is a recognized right). Exceptional limitation of resources cannot be total deprivation. Advanced care planning requires talking about fears and values with patients and their families. It is a deliberative process we must recover in the COVID-19 era

Weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation.

Opioid and sedative use are common 'active' practices in the provision of mainstream palliative care services, and are typically distinguished from euthanasia on the basis that they do not shorten survival time. Even supposing that they did, it is often argued that they are justified and distinguished from euthanasia via appeal to Aquinas' Doctrine of Double Effect. In this essay, I will appraise the empirical evidence regarding opioid/sedative use and survival time, and argue for a position of agnosticism. I will then argue that the Doctrine of Double Effect is a useful ethical tool but is ultimately not a sound ethical principle, and even if it were, it is unclear whether palliative opioid/sedative use satisfy its four criteria. Although this essay does not establish any definitive proofs, it aims to provide reasons to doubt-and therefore weaken-the often-claimed ethical distinction between euthanasia and palliative opioid/sedative use.

[Palliative Sedation: Comments on a controversial topic]. / Palliative Sedierung: Anmerkungen zu einem strittigen Thema.

Palliative Sedation: Comments on a controversial topic Abstract. Palliative sedation (PS) is an accepted medical practice for terminally ill patients. It intends the alleviation of unbearable suffering by intentionally lowering the level of consciousness. In contrast to physician assisted suicide and euthanasia, palliative sedation aims to relieve burdensome symptoms with no intention of hastening death. PC can be applied as "intermittent palliative sedation" or "continuous (deep) sedation until death". Most ethical controversies are related to the latter form of PS: 1: Is existential or psychosocial suffering a possible indication for PS? 2: What is the earliest possible time point to start PS? 3: The withdrawal or withholding of artificial nutrition and hydration during PS. A critical reflection of these ethical controversial aspects within the treatment team is highly desirable. However, the patient's well-being and the respect for the patient's decisions that are based on experiences which are made only by him or her, must remain the guiding principle for medical actions.

A Survey of Hospice and Palliative Care Clinicians' Experiences and Attitudes Regarding the Use of Palliative Sedation.

BACKGROUND: A variety of terms and attitudes surround palliative sedation (PS) with little research devoted to hospice and palliative care (HPC) clinicians' perceptions and experiences with PS. These factors may contribute to the wide variability in the reported prevalence of PS. OBJECTIVE: This study was designed to better identify hospice and palliative care (HPC) clinician attitudes toward, and clinical experiences with palliative sedation (PS). METHODS: A 32-question survey was distributed to members of the American Academy of Hospice and Palliative Medicine (n = 4678). The questions explored the language clinicians use for PS, and their experiences with PS. RESULTS: Nine hundred thirty-six (20% response rate) responded to the survey. About 83.21% preferred the terminology of PS compared with other terms. A majority felt that PS is a bioethically appropriate treatment for refractory physical and nonphysical symptoms in dying patients. Most felt PS was not an appropriate term in clinical scenarios when sedation occurred as an unintended side effect from standard treatments. Hospice clinicians use PS more consistently and with less distress than nonhospice clinician respondents. Benzodiazepines (63.1%) and barbiturates (18.9%) are most commonly prescribed for PS. CONCLUSION: PS is the preferred term among HPC clinicians for the proportionate use of pharmacotherapies to intentionally lower awareness for refractory symptoms in dying patients. PS is a bioethically appropriate treatment for refractory symptoms in dying patients. However, there is a lack of clear agreement about what is included in PS and how the practice of PS should be best delivered in different clinical scenarios. Future efforts to investigate PS should focus on describing the clinical scenarios in which PS is utilized and on the level of intended sedation necessary, in an effort to better unify the practice of PS.

French laypeople's and health professionals' views on the acceptability of terminal sedation.

AIM: To study the views on the acceptability of terminal sedation (TS) of laypeople and health professionals in France. METHOD: In November 2013-June 2015, 223 laypeople and 53 health professionals (21 physicians and 32) judged the acceptability of TS in 48 realistic scenarios composed of all combinations of four factors: (a) the patients' life expectancy, (b) their request for sedation, (c) the decision-making process and (d) the type of sedation. In all scenarios, the patients were women with a terminal illness suffering from intractable pain and receiving the best possible care. The ratings were subjected to cluster analysis and analyses of variance. RESULTS: Five qualitatively different positions were found that were termed TS acceptable if decision taken collectively (15%), TS acceptable if patient explicitly requested it (19%), TS acceptable if patient did not explicitly oppose it (47%), 24-hour sedation not acceptable (6%) and TS always acceptable (13%). The percentage of older participants in the 'always acceptable' cluster was higher than the percentage of younger participants. CONCLUSIONS: Laypeople and health professionals do not appear to be systematically opposed to TS. The most important factors in increasing its acceptability were the patients' request for sedation and the collective character of the decision-making process.

Sedation Until Death: Are the Requirements Laid Down in the Guidelines Too Restrictive?

Guidelines that have been published on sedation until death take the following positions: the patient's consciousness should not be lowered more than is necessary for preventing her from suffering; it must be impossible to alleviate the suffering in any alternative way; and the patient's mere preference for dying peacefully cannot justify the procedure. Some guidelines also stipulate that purely existential suffering cannot do so either. I will discuss the (few) arguments that can be found in the literature for these restrictions. I will focus in particular on the argument that it is either a vital interest, or even a duty, of the patient to preserve consciousness as long as possible at all times. None of these arguments turn out to be convincing. On the other hand, deviation from the requirements can be justified only by appealing to the priorities of the patient. These should therefore have been discussed in detail at an earlier stage of the patient's illness.

[Palliative sedation for psycho-existential suffering]. / Palliative Sedierung bei psycho-existentieller Not.

Sedation in palliative care is generally considered as an important therapy in terminally ill patients with refractory symptoms. However the sedation of patients with intractable psycho-existential suffering is still under discussion. This paper discusses the case of a 56-year-old patient in the final phase of carcinoma of the ovaries, who required palliative sedation for refractory, mainly psycho-existential suffering. It describes the course on our ward and the difficult process of decision-making. We discuss our approach based on literature.

Amnesia, anesthesia, and warranted fear.

Is a painful experience less bad for you if you will not remember it? Do you have less reason to fear it? These questions bear on how we think about medical procedures and surgeries that use an anesthesia regimen that leaves patients conscious - and potentially in pain - but results in complete 'drug-induced amnesia' after the fact. I argue that drug-induced amnesia does not render a painful medical procedure a less fitting object of fear, and thus the prospect of amnesia does not give patients a reason not to fear it. I expose three mistakes in reasoning that might explain our tendency to view pain or discomfort as less fearful in virtue of expected amnesia: a mistaken view of personal identity; a mistaken view of the target of anticipation; and a mistaken method of incorporating past evidence into calculations about future experiences. Ultimately my argument has implications for whether particular procedures are justified and how medical professionals should speak with anxious patients about the prospect of drug-induced amnesia.

Estimating the potential life-shortening effect of continuous sedation until death: a comparison between two approaches.

CONTEXT: In some cases, physicians estimate that continuous sedation until death may have a life shortening effect. The accuracy of these estimations can be questioned. AIM: The aim of this study is to compare two approaches to estimate the potential life-shortening effect of continuous sedation until death. METHODS: In 2008, 370 Dutch physicians filled out a questionnaire and reported on their last patient who received continuous sedation until death. The potential life-shortening effect of continuous sedation was estimated through a direct approach (question: Did continuous sedation, according to your estimation,hasten the patient's death? If yes: by how much time?)and an indirect approach (estimated life expectancy minus duration of sedation). The intrarater agreement between both approaches was determined with a weighted κ. RESULTS: According to the direct approach, sedation might have had a life-shortening effect in 51% of the cases and according to the indirect approach in 84%.The intrarater agreement between both approaches was fair (weighted κ=0.38). In 10% of all cases, the direct approach yielded higher estimates of the extent to which life had been shortened; in 58% of the cases, the indirect approach yielded higher estimates. CONCLUSIONS: The results show a discrepancy between different approaches to estimate the potential life shortening effect of continuous sedation until death.

[Continuous sedation: practical and ethical aspects]. / Sédation continue: considérations pratiques et éthiques.

Continuous sedation is an acknowledged medical practice in the management of refractory symptoms at the end of life. Guidelines and recommendations have been proposed in palliative care. This paper presents the state-of-the-art (definitions, indications, technical aspects) on continuous sedation followed by an ethical reflection essentially based on the "double effect" principle, on the impact on life expectancy and the assimilation of continuous sedation as a "natural death". Distinction between continuous sedation and legal euthanasia is clarified.

Continuous sedation until death: moral justifications of physicians and nurses--a content analysis of opinion pieces.

Continuous sedation until death (CSD), the act of reducing or removing the consciousness of an incurably ill patient until death, often provokes medical-ethical discussions in the opinion sections of medical and nursing journals. A content analysis of opinion pieces in medical and nursing literature was conducted to examine how clinicians define and describe CSD, and how they justify this practice morally. Most publications were written by physicians and published in palliative or general medicine journals. Terminal Sedation and Palliative Sedation are the most frequently used terms to describe CSD. Seventeen definitions with varying content were identified. CSD was found to be morally justified in 73% of the publications using justifications such as Last Resort, Doctrine of Double Effect, Sanctity of Life, Autonomy, and Proportionality. The debate over CSD in the opinion sections of medical and nursing journals lacks uniform terms and definitions, and is profoundly marked by 'charged language', aiming at realizing agreement in attitude towards CSD. Not all of the moral justifications found are equally straightforward. To enable a more effective debate, the terms, definitions and justifications for CSD need to be further clarified.