Considerações éticas relacionadas às condutas terapêuticas de pacientes terminais / Ethical considerations related to the therapeutic management of terminally ill patients / Consideraciones éticas relacionadas con la conducta terapéutica de los pacientes terminales

Objetivo: Conhecer as considerações éticas relacionadas às condutas terapêuticas das equipes de saúde frente aos pacientes terminais. Metodologia: Trata-se de um estudo exploratório de natureza qualitativa. Realizado no período de dezembro de 2020, através do acesso ao Banco de Teses e Dissertações da CAPES, considerando que este, coordena o Sistema de Pós-graduação brasileiro. Resultados: Foram identificadas seis classes semânticas, de modo que a mesma formulou a seguinte distribuição de contextos temáticos: Classe 1 Paciente terminal; Classe 2 Condutas médicas; Classe 3 Manejo terapêutico; Classe 4 Protocolos clínicos e aspectos metodológicos dos estudos; Classe 5 Dependências metodológicas e Classe 6 Suporte clínico na terminalidade Dependências metodológicas. Discussão: A morte e a vida tornam-se um impasse enfrentado pelos profissionais de saúde, pois existem fatores decisivos na vida de cada paciente em situação terminal com nenhuma esperança de cura, envolvendo assim questões éticas. Conclusão: Portanto, torna-se necessário que as instâncias de saúde assegurem protocolos, treinamentos e aporte psicológicos para esses profissionais que atuam diretamente com pacientes em situações terminais de vida, para que possa haver uma ressignificação do processo de cuidado com pacientes e segurança na tomada de decisões por parte dos profissionais de saúde, e assim possa preservar a ética.

Objective: To know the ethical considerations related to the therapeutic behavior of health teams towards terminal patients. Methodology: This is an exploratory study of a qualitative nature. Carried out in January 2020, through access to the CAPES Theses and Dissertations Bank, considering that it coordinates the Brazilian Postgraduate System. Results: Six semantic classes were identified, so that it formulated the following distribution of thematic contexts: Class 1 Terminal patient; Class 2 Medical conducts; Class 3 Therapeutic management; Class 4 Clinical protocols and methodological aspects of the studies; Class 5 Methodological dependencies and Class 6 Clinical support in terminality Methodological dependencies. Discusson: Death and life become an impasse faced by health professionals, as decisive there are factors in the life of each patient in a terminal situation with no hope of cure, thus involving ethical issues. Conclusion: Therefore, it is necessary that health institutions ensure protocols, training and psychological support for these professionals who work directly with patients in terminal situations, so that there can be a new meaning for the process of patient care and safety in decision-making by health professionals, and thus can preserve ethics.

Objetivo: Conocer las consideraciones éticas relacionadas con las conductas terapéuticas de los equipos de salud frente a los pacientes terminales. Metodología: Se trata de un estudio exploratorio de carácter cualitativo. Realizado en el período de diciembre de 2020, a través del acceso al Banco de Tesis y Disertaciones de la CAPES, considerando que este, coordina el Sistema de Pós-graduación brasileño. Resultados: Se identificaron seis clases semánticas, por lo que se formuló la siguiente distribución de contextos temáticos: Clase 1 Paciente terminal; Clase 2 Conductas médicas; Clase 3 Manejo terapéutico; Clase 4 Protocolos clínicos y aspectos metodológicos de los estudios; Clase 5 Dependencias metodológicas y Clase 6 Apoyo clínico en la terminalidad Dependencias metodológicas. Discusión: La muerte y la vida se convierten en un impasse al que se enfrentan los profesionales de la salud, porque hay factores decisivos en la vida de cada paciente en situación terminal sin esperanza de curación, lo que implica cuestiones éticas. Conclusión: Por lo tanto, se hace necesario que las instancias de salud garanticen protocolos, capacitación y apoyo psicológico para estos profesionales que trabajan directamente con los pacientes en situaciones de vida terminal, para que pueda haber una resignificación del proceso de atención al paciente y seguridad en la toma de decisiones por parte de los profesionales de la salud, y así poder preservar la ética.

Proyecto "Humanizando los Cuidados Intensivos", nuevo paradigma de orientación de los Cuidados Intensivos / Project "Humanizing Intensive Care", new paradigm of guidance in Intensive Care Unit / El projecte "Humanitzant la vigilància intensiva", un nou paradigma d'orientació de la vigilància intensiva

En los últimos 50 años, la Medicina Intensiva ha alcanzado las más altas cifras de supervivencia gracias al trabajo de equipos multi disciplinares altamente cualificados y formados, del papel de una avanzada tecnología en el campo del tratamiento, la enfermedad como centro, el soporte vital y el diagnóstico clínico. Este reconocimiento no ha llegado sin costes, en el 2008, una conocida persona pública explicó su experiencia vivida como paciente en una Unidad de Cuidados Intensivos (UCI), el cual describió la UCI como la sucursal del infierno. El esfuerzo en la atención del paciente critico implica el uso de la tecnología y todo el medio que rodea la UCI, centradas en tratar la enfermedad del paciente, pero había desplazado a las personas y a sus individualidades del centro de cuidado. Esto dio como consecuencia la despersonalización de todos los agentes implicados (pacientes, familias, cuidadores e incluso los profesionales). Las investigaciones han demostrado las graves lesiones físicas y psíquicas en nuestros supervivientes, con importantes consecuencias éticas

In the last 50 years, Intensive Medicine has reached the highest survival figures thanks to the work of highly qualified and trained multi-disciplinary teams, the role of advanced technology in the field of treatment, the disease as a center, life support and clinical diagnosis. The effort involves the use of technology and all the environment surrounding the Intensive Care Unit (ICU), focused on treating patient disease, but had displaced people and their individualities from the care facility. This resulted in the depersonalization of all the agents involved (patients, families, caregivers and even professionals). Research has shown the serious physical and psychological injuries in our survivors, with significant ethical consequences. Depersonalization is one of the signs of burnout syndrome, which is a serious unresolved and growing problem among health professionals that in early 2019 has been admitted as a disease by the WHO. The great bioethical principles have not been able to respond to the causes of physical and psychic suffering. New ethical orientations are needed that are resized to the individual and their particularity, under more emotional and affective aspects, by which we refer to the ''ethics of care'' as a gravitational nucleus where professionalism and the practice of resilience in the health field are growing. The importance of integrating the ethics of care oriented towards the patient-family binomial, and of combating burnout by performing care for professionals, is a real challenge within the ICU, two different but linked sides that belong to the same currency

En els últims 50 anys, la Unitat de Vigilància intensiva (UVI) ha aconseguit les xifres més altes de supervivència gràcies al treball d'equips multidisciplinaris, al paper de la tecnologia en el camp del tractament, la malaltia com a centre, el suport vital I el diagnòstic clínic. Aquest esforç sumat a l'ús de la tecnologia, el mitjà que envolta al pacient, centrant-se només en el tractament de la seva malaltia, havia desplaçat les persones I la seva individualitat del centre de la cura. Això va resultar en la despersonalització de tots els agents involucrats (pacients, famílies, cuidadors I fins I tot professionals). Les últimes recerques han demostrat greus seqüeles físiques I psicològiques en els supervivents, amb conseqüències ètiques. La despersonalització és un dels signes de la síndrome de burnout, un problema greu no resolt I creixent entre els professionals, I va ser admès com una malaltia per l'OMS el 2019. Els grans principis bioètics no han estat capaços de respondre a les causes del sofriment físic-psíquic. Es necessiten noves orientacions ètiques dirigides a l'individu I a la seva particularitat, incloent-hi aspectes més emocionals I afectius, referint-nos a l' ètica del curar com un nucli gravitacional on creix el professionalisme I la pràctica de la resiliència en el camp de la salut. La importància d'integrar l'ètica de l'atenció orientada cap al binomi pacient-família, I de combatre l'esgotament mitjançant l'atenció a professionals, és un veritable desafiament dins de l'UVI, dues cares diferents però vinculades que pertanyen a la mateixa moneda. Paraules clau: Vigilància intensiva, humanització UVI, projecte HU-CI, ètica del curar, professionalització, desgast professional, síndrome burnout, síndrome overla

Bioética en la práctica clínica del fisioterapeuta / Bioethics in the clinical practice of the physiotherapist / Bioètica en la pràctica clínica del fisioterapeuta

En la bibliografía actual, la dedicación a los dilemas bioéticos es abundante, pero hay algunas profesiones de ciencias de la salud, como fisioterapia, en que estas problemáticas no han sido ampliamente estudiadas, y por lo tanto la resolución y análisis de los problemas éticos también es deficiente ya que no se cuenta con los elementos de análisis propios de la bioética. Esto repercute en la formación y en el desarrollo profesional de los fisioterapeutas. En este artículo se plantean algunas clasificaciones de los dilemas éticos más comunes y se analizan brevemente algunas propuestas educativas. Se concluye que la bioética es importante para el desarrollo integral de la fisioterapia, pero falta más investigación en relación con las problemáticas éticas y con la formación de la ética en la carrera

In current literature, dedication to bioethical dilemmas is abundant, however there are some professions of health sciences, in this case physiotherapy, in which these problems have not been widely studied. Therefore resolution of the ethical problems is also deficient since there are no elements of analysis inherent to bioethics and it also has an effect on training and professional development of physiotherapists. In this study some classifications of the most common ethical dilemmas are raised and some educational proposals are briefly analyzed. It is concluded that bioethics is important for the integral development of physiotherapy, but more research is lacking in relation to the ethical problems and to the formation of the ethics in the career

En la bibliografia actual, l'anàlisi de dilemes bioètics és força abundant, però hi ha algunes professions de ciències de la salut, com ara la fisioteràpia, en què aquesta problemàtica ha estat escassament estudiada i, per tant, la resolució́ I l'anàlisi dels problemes ètics de la professió també́ és deficient, ja que no existeixen elements d'anàlisi propis de la bioètica en el camp de la fisioteràpia. Això repercuteix en la formació́ I en el desenvolupament professional dels fisioterapeutes. En aquest article es plantegen diferents classificacions dels dilemes ètics més comuns I s'hi presenten algunes propostes educatives. Es conclou que la bioètica és important per al desenvolupament integral de la fisioteràpia, però falta més investigació́ en tot el que té a veure amb la formació en ètica al llarg de la carrera

Homeless, Ill, and Psychiatrically Complex: The Grueling Carousel of Cassandra Lee.

Ask any clinical ethics consultant, and they can tell you about their transformative cases. Some stick with us because all roads led nowhere. Cassandra Lee had a history of pulling out lines and tubes and a distaste of warming blankets. Her admission marked her thirtieth over the past year. Many of the challenges facing the hospital caring for her were not unique: significant psychiatric issues, prolonged nonadherence to medical advice, and end-of-life decision-making combined to create an ethically dense and vexing situation. Ms. Lee, like so many patients, was suffering because of system failures.

Moral Distress and Attitudes About Timing Related to Comfort Care for Hospitalized Patients: A Survey of Inpatient Providers and Nurses.

CONTEXT: Providing nonbeneficial care at the end of life and delays in initiating comfort care have been associated with provider and nurse moral distress. OBJECTIVE: Evaluate provider and nurse moral distress when using a comfort care order set and attitudes about timing of initiating comfort care for hospitalized patients. METHODS: Cross-sectional survey of providers (physicians, nurse practitioners, and physician assistants) and nurses at 2 large academic hospitals in 2015. Providers and nurses were surveyed about their experiences providing comfort care in an inpatient setting. RESULTS: Two hundred five nurse and 124 provider surveys were analyzed. A greater proportion of nurses compared to providers reported experiencing moral distress "some, most, or all of the time" when using the comfort care order set (40.5% and 19.4%, respectively, P = .002). Over 60% of nurses and providers reported comfort care was generally started too late in a patient's course, with physician trainees (81.4%), as well as providers (80.9%) and nurses (84.0%) < 5 years from graduating professional school most likely to report that comfort care is generally started too late. CONCLUSIONS: The majority of providers and nurses reported that comfort care was started too late in a patient's course. Nurses experienced higher levels of moral distress than providers when caring for patients using a comfort care order set. Further research is needed to determine what is driving this moral distress in order to tailor interventions for nurses and providers.

Cuidados al paciente y su familia al final de la vida: la anticipación compasiva / Care for the patient and his family at the end of life: compassionate advance care planning

El final de la vida va acompañado de sufrimiento y penalidades que pueden ser aliviados en las unidades de Cuidados Paliativos (CP) con una atención compasiva. El objetivo de este trabajo consiste en describir el concepto de "anticipación compasiva" como una forma de cuidar al paciente y a su familia al final de la vida desde la perspectiva tanto de los profesionales, profesores y estudiantes de las ciencias de la salud, como de las personas con enfermedad avanzada y sus familiares. Se ha empleado para ello una metodología cualitativa. Los datos se recogieron a través de entrevistas en profundidad y de grupos focales, siendo analizados y codificados usando la técnica de la teoría fundamentada. Se obtuvo la aprobación de un Comité de Ética. La muestra intencionada fue de 29 participantes: pacientes y familiares de pacientes con enfermedad avanzada, profesionales asistenciales de CP y expertos en bioética, profesores universitarios y estudiantes de Ciencias de la Salud. Los datos se recogieron en un Hospital de CP en Madrid, España. Los participantes valoran positivamente la anticipación compasiva de los profesionales que supone estudiar y reflexionar sobre las posibles complicaciones que pueden derivarse de la situación de enfermedad avanzada que padece el enfermo y dialogar con él acerca de las posibles actuaciones al respecto. El artículo concluye que la compasión es una virtud que implica adelantarse a las necesidades de los pacientes para que el enfermo pueda tomar decisiones compartidas acertadas. Es lo que se denomina anticipación compasiva. Son necesarios ulteriores estudios que profundicen en las características de la anticipación compasiva y cómo desarrollarla de forma óptima en los pacientes al final de la vida

End of life is frequently accompanied by suffering and hardships that can be alleviated in the Palliative Care (PC) units by applying compassionate advance care. It is the aim of this paper to describe the concept of "compassionate advance care" as a way of caring for the patient and his family at the end of life from the perspective of both professionals, teachers and students of the health sciences, and persons with advanced disease and their families. A qualitative methodology was used. Data were collected through in-depth interviews and focus groups, and analysed and coded using the theory of Grounded Theory. Approval of an Ethics Committee was obtained. The intentional sample consisted of 29 participants, who were patients and relatives of patients with advanced disease, PC professionals and experts in bioethics, university professors and Health Sciences students. Data were collected in a PC Hospital in Madrid, Spain. The participants positively valued the compassionate advance care provided by professionals: analysing and reflecting on possible complications that may arise from the advanced disease situation suffered by the patient and establishing a dialogue with him about possible actions in this regard. The paper concludes that compassion is a virtue that implies anticipating the needs of patients, thus allowing the patient to make the right shared decisions. This is what the term Compassionate Advance Care Planning entails. Further studies are needed to delve into the characteristics of compassionate Advance Care Planning and how to optimally implement it in patients at the end of life. To admit the opposite is to enter a spiral where the dignity of the human being would become an object of weighting with respect to another value, which, in a hypothetical conflict could be postponed by another. However, Palliative Care takes into account the social dimension of the end of life of the human being. They take care of the sick human being in its entirety. That is why they are the option most in line with the dignity of the human being at the end of his life

Comforting when we cannot heal: the ethics of palliative sedation.

This essay considers whether palliative sedation is or is not appropriate medical care. This requires one to consider (a) whether, in addition to the good of health, relief of suffering is also a proper end of medicine; (b) whether unconsciousness can ever be a good for a human being; and (c) how double-effect reasoning can help us think about difficult cases. The author concludes that palliative sedation may be proper medical care, but only in a limited range of cases.

The last low whispers of our dead: when is it ethically justifiable to render a patient unconscious until death?

A number of practices at the end of life can causally contribute to diminished consciousness in dying patients. Despite overlapping meanings and a confusing plethora of names in the published literature, this article distinguishes three types of clinically and ethically distinct practices: (1) double-effect sedation, (2) parsimonious direct sedation, and (3) sedation to unconsciousness and death. After exploring the concept of suffering, the value of consciousness, the philosophy of therapy, the ethical importance of intention, and the rule of double effect, these three practices are defined clearly and evaluated ethically. It is concluded that, if one is opposed to euthanasia and assisted suicide, double-effect sedation can frequently be ethically justified, that parsimonious direct sedation can be ethically justified only in extremely rare circumstances in which symptoms have already completely consumed the patient's consciousness, and that sedation to unconsciousness and death is never justifiable. The special case of sedation for existential suffering is also considered and rejected.