Aspectos éticos en el consentimiento informado en la endoscopia digestiva / Ethical aspects in the informed consent in digestive endoscopy

Fundamento: en los últimos años la endoscopia digestiva se ha visto favorecida por el progreso científico técnico, donde juega un papel muy importante tanto en el diagnóstico como la terapéutica de diferentes enfermedades; sin embargo no se debe olvidar los aspectos éticos que sirven de puntales reguladores, para que de forma conjunta con los beneficios que se aportan a los individuos, se respete la integridad y dignidad de estos, y donde además se les permita tomar decisiones en relación a lo que desean para su salud, uno de estos elementos reguladores lo constituye el consentimiento informado.Objetivo: revisar los aspectos de la ética en relación con el consentimiento informado y exponer algunas reflexiones de su aplicación en los procederes endoscópicos digestivos.Métodos: se realizó una búsqueda en las bases de datos biomédicas (SciELO Regional, SciELO Cuba, Pub-Med y Medline), así como repositorios de tesis de grado de especialidades biomédicas desde el año 2000 hasta la actualidad. Donde se utilizaron 31 citas relacionadas con el tema.Desarrollo: se abordaron la importancia y necesidad de la puesta en práctica del consentimiento, las características que debe tener para su correcta elaboración y ejecución, su papel en los grupos vulnerables, aspectos generales en la asistencia médica y específcos en el campo de la endoscopía digestiva.Conclusiones: el consentimiento informado, es uno de los aspectos éticos más importante de la asistencia médica y la investigación. En los procedimientos endoscópicos tanto diagnóstico como terapéutico constituye una herramienta fundamental que no se puede omitir, deben especificarse siempre los riesgos de manera clara y en el caso de investigación dentro de este campo, se debe hacer especial énfasis en el propósito de la misma y no fomentar ideas erróneas(AU)

Background: in the last years digestive endoscopy has been favored by the scientific technical progress, playing a very important role either in the diagnosis and the therapy of different diseases. However we should not forget the ethical aspects that serve as regulator points, so that jointly with the benefits that are contributed to the people, integrity and dignity are respected, and where they are also allowed to make decisions regarding what they want for its health. One of these elements regulators is the informed consent. Objective: to review the aspects of the ethics regarding the informed consent and to expose some reflections of its application in the digestive endoscopic procedures.Methods: a search in biomedical databases (SCIELO Regional, SCIELO Cuba, Pub-Med and Medline), as well as repositories of biomedical specialty thesis from 2000 to the present was conducted. Key words were used: ethics, bioethics, informed consent and endoscopy. Original articles, reviews, opinion articles and contributions, as well as books and thesis were taken into consideration. Finally, 31 citations related to the topic were used.Development: the importance and necessity of the implementation of informed consent were approached, as well as the characteristics that must have for its proper elaboration and execution, its role in vulnerable groups, general aspects in medical care and specifically in the field of digestive endoscopy.Conclusions: informed consent is one of the most important ethical aspects of medical care and research. In both endoscopic diagnostic and therapeutic procedures, it is a fundamental tool that cannot be omitted, risks must always be clearly specified and in the case of research within this field, special emphasis should be placed with the the purpose of not creating misconceptions(AU)

Ethical issues in therapeutic endoscopy - can communication between patient and physician make a difference?

Therapeutic endoscopy represents a major step in evidence-based medicine with great potential in the evolution of non-invasive surgery. The evolutionary status of endoscopy has reached a level where some of the surgical intervention can be performed in a minimal invasive way, with great benefits for the patient. However, this rises up some ethical issues regarding the patient's comfort zone, possible risks and complications and subjected the physician to possible litigation situations if not well trained. A rather good interaction and communication between patient and endoscopist is mandatory, as the health-care experience might be more satisfying. Unfortunate situations may also be avoided if intensive training and up to date knowledge and skills are acquired before jumping to therapeutic endoscopy. The continuous development and general focus on interventional endoscopy seems to have a key role on current medical standings. Therefore, in the following paper we have tried to underline the potential ethical problems that both the patient and the physician should take into consideration towards a better therapeutic endoscopic result.

[DEONTOLOGICAL QUESTIONS IN PROPHYLACTIC OF ENDOSCOPIC COMPLICATIONS: THE SIGNIFICANCE OF RATIONAL AND PSYCHOLOGICAL FACTORS (analytical overview)].

THE AIM OF STUDY: To evaluate the ways of reduction complications during endoscopic procedures based on principals of professional ethics and improving the quality of working area. MATERIALS AND METHODS: Data of fundamental literature, evidence based medicine, science publications and internet portals. RESULTS: Deontology is the fundamental principle of medical practice and one of the main factors of professional effectiveness. Complications in endoscopy are often the investigations of deviation from the deontological principals. The whole number of psychological factors influences on professional activity of endoscopists, where the emotional "burn-out" syndrome (EBS) occupies one of the main places. Prophylactic and timely relief of EBS serves improvement of the practical work quality. CONCLUSION: Creation of favorable working area is the strategically important task in prophylactics of endoscopy complications. The questions of practical realization of deontological principles in endoscopy are the subject of further discussion.

Endoscopy during a missile attack: a military dilemma for civilians.

In modern warfare, civilian populations may find themselves under immediate personal danger with very little warning. While there are ways to minimize this danger, there is a paucity of literature discussing this modern dilemma, and it is therefore important to try to address these situations in advance both logistically and ethically. Discussion of this case includes several relevant ethical principles.

Training model for teaching endoscopic submucosal dissection of gastric tumors

Introduction: the elevated risk of complications and technicalcomplexity of endoscopic submucosal dissection (ESD) has limitedits implementation in our medical system.Objective: to design and evaluate a training program forlearning the ESD technique.Methods: four endoscopists with no experience with ESD underwenta 4-step training program: 1) review of the existing literature,didactic material, and theoretical aspects of ESD; 2) ESDtraining in an ex-vivo animal model; 3) ESD training in an in-vivoanimal model (supervised by ESD expert); and 4) ESD performancein a patient. A standard gastroscope and an ESD knife (IT,Flex or Hook-knife Olympus®) were employed. The classical ESDtechnique was performed: rising of the lesion, circumferential incision,and submucosal dissection.Results: ex-vivo animal model: 6 x swine stomach/esophagus–cost < 100 euro; 6 x ESD: antrum (n = 2), body (n = 3) andfundus/cardia (n = 1)–; size of resected specimen: 4-10 cm; ESDduration: 105-240 minutes; therapeutic success: 100%; complications:perforation (1/6: 16%) sealed with clips. In-vivo animalmodel: 6 ESD (antrum/body of stomach: 4; esophagus: 2); size:2-5 cm; duration: 40-165 minutes; success: 100%; complications:0%. Patient: ESD of a gastric lesion located in theantrum/body; size: 3 cm; duration 210 minutes; a complete resectionwas achieved; no complications.Conclusions: the results of the present study support the usefulnessof this model for learning ESD in our system(AU)

Ethical issues in the management of elderly patients in gastroenterology and digestive endoscopy.

Over the past 30 years, the population of old-aged citizens in most Western countries has been dramatically increasing. These people usually have several comorbidities and often lose their independence, mostly due to neurodegenerating diseases. Benign and malignant gastrointestinal disorders are very common in all age groups, but their incidence increases with age, requiring investigation and therapy. In this setting several ethical issues arise, mostly related to the extent of invasive investigations, adverse drug reactions due to polypharmacy, the risk:benefit ratio of endoscopic therapy, and the quality and validity of informed consent in this frail elderly population.

Role of cognitive function in assessing informed consent for endoscopy.

BACKGROUND: Patient understanding of the consent process is often suboptimal and the reasons for this are poorly understood. In particular the role of cognitive function in assessing the level of understanding of consent has not been evaluated. AIMS: This study aims to assess the level of patient understanding of the informed consent process and the role of cognitive function in those with low levels of understanding. METHODS: The study was prospective, interviewing patients immediately after they had given consent but before undergoing their procedure. Understanding of the reason for the procedure, the risks attendant upon it, details of the procedure itself and post procedure care was scored with the total representing overall level of understanding. A mini mental state examination (MMSE) was then performed with the score recorded. RESULTS: 100 patients were interviewed. A low level of understanding was shown in 36%. Ninety two patients had a MMSE score greater than 24. All patients with a high level of understanding had MMSE scores greater then 24 compared with 78% of those with a low level of understanding. All patients (n = 8) who displayed a MMSE score less than 24 had a low level of understanding. Men displayed poorer levels of understanding than women. A subnormal MMSE only identified 22% of those with low levels of understanding. CONCLUSIONS: Understanding of the consent process is suboptimal. Adequate cognitive function does not predict a high level of understanding of the informed consent process while cognitive impairment precludes it. It is evident, however that factors other than cognitive dysfunction are at play when attempting to explain low levels of understanding.