Toma de decisiones en hemodiálisis crónica: estudio cualitativo en adultos mayores / Decision making among older adults in hemodialysis. A qualitative assessment

Background: In Chile there are 22,310 people in Chronic Hemodialysis (CHD), 53% of them older adults (OA). Shared decision-making and advance directives (AD) are especially important in OA with end-stage chronic renal failure, since they have greater levels of disability, morbidity and mortality, raising doubts about the benefit of therapy. Aims: To understand the experience in decision making and explore ways to express AD, in OA in CHD. Material and Methods: A qualitative phenomenological study, performing 12 in-depth interviews to OA who had been at CHD for at least one year. Results: The analysis revealed four broad comprehensive categories, two related to participation in the decision to enter CHD, namely the experience of subjects as spectators and their lack of interest for decision support and two referred to the expression of AD, namely the difficulty in facing their own finitude and resistance to express AD. Conclusions: There is little participation of older adults in the decision about their admission to dialysis therapy, and once they enter the CHD program they are not prepared to discuss AD in general, nor an eventual suspension of dialysis in particular.

Problemas éticos y de salud planteados por la reciente epidemia de Ébola: ¿Qué debemos aprender? / Ethical and health issues posed by the recent Ebola epidemic: What should we learn?

The recent Ebola epidemic that affected several countries in Africa, with very high mortality and a pandemic threat, posed problems of justice, public health, prevention, treatment and research, each of which has relevant ethical issues. Despite severe initial difficulties, an effective international response was achieved, whose outcome has left significant teachings to be considered in order to deal with future epidemics or pandemics. In this article, the authors analyze the main problems faced during the Ebola epidemic, including the unequal distribution of health resources between countries, the need for international collaboration, the requirement for a review of the ethical standards of clinical trials in emergencies, and the necessity of an organized global system of prevention and timely response to these outbreaks. Authors conclude that at the present time health is a global issue without borders, that insufficient healthcare resources in some countries poses risks and affects all countries and that the confrontation of the threats of epidemics requires a solution based in universal solidarity. At the same time, a moral duty to investigate should be acknowledged, seeking a balance between sense of urgency, scientific rigor and involvement of local communities.

Recomendaciones del Comité de Ética de la Sociedad Chilena de Nefrología para el manejo de los problemas ético-clínicos de pacientes adultos con enfermedad renal crónica terminal / Recommendations of the Ethics Committee of the Chilean Society of Nephrology for the management of ethical problems in adult end stage renal disease patients

There are different approaches to treat patients with End Stage Renal Disease (ESRD): hemodialysis, peritoneal dialysis, renal transplantation and conservative medical management. The choice of the best therapy for each patient, needs both clinical and ethical skills. The Ethics Committee of the Chilean Society of Nephrology has elaborated recommendations to help health workers to deal with the ethical and clinical problems related to patients suffering ESRD. Its goal is to guide, at a national level, the effective use of minimal standards in the treatment and care of patients with ESRD, including appropriate care and information for patients, therapy selection, management of difficult cases and potential conflicts.

Encuesta de opinión pública sobre reproducción humana y usos de tecnología de reproducción asistida en habitantes de Santiago, Chile / Opinion survey on the use of assisted reproductive technologies applied to inhabitants of Santiago, Chile

Background: Advances in reproductive medicine and the use of assisted reproductive technologies (ART) have a great impact in the lives of people and the conformation of their families. Aim: To report the results of an opinion survey applied to inhabitants of Santiago, Chile about the use of ART to conceive. Material and Methods: A survey was designed and applied to a random representative sample of 1.500 people between the ages of 18 and 65 in the 34 municipalities of Santiago. Results: Eighty eight percent of respondents support the use of medical assistance to conceive children. Wide approval exists for the use of in vitro fertilization (IVF) by heterosexual couples, even when not married (85.9%) and by single women (70.4%), by both mole and female participants of every socioeconomic level, age group and religious affiliation. Support decreases significantly when the use of IVF is considered for post-menopausal women (35.1 %) and by same-sex couples (26.6%). Conclusions: Results of this survey indicate that the majority of inhabitants in Santiago favor the use of ART, including IVF. This support decreases significantly for elderly women and homosexual couples.

Acompañamiento del enfermo: Una experiencia de aprendizaje sobre el significado de la enfermedad / Accompanying a patient as an experience to learn the meaning of disease

Background: Due to technical advances and progressive specialization, patient physician relationship evolved from being based on confidence and comprehension to be impersonal and contractual. Aim: To evaluate the change produced in medical students' concept of the meaning of disease, after living an experience of accompanying a patient and their family environment. Material and methods: We used a qualitative research methodology based on participative-action to evaluate an educational method in which a group of third year medical students accompanied a previously selected chronic patient during two months. We performed two focal groups, one previous to the experience and the second one a month later. Additionally, every student wrote a personal narration of the experience. We compared the students' perception of the meaning of disease for the patients and their relatives, before and after the experience. Results: The students confirmed their previous conception about chronic disease, but they also discovered the ways in which some patients and their families overcome their ¡imitations. They pointed out their belief that the physician's comprehension of the meaning of disease for the patient and the family, a need to practice a good medicine and that this knowledge change the physician-patient relationship. Conclusions: This experience was an effective way of ¡earning the meaning of disease, which might be a part of medical student' training, with the corresponding adjustments and changes.