Impact of the Coronavirus Disease 2019 Pandemic on Moral Distress Among Nurses and Physicians in Spanish ICUs.

OBJECTIVES: To assess the impact of COVID-19 pandemic on moral distress (MD) among healthcare professionals (HCPs) (physicians and nurses) in Spanish ICUs. DESIGN: Cross-sectional, prospective study. SETTING: ICUs in Spain. PARTICIPANTS: HCPs currently working in Spanish ICUs. INTERVENTIONS: Data were collected via electronic survey with the use of a 50-item questionnaire in two different periods: prepandemic (October-December 2019) and during the second wave of COVID-19 (September-November 2020). MEASUREMENTS AND MAIN RESULTS: During the prepandemic and pandemic periods, 1,065 (57.1% nurses) and 1,115 (58.5% nurses) HCPs completed the questionnaire, respectively. Higher MD levels were reported during COVID-19 pandemic, particularly among ICU nurses, when compared with the prepandemic period. Before COVID-19, physicians reported significantly higher levels of MD than ICU nurses (80.0 [interquartile range {IQR}, 40.0-135.0] vs 61.0 [IQR, 35.0-133.0]; p = 0.026). These differences disappeared during the pandemic period (81.0 [IQR, 39.0-138.5] vs 74.0 [IQR, 41.0-143.0]; p = 0.837). During the pandemic, younger and less experienced HCPs working in hospital areas that were converted in ICU or in ICUs with multiple occupancy rooms reported higher MD levels. In addition, HCPs who were off work for psychologic burden reported higher MD levels (108.0 [IQR, 66.0-139.0] vs 76.0 [IQR, 40.0-141.0]; p < 0.05). In the prepandemic period, patient-level root causes were the most morally distressing for nurses, whereas physicians reported higher MD on system-level root causes. During the pandemic, both groups reported higher MD on system-level root causes. During COVID-19, significantly more HCPs considered leaving their job due to MD. CONCLUSIONS: MD has increased among ICU HCPs in Spain during COVID-19 pandemic. Physicians reported higher MD levels than nurses in the prepandemic period, whereas both HCPs groups reported similar MD levels in the pandemic period. Strategies are needed and should be implemented to mitigate MD among HCPs.

Measuring family-centred care practices in adult intensive care units: The EMPATHIC-F questionnaire.

BACKGROUND: Engaging relatives in the care of critically ill patients is associated with better outcomes. It is crucial to empower relatives to provide feedback. Valid satisfaction instruments are essential to identify best practices and areas for improvement. AIM: The aim of the study was to adapt the Spanish version of the EMpowerment of PArents in The Intensive Care-30 (EMPATHIC-30) questionnaire in adult intensive care units (ICUs) and psychometrically test the EMpowerment of PAtients in The Intensive Care-Family (EMPATHIC-F) questionnaire to measure family satisfaction. DESIGN: This is a cross-sectional, prospective study conducted in two adult ICUs. Participants were relatives of patients who were discharged alive from the ICUs with an ICU length-of-stay >24 hours. The EMPATHIC-F questionnaire is divided into five domains that are related to the family-centred care principles. Responses are provided on a 6-point ordinal Likert scale, a score of >5 is considered acceptable. RESULTS: Patients' relatives confirmed the adaptation of the instrument. A total of 262 relatives responded to the EMPATHIC-F questionnaire (97% response rate). The empirical structure of the instrument was established by confirmatory factor analysis confirming 30 statements within five theoretically conceptualized domains: information, care and treatment, family participation, organization, and professional attitude. On item level, two statements scored a mean below 5.0. Cronbach's α at the domain level was between .64 and .75. Congruent validity was adequate between the five domains and four general satisfaction items (r's .26-.54). The non-differential validity was confirmed with no significant effect size between three patients' demographic characteristics and the domains. CONCLUSIONS: The EMPATHIC-F questionnaire is a reliable and valid quality performance indicator to measure the perceptions of family members in adult ICU settings. RELEVANCE TO CLINICAL PRACTICE: The EMPATHIC-F questionnaire can be used to benchmark and provides a framework for standardized quality improvement towards the development of a family-centred care philosophy within adult ICUs.

[Patient safety culture in Family practice residents of Galicia]. / La cultura de seguridad del paciente en los médicos internos residentes de Medicina Familiar y Comunitaria de Galicia.

OBJECTIVE: To determine the views held by Family practice (FP) residents on the different dimensions of patient safety, in order to identify potential areas for improvement. DESIGN: A cross-sectional study. LOCATION: Seven FP of Galicia teaching units. PARTICIPANTS: 182 FP residents who completed the Medical Office Survey on Patient Safety Culture questionnaire. MEASUREMENTS: The Medical Office Survey on Patient Safety Culture questionnaire was chosen because it is translated, validated, and adapted to the Spanish model of Primary Care. The results were grouped into 12 composites assessed by the mentioned questionnaire. The study variables were the socio-demographic dimensions of the questionnaire, as well as occupational/professional variables: age, gender, year of residence, and teaching unit of FP of Galicia. RESULTS: The "Organisational learning" and "Teamwork" items were considered strong areas. However, the "Patient safety and quality issues", "Information exchange with other settings", and "Work pressure and pace" items were considered areas with significant potential for improvement. First-year residents obtained the best results and the fourth-year ones the worst. CONCLUSIONS: The results may indicate the need to include basic knowledge on patient safety in the teaching process of FP residents in order to increase and consolidate the fragile patient safety culture described in this study.

Shifting trends in modes of death in the Intensive Care Unit.

PURPOSE: To describe the way patients die in a Spanish ICU, and how the modes of death have changed in the last 10 years. MATERIALS AND METHODS: Retrospective observational study evaluating all patients who died in a Spanish tertiary ICU over a 10-year period. Modes of death were classified as death despite maximal support (D-MS), brain death (BD), and death following life-sustaining treatment limitation (D-LSTL). RESULTS: Amongst 9264 ICU admissions, 1553 (16.8%) deaths were recorded. The ICU mortality rate declined (1.7%/year, 95% CI 1.4-2.0; p = 0.021) while ICU admissions increased (3.5%/year, 95% CI 3.3-3.7; p < 0.001). More than half of the patients (888, 57.2%) died D-MS, 389 (25.0%) died after a shared decision of D-LSTL and 276 (17.8%) died due to BD. Modes of death have changed significantly over the past decade. D-LSTL increased by 15.1%/year (95% CI 14.4-15.8; p < 0.001) and D-MS at the end-of-life decreased by 7.1%/year (95% CI 6.6-7.6; p < 0.001). The proportion of patients diagnosed with BD remained stable over time. CONCLUSIONS: End-of-life practices and modes of death in our ICU have steadily changed. The proportion of patients who died in ICU following limitation of life-prolonging therapies substantially increased, whereas death after maximal support occurred significantly less frequently.

Dental age estimation in Spanish and Venezuelan children. Comparison of Demirjian and Chaillet's scores.

Orthopantomographs taken from 308 Spanish Caucasian and 200 Venezuelan Amerindian children, aged between 2 and 18 years, were analysed following the Demirjian's method. The aims of this study were to test the applicability of the Demirjian's method to two different sample populations, and to develop age prediction models for both populations using the original French Canadian scores described by Demirjian (1976) and the new multi-ethnic dental scores proposed by Chaillet et al. (2005) when the ethnic origin is unknown. Results showed that despite the good correlation between dental and chronological age, Demirjian's method overestimates the age in the Spanish Caucasian sample using both scores, the mean overestimation being higher when the Demirjian's scores were used than when the Chaillet's scale was applied. In the Venezuelan Amerindian sample, the opposite was found: Demirjian's method underestimates the age using both scores, the underestimation being higher when the Chaillet's scale was applied than when Demirjian's scale was used. New graphs were produced to convert the maturity scores to dental age for Spanish and Venezuelan children. With these graphs, the Demirjian's scores showed to be inadequate after the age of 12 in both populations, while Chaillet's scores offered useful information until 14 years of age.

Laryngeal anatomical variants and their impact on the diagnosis of mechanical asphyxias by neck pressure.

The aims of this investigation were to determine the characteristics and prevalence of anatomical variants of the larynx apparatus and to evaluate the impact of these variants on the accurate diagnosis of laryngeal fractures. A population-based study was carried out, analyzing a series of 207 consecutive autopsied cases in the Institute of Legal Medicine of Galicia (Northwestern Spain). The prevalence of triticeal cartilage was 52.7% and that of agenesis of thyroid horns 10%. Calcification of the stylo-hyoid ligament accounted for 1.4%. We identified three new anatomical variants: the terminal segmentation of the thyroid horns (11.6%), ectopic superior thyroid horns (8%) and lateral thyrohyoid ossification (5.3%). These three names, based on anatomical criteria, are the author's proposal to solve the lack of uniformity in the designation of these variants. Agenesis of thyroid horns were related to the presence of ectopic superior thyroid horns in 93% of cases, either uni or bilateral. The combination of variants was present in 6.8% of the cases, being the terminal segmentation of the thyroid horns in association with triticeal cartilage the most frequent (3.8%). The probability of misdiagnosis due to the presence of anatomical variations in deaths by pressure on the neck was high in this population (71.5%). The prevalence of triticeal cartilage in more than half of the sample, determined an important rate of potential errors (46.4%), followed by the mistaken diagnoses induced by terminal segmentation of thyroid horns (7.3%) and by ectopic superior thyroid horns (6.3%). The likelihood of a misdiagnosed laryngeal fracture was greater if the thyroid cartilage was affected, with a higher proportion of false positives comparing to the hyoid bone (p<0.001). The higher frequency of thyroid fractures in neck pressure together with the prevalence and location of triticeal cartilage on the lower third of the lateral thyrohyoid ligament are the main reasons for these results. Further studies should be done with larger samples to expand epidemiological data and consolidate these results and their influence on the diagnosis of mechanical asphyxias.

[Descriptive Study on the Application of Informed Consent in Health Centers of Galicia Spain]. / Estudio Descriptivo Sobre la Aplicación del Consentimiento Informado en Centros Sanitarios de Galicia España.

OBJECTIVES: The aims of this study were to know the opinion and general knowledge of patients about the informed consent (IC), and their participation in the decision-making (DM) process. MATERIAL AND METHODS: A descriptive, transversal, observational, qualitative and quantitative study was designed with 120 patients randomly surveyed at the 8 University Hospital Complexes of Galicia, Spain. RESULTS AND DISCUSSION: The mean age was 52.14 years, with 50% of men. 84.21% of the ICs provided by non-medical personnel were limited to delivering and reading it. 90% of patients after signing the IC, trust their doctor. Only 50% of the professionals tried to involve the patient in DM. 53.33% of the patients participated in DM. 45.83% patients signed for having understood and accepted the explanation, being completely satisfied 95 of the patients surveyed (79.17%). CONCLUSIONS: It is essential to change the attitude of non-medical health professionals involved in the DM process, because their involvement is not being promoted. Although less than half of the respondents have signed the IC for having understood, the degree of satisfaction and confidence in the doctor was not compromised.

How reliable is the Spanish bodily harm assessment scale?

The use of scales to quantify or qualify bodily harm resulting from an unintentional car accident has been mandatory in Spain since 1995 and compensation for personal injuries resulting from a traffic accident is calculated according to a legal ruling established by Royal Decree 8/2004 (RDL). This present study assesses the reliability of the scale. Agreement between the evaluations for the same patient by 24 qualified observers following the Royal Decree 8/2004 was measured using the Kappa index. The variables assessed were the days of hospitalization, impeditive days, non impeditive days and the functional and aesthetic sequelae. The application of the Fleiss Kappa index obtained a result of 0.37, indicating a "fair agreement" according to the rating scale proposed by Landis and Koch. This study demonstrates the unreliability of the Spanish medical scale for the assessment of injury as described in the RDL 8/2004. The scale should adopt the measurement systems and clinical classifications of outcomes such as the ASIA, SCI scale or the Daniels scale of neurological injury and allow scientific discussion of the findings of the report. The resulting quantitative value should operate as a reliable indicator of a specific quality of the damage.

Intimate partner violence against women in Spain: A medico-legal and criminological study.

Intimate partner violence (IPV) is a significant worldwide problem whose magnitude and risk factors vary across different settings and cultures. Nowadays, it is a priority to improve the knowledge on this issue in order to formulate better evidence-based policy responses. This study aims to contribute to a better understanding of non-fatal IPV against women in Spain. A retrospective analysis of IPV cases with a final judicial decision was carried out. The period under study extended from January 2005 to December 2012, with a total of 582 files included in the investigation. Most IPV victims were young adult women of Spanish origin, either married or single, with children, unemployed and with a low family income level. The majority of alleged perpetrators were young adults, employed, with a middle-low income level, a history of alcohol consumption/abuse, but no criminal records. Most victims had previous history of IPV, were engaged in a long-term relationship with their abuser and lived with him at the time of assault. The combination of psychological and physical abuse was the most frequent form of violence. The most common mechanisms of assault consisted in minor acts of physical violence, which resulted in mild injuries, most of them in the upper limbs and face. Nearly half of women sought medical care, but physician's injury report was only made in about a quarter of these cases, even though it is mandatory for health professionals. The majority of criminal proceedings were initiated by the victim's report and ended in conviction, most of them being considered occasional mistreatment. This study confirms the heterogeneity of the phenomenon of intimate partner violence. The importance of adopting standard IPV concepts and promoting the recognition and assessment of this form of violence amongst health care professionals, criminal investigators and forensic personnel is emphasized.

Attitudes towards physician-assisted suicide and euthanasia in Spanish university students / Actitudes hacia la eutanasia y el suicidio medicamente asistido en estudiantes universitarios españoles / Atitudes em relação a eutanásia e suicídio medicamente assistido em estudantes universitários espanhóis

Abstract Attitudes toward physician-assisted death among medical students differ between populations. The aim of this study was to explore attitudes towards euthanasia and physician-assisted suicide among Spanish university students. A cross-sectional survey was conducted by asking undergraduate students (Medicine, Nursing and Law) of the University of Santiago de Compostela to complete an anonymous 17-item questionnaire. Most participants exhibited a positive attitude towards physician-assisted suicide (54%) and euthanasia (75%), as well as towards their legalization. Attitudes were consistent with the underlying ethical reasoning, with no differences in terms of age, gender or academic degree. In addition, consistency was found between attitudes and willingness to participate in physician-assisted suicide and euthanasia, should they be legal. The results showed that the attitudes of medical students towards euthanasia and physician-assisted suicide were positive and similar to non-medical students.

Resumen La actitud de los estudiantes de Medicina ante a la muerte médicamente asistida difiere entre poblaciones. El objetivo de este estudio ha sido explorar las actitudes hacia la eutanasia y el suicidio médicamente asistido en estudiantes universitarios españoles. Se realizó una encuesta transversal en estudiantes de grado (Medicina, Enfermería y Derecho) de la Universidad de Santiago de Compostela que completaron un cuestionario anónimo de 17 preguntas. La mayoría de los participantes mostraron una actitud positiva hacia el suicidio médicamente asistido (54%) y la eutanasia (75%), así como hacia su legalización. Las actitudes fueron coherentes con los argumentos éticos, no encontrando diferencias en relación con la edad, el sexo o la titulación. Asimismo, las actitudes estaban de acuerdo con la intención de participar en estos procedimientos, si fueran legales. Los resultados muestran que la actitud de los estudiantes de medicina hacia la eutanasia y el suicidio asistido es positiva y similar a la de estudiantes de enfermería y derecho.

Resumo A atitude dos estudantes de medicina ante a morte medicamente assistida difere entre populações. O objetivo deste estudo foi explorar as atitudes para a eutanásia e o suicídio medicamente assistido em estudantes universitários espanhóis. Foi realizada uma pesquisa transversal em estudantes de graduação (medicina, enfermagem e direito) da Universidade de Santiago de Compostela que completaram um questionário anônimo de 17 perguntas. A maioria dos participantes mostrou atitude positiva para o suicídio medicamente assistido (54%) e a eutanásia (75%), bem como para a sua legalização. As atitudes foram coerentes com os argumentos éticos, não encontrando diferenças em relação a idade, sexo ou titulação. Assim mesmo, as atitudes estavam de acordo com a intenção de participar nestes procedimentos, se fossem legais. Os resultados mostram que a atitude dos estudantes de medicina para a eutanásia e o suicídio assistido é positiva e similar à de estudantes de enfermagem e direito.

University students' attitudes towards Voluntary Interruption of Pregnancy.

An evaluation of the future professional trends was performed by analyzing the attitudes of university students to the Voluntary Interruption of Pregnancy (VIP). An anonymous questionnaire was distributed to 300 students (Medicine, Nursing and Law) of the University of Santiago de Compostela, with questions on their personal beliefs, opinion on the law and intention to participate in VIP. Of the 245 respondents (response rate 82%), 66.5% were pro-abortion and their attitudes towards VIP were consistent with their opinion on the beginning of life and with the ethical arguments related to the fetus and the mother. No differences were found with age, sex or degree. The students showed to be well informed on the VIP law, and the majority of them considered unsuitable termination of pregnancy in minors without parental consent. Students' intentions to take part in abortion provision were influenced by their views on abortion, level of participation and circumstances of pregnancy. Although the majority of participants would be willing to perform VIP in situations that affect fetus and mother's life or health (87-66%), their intentions clearly diminished in other situations, such as abortion on demand (17%). These data suggest that conscientious objection of health professionals can even increase with the new policy, a fact that might affect VIP availability. It is important to stress the need of ethical training to help in the solution of conflicts between patient and health professional values.

PMICALC: an R code-based software for estimating post-mortem interval (PMI) compatible with Windows, Mac and Linux operating systems.

In legal medicine the correct determination of the time of death is of utmost importance. Recent advances in estimating post-mortem interval (PMI) have made use of vitreous humour chemistry in conjunction with Linear Regression, but the results are questionable. In this paper we present PMICALC, an R code-based freeware package which estimates PMI in cadavers of recent death by measuring the concentrations of potassium ([K+]), hypoxanthine ([Hx]) and urea ([U]) in the vitreous humor using two different regression models: Additive Models (AM) and Support Vector Machine (SVM), which offer more flexibility than the previously used Linear Regression. The results from both models are better than those published to date and can give numerical expression of PMI with confidence intervals and graphic support within 20 min. The program also takes into account the cause of death.

Molecular genetics of sudden cardiac death.

Sudden cardiac death (SCD) is one of the most common causes of death. An important number of sudden deaths, especially in the young, are due to genetic heart disorders, both with structural and arrhythmogenic abnormalities. In recent years, significant advances have been made in understanding the genetic basis of SCD. Identification of the genetic causes of sudden death is important because close relatives are also at potential risk of having a fatal cardiac condition. A comprehensive post-mortem investigation is vital to determine the cause and manner of death and provides the opportunity to assess the potential risk to the family after appropriate genetic counselling. In this paper, we present an update of the different genetic causes of sudden death, emphasizing their importance for the forensic pathologist due to his relevant role in the diagnosis and prevention of SCD.