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Riva N, Domi T, Pozzi L, Lunetta C, Schito P, Spinelli EG, Cabras S, Matteoni E, Consonni M, Bella ED, Agosta F, Filippi M, Calvo A, Quattrini A. Update on recent advances in amyotrophic lateral sclerosis. J Neurol 2024; 271:4693-4723. [PMID: 38802624 PMCID: PMC11233360 DOI: 10.1007/s00415-024-12435-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/07/2024] [Accepted: 05/09/2024] [Indexed: 05/29/2024]
Abstract
In the last few years, our understanding of disease molecular mechanisms underpinning ALS has advanced greatly, allowing the first steps in translating into clinical practice novel research findings, including gene therapy approaches. Similarly, the recent advent of assistive technologies has greatly improved the possibility of a more personalized approach to supportive and symptomatic care, in the context of an increasingly complex multidisciplinary line of actions, which remains the cornerstone of ALS management. Against this rapidly growing background, here we provide an comprehensive update on the most recent studies that have contributed towards our understanding of ALS pathogenesis, the latest results from clinical trials as well as the future directions for improving the clinical management of ALS patients.
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Affiliation(s)
- Nilo Riva
- 3Rd Neurology Unit and Motor Neuron Disease Centre, Fondazione IRCCS "Carlo Besta" Neurological Insitute, Milan, Italy.
| | - Teuta Domi
- Experimental Neuropathology Unit, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Laura Pozzi
- Experimental Neuropathology Unit, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Christian Lunetta
- Istituti Clinici Scientifici Maugeri IRCCS, Neurorehabilitation Unit of Milan Institute, 20138, Milan, Italy
| | - Paride Schito
- Experimental Neuropathology Unit, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Neurology, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Edoardo Gioele Spinelli
- Department of Neurology, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neuroimaging Research Unit, Department of Neurology, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sara Cabras
- ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin; SC Neurologia 1U, AOU città della Salute e della Scienza di Torino, Turin, Italy
| | - Enrico Matteoni
- ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin; SC Neurologia 1U, AOU città della Salute e della Scienza di Torino, Turin, Italy
| | - Monica Consonni
- 3Rd Neurology Unit and Motor Neuron Disease Centre, Fondazione IRCCS "Carlo Besta" Neurological Insitute, Milan, Italy
| | - Eleonora Dalla Bella
- 3Rd Neurology Unit and Motor Neuron Disease Centre, Fondazione IRCCS "Carlo Besta" Neurological Insitute, Milan, Italy
| | - Federica Agosta
- Department of Neurology, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neuroimaging Research Unit, Department of Neurology, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute Huniversity, Milan, Italy
| | - Massimo Filippi
- Department of Neurology, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neuroimaging Research Unit, Department of Neurology, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute Huniversity, Milan, Italy
| | - Andrea Calvo
- ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin; SC Neurologia 1U, AOU città della Salute e della Scienza di Torino, Turin, Italy
| | - Angelo Quattrini
- Experimental Neuropathology Unit, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Graustein A, Carmona H, Benditt JO. Noninvasive respiratory assistance as aid for respiratory care in neuromuscular disorders. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1152043. [PMID: 37275400 PMCID: PMC10233137 DOI: 10.3389/fresc.2023.1152043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/02/2023] [Indexed: 06/07/2023]
Abstract
Chronic respiratory failure is a common complication of neuromuscular disease. The use of noninvasive ventilation and mechanically assisted cough can reduce symptoms of hypoventilation, slow lung function decline, improve sleep quality, and in some cases prolong survival in patients with neuromuscular disease. In this article, we review indications for the initiation of noninvasive ventilation and mechanically assisted cough as well as provide recommendations for settings and titration. We discuss the evidence supporting the use of noninvasive ventilation as an adjunct to rehabilitation in patients with neuromuscular disease. Lastly, we review the ethical considerations that are relevant to decisions regarding initiation and cessation of noninvasive ventilation. While noninvasive ventilation and mechanically assisted cough have become standards of care in many forms of neuromuscular disease, most current recommendations are based on expert opinion rather than much-needed data from prospective clinical trials and we emphasize topics requiring future research.
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Affiliation(s)
- Andrew Graustein
- Division of Pulmonary, Critical Care and Sleep Medicine, United States Department of Veterans Affairs, VA Puget Sound Health Care System, Veterans Health Administration, Seattle, WA, United States
| | - Hugo Carmona
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, School of Medicine, University of Washington, Seattle, WA, United States
| | - Joshua O. Benditt
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, School of Medicine, University of Washington, Seattle, WA, United States
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Erdmann A, Spoden C, Hirschberg I, Neitzke G. Talking about the end of life: communication patterns in amyotrophic lateral sclerosis – a scoping review. Palliat Care Soc Pract 2022; 16:26323524221083676. [PMID: 35309870 PMCID: PMC8928370 DOI: 10.1177/26323524221083676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 02/04/2022] [Indexed: 11/26/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) leads to death on average 2–4 years after the onset of symptoms. Although many people with the disease decide in favour of life-sustaining measures, some consider hastening death. The objectives of this review are to provide an insight into the following questions: (1) How do people with amyotrophic lateral sclerosis (PALS), their families and health care professionals (HCPs) communicate about life-sustaining and life-shortening options? (2) What are the challenges for all involved in decision making and communication about this topic? To answer these questions, we searched eight databases for publications in English and German on end-of-life issues of PALS. We included texts published between 2008 and 2018, and updated our search to May 2020. Sources were analysed in MAXQDA using deductively and inductively generated codes. After the final analysis, 123 full texts were included in this review. We identified a wide range of communicative challenges and six different and, in part, opposite communication patterns: avoiding or delaying communication on end-of-life issues, openly considering dying and actively seeking assistance, ignoring or disregarding patients’ wishes, discussing and respecting the patients’ wishes, engaging in advance care planning and avoiding or delaying advance care planning. The literature reveals a very heterogeneous response to end-of-life issues in ALS, despite several good-practice suggestions, examples and guidelines. We derive a strong need for harmonization and quality assurance concerning communication with PALS. Avoiding or delaying communication, decision making and planning, as well as ignoring or disregarding the patient’s will by HCP can be judged as a violation of the ethical principles of autonomy and non-maleficence.
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Affiliation(s)
- Anke Erdmann
- Institute for Experimental Medicine, Medical Ethics Working Group, Kiel University, 24105 Kiel, Germany
- Institute for Ethics, History and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Celia Spoden
- German Institute for Japanese Studies, Tokyo, Japan
- Institute for Ethics, History and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Irene Hirschberg
- Institute for Ethics, History and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Gerald Neitzke
- Institute for Ethics, History and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
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Eichinger J, Elger BS, Koné I, Filges I, Shaw D, Zimmermann B, McLennan S. The full spectrum of ethical issues in pediatric genome-wide sequencing: a systematic qualitative review. BMC Pediatr 2021; 21:387. [PMID: 34488686 PMCID: PMC8420043 DOI: 10.1186/s12887-021-02830-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 08/11/2021] [Indexed: 11/10/2022] Open
Abstract
Background The use of genome-wide sequencing in pediatric medicine and research is growing exponentially. While this has many potential benefits, the normative and empirical literature has highlighted various ethical issues. There have not been, however, any systematic reviews of these issues. The aim of this systematic review is to determine systematically the spectrum of ethical issues that is raised for stakeholders in in pediatric genome-wide sequencing. Methods A systematic review in PubMed and Google Books (publications in English or German between 2004 and 2021) was conducted. Further references were identified via reference screening. Data were analyzed and synthesized using qualitative content analysis. Ethical issues were defined as arising when a relevant normative principle is not adequately considered or when two principles come into conflict. Results Our literature search retrieved 3175 publications of which 143 were included in the analysis. Together these mentioned 106 ethical issues in pediatric genome-wide sequencing, categorized into five themes along the pediatric genome-wide sequencing lifecycle. Most ethical issues identified in relation to genome-wide sequencing typically reflect ethical issues that arise in general genetic testing, but they are often amplified by the increased quantity of data obtained, and associated uncertainties. The most frequently discussed ethical aspects concern the issue of unsolicited findings. Conclusion Concentration of the debate on unsolicited findings risks overlooking other ethical challenges. An overarching difficulty presents the terminological confusion: both with regard to both the test procedure/ the scope of analysis, as well as with the topic of unsolicited findings. It is important that the genetics and ethics communities together with other medical professions involved work jointly on specific case related guidelines to grant the maximum benefit for the care of the children, while preventing patient harm and disproportionate overload of clinicians and the healthcare system by the wealth of available options and economic incentives to increase testing. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-02830-w.
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Affiliation(s)
- Johanna Eichinger
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland. .,Institute of History and Ethics in Medicine, Technical University of Munich, Munich, Germany.
| | - Bernice S Elger
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland.,Center for legal medicine (CURML), University of Geneva, Geneva, Switzerland
| | - Insa Koné
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
| | - Isabel Filges
- Medical Genetics, Institute of Medical Genetics and Pathology, University Hospital Basel and University of Basel, Basel, Switzerland.,Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - David Shaw
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland.,Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Bettina Zimmermann
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland.,Institute of History and Ethics in Medicine, Technical University of Munich, Munich, Germany
| | - Stuart McLennan
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland.,Institute of History and Ethics in Medicine, Technical University of Munich, Munich, Germany
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Erdmann A, Spoden C, Hirschberg I, Neitzke G. The wish to die and hastening death in amyotrophic lateral sclerosis: A scoping review. BMJ Support Palliat Care 2021; 11:271-287. [PMID: 33397660 PMCID: PMC8380909 DOI: 10.1136/bmjspcare-2020-002640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/05/2020] [Accepted: 11/18/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) develops into a life-threatening condition 2 to 4 years after the onset of symptoms. Although many people with the disease decide in favour of life-sustaining measures, thoughts about hastening death are not uncommon. OBJECTIVES Our aim was to examine the scope of literature on the wish to die in ALS and provide an insight into determinants and motives for different end-of-life options. METHODS We searched eight databases for English and German publications on death wishes in ALS for the period from 2008 to 2018 and updated the search up to May 2020. After the screening process, 213 full texts were included for the final analysis. We analysed the texts in MAXQDA, using deductively and inductively generated codes. RESULTS We identified end-of-life considerations, ranging from wishes to die without hastening death, to options with the possibility or intention of hastening death. Besides physical impairment, especially psychosocial factors, socio-demographic status and socio-cultural context have a great impact on decisions for life-shortening options. There is huge variation in the motives and determinants for end-of-life considerations between individuals, different societies, healthcare and legal systems. CONCLUSIONS For a variety of reasons, the information and counselling provided on different options for sustaining life or hastening death is often incomplete and insufficient. Since the motives and determinants for the wish to hasten death are extremely diverse, healthcare professionals should investigate the reasons, meaning and strength of the desire to die to detect unmet needs and examine which interventions are appropriate in each individual case.
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Affiliation(s)
- Anke Erdmann
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
- Institute for Experimental Medicine, Medical Ethics Working Group, Kiel University, Kiel, Germany
| | - Celia Spoden
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Irene Hirschberg
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Gerald Neitzke
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
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Mertz M. How to tackle the conundrum of quality appraisal in systematic reviews of normative literature/information? Analysing the problems of three possible strategies (translation of a German paper). BMC Med Ethics 2019; 20:81. [PMID: 31727134 PMCID: PMC6857152 DOI: 10.1186/s12910-019-0423-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 11/06/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the last years, there has been an increase in publication of systematic reviews of normative ("argument-based") literature or of normative information (such as ethical issues) in bioethics. The aim of a systematic review is to search, select, analyse and synthesise literature in a transparent and systematic way in order to provide a comprehensive and unbiased overview of the information sought, predominantly as a basis for informed decision-making in health care. Traditionally, one part of the procedure when conducting a systematic review is an appraisal of the quality of the literature that could be included. MAIN TEXT However, while there are established methods and standards for appraising e.g. clinical studies or other empirical research, quality appraisal of normative literature (or normative information) in the context of a systematic review is still rather a conundrum - not only is it unclear how it could or should be done, but also the question whether it necessarily must be done is not settled yet. Based on a pragmatic definition of "normative literature" as well as on a typology of different types of systematic reviews of normative literature/information, this paper identifies and critically discusses three possible strategies of conducting quality appraisal. CONCLUSIONS The paper will argue that none of the three strategies is able to provide a general and satisfying solution to the problems associated with quality appraisal of normative literature/information. Still, the discussion of the three strategies allows outlining minimal conditions that elaborated strategies have to meet in future, and facilitates sketching a theoretically and practically promising strategy.
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Affiliation(s)
- Marcel Mertz
- Working Group Research/Public Health Ethics & Methodology, Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany.
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Advance Directives of German People with Parkinson's Disease Are Unspecific in regard to Typical Complications. PARKINSONS DISEASE 2019; 2019:2107821. [PMID: 31482006 PMCID: PMC6701430 DOI: 10.1155/2019/2107821] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 07/16/2019] [Indexed: 12/15/2022]
Abstract
Parkinson's disease (PD) is a progressive neurodegenerative movement disorder with an increased morbidity and mortality. People with PD (PwP) may suffer from decreased quality of life due to various motor and nonmotor symptoms. To a huge proportion, PwP have written an advance directive (AD); however, the content of these forms in regard to PD-specific complications is unclear. The aim of this study was to qualitatively and quantitatively analyze ADs of PwP in Germany. ADs of PwP were analyzed in a German sample of members of the German PD patient association. Participants completed a questionnaire about their AD and sent a copy of their AD to the study center for detailed analyses. ADs were qualitatively and quantitatively analyzed for general and PD-specific aspects and usefulness concerning treatment decisions. 82 PwP were included in the study, and in 76, an AD could be analyzed. Family members, notaries, lawyers, and general physicians mainly counseled writing of the ADs. 4 PwP consulted a neurologist to establish a specific AD for PD. In the analysis, ADs displayed a good specificity for general aspects, but they were unspecific to PD in the vast majority of cases. PwP should be encouraged to create an AD early in their disease and adapt it in the course of the disease. PD-specific aspects for an AD could be details in relation to dopaminergic therapies at the end of life, management of non-oral advanced therapies, neuropsychiatric symptoms, dementia, and swallowing disturbances.
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Scull Torres M. La observancia de la bioética en el cuidado paliativo de enfermos con esclerosis lateral amiotrófica. PERSONA Y BIOÉTICA 2019. [DOI: 10.5294/pebi.2019.23.1.7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
La esclerosis lateral amiotrófica (ELA) es una enfermedad neurodegenerativa de etiología desconocida, curso progresivo y pronóstico desfavorable, para la cual no existe tratamiento curativo. Muchos son los profesionales de la salud involucrados en la atención de un paciente con ELA. El manejo apropiado de los problemas éticos es de gran importancia en todas las etapas de la ELA. Es objetivo del siguiente trabajo identificar las categorías éticas más vulneradas que atentan la calidad de la atención a estos pacientes. Se realizó una investigación cualitativa, observacional descriptiva longitudinal se empleó la observación participativa y se tomó como base el espectro completo de cuestiones éticas en la atención de pacientes con ELA. Como resultado se encontró cumplimiento incompleto del respeto al derecho del paciente a una información completa, poca consideración de las consecuencias de la información insuficiente, así como irrespeto por las preferencias de la persona enferma en el tratamiento de situaciones de emergencia. Las categorías más vulneradas por los profesionales de salud fueron: el proceso de toma de decisiones, la toma de decisiones al final de la vida y la indicación médica.
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Thurn T, Borasio GD, Chiò A, Galvin M, McDermott CJ, Mora G, Sermeus W, Winkler AS, Anneser J. Physicians' attitudes toward end-of-life decisions in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2019; 20:74-81. [PMID: 30789031 DOI: 10.1080/21678421.2018.1536154] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This study aims (1) to assess physicians' attitudes toward different palliative end-of-life (EOL) practices in amyotrophic lateral sclerosis (ALS) care, including forgoing artificial nutrition and hydration (FANH), continuous sedation until death (CSD), and withdrawing invasive ventilation (WIV), and toward physician-assisted dying (PAD) including physician-assisted suicide and euthanasia and (2) to explore variables influencing these attitudes. METHODS We used two clinical vignettes depicting ALS patients in different stages of their disease progression to assess the influence of suffering (physical/psycho-existential) on attitudes toward WIV and the influence of suffering and prognosis (short-term/long-term) on attitudes toward FANH, CSD, and PAD. RESULTS 50 physicians from European ALS centers and neurological departments completed our survey. Short-term prognosis had a positive impact on attitudes toward offering FANH (p = 0.014) and CSD (p = 0.048) as well as on attitudes toward performing CSD (p = 0.036) and euthanasia (p = 0.023). Predominantly psycho-existential suffering was associated with a more favorable attitude toward WIV but influenced attitudes toward performing CSD negatively. Regression analysis showed that religiosity was associated with more reluctant attitudes toward palliative EOL practices and PAD, whereas training in palliative care was associated with more favorable attitudes toward palliative EOL practices only. CONCLUSION ALS physicians seem to acknowledge psycho-existential suffering as a highly acceptable motive for WIV but not CSD. Physicians appear to be comfortable with responding to the patient's requests, but more reluctant to assume a proactive role in the decision-making process. Palliative care training may support ALS physicians in these challenging situations.
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Affiliation(s)
- Tamara Thurn
- a Palliative Care Team, Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar , Technical University Munich , Munich , Germany
| | - Gian Domenico Borasio
- b Palliative and Supportive Care Service, Centre Hospitalier Universitaire Vaudois (CHUV) , University of Lausanne , Lausanne , Switzerland
| | - Adriano Chiò
- c Department of Neuroscience "Rita Levi Montalcini" , University of Turin , Turin , Italy
| | - Miriam Galvin
- d Academic Unit of Neurology, Trinity Biomedical Sciences Institute , Trinity College Dublin , Dublin , Ireland
| | - Christopher J McDermott
- e Sheffield Institute for Translational Neuroscience , University of Sheffield , Sheffield , United Kingdom
| | | | - Walter Sermeus
- g Leuven Institute for Healthcare Policy , KU Leuven , Leuven , Belgium
| | - Andrea S Winkler
- h Department of Neurology, Klinikum rechts der Isar , Technical University Munich , Munich , Germany.,i Centre for Global Health, Institute of Health and Society , University of Oslo , Oslo , Norway
| | - Johanna Anneser
- a Palliative Care Team, Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar , Technical University Munich , Munich , Germany
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McLennan S, Kahrass H, Wieschowski S, Strech D, Langhof H. The spectrum of ethical issues in a Learning Health Care System: a systematic qualitative review. Int J Qual Health Care 2018; 30:161-168. [PMID: 29394354 DOI: 10.1093/intqhc/mzy005] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 01/08/2018] [Indexed: 02/06/2023] Open
Abstract
Purpose To determine systematically the spectrum of ethical issues that is raised for stakeholders in a 'Learning Health Care System' (LHCS). Data sources The systematic review was conducted in PubMed and Google Books between the years 2007 and 2015. Study selection The literature search retrieved 1258 publications. Each publication was independently screened by two reviewers for eligibility for inclusion. Ethical issues were defined as arising when a relevant normative principle is not adequately considered or two principles come into conflict. Data extraction A total of 65 publications were included in the final analysis and were analysed using an adapted version of qualitative content analysis. A coding frame was developed inductively from the data, only the highest-level categories were generated deductively for a life-cycle perspective. Results of data synthesis A total of 67 distinct ethical issues could be categorized under different phases of the LHCS life-cycle. An overarching theme that was repeatedly raised was the conflict between the current regulatory system and learning health care. Conclusion The implementation of a LHCS can help realize the ethical imperative to continuously improve the quality of health care. However, the implementation of a LHCS can also raise a number of important ethical issues itself. This review highlights the importance for health care leaders and policy makers to balance the need to protect and respect individual participants involved in learning health care activities with the social value of improving health care.
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Affiliation(s)
- Stuart McLennan
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, OE 5450, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.,Institute for Biomedical Ethics, Universität Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
| | - Hannes Kahrass
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, OE 5450, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Susanne Wieschowski
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, OE 5450, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Daniel Strech
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, OE 5450, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Holger Langhof
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, OE 5450, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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Hummel P, Saxena A, Klingler C. Rapid qualitative review of ethical issues surrounding healthcare for pregnant women or women of reproductive age in epidemic outbreaks. Epidemiol Health 2018; 40:e2018003. [PMID: 29370682 PMCID: PMC5900442 DOI: 10.4178/epih.e2018003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 01/23/2018] [Indexed: 11/16/2022] Open
Abstract
This article describes, categorizes, and discusses the results of a rapid literature review aiming to provide an overview of the ethical issues and corresponding solutions surrounding pregnancies in epidemic outbreaks. The review was commissioned by the World Health Organization to inform responses to the Zika outbreak that began in 2015. Due to the urgency of the response efforts that needed to be informed by the literature search, a rapid qualitative review of the literature published in PubMed was conducted. The search and analysis were based on the operationalization of 3 key concepts: ethics, pregnancy, and epidemic outbreak. Ethical issues and solutions were interpreted within a principlist framework. The data were analyzed using qualitative content analysis. The search identified 259 publications, of which the full text of 23 papers was read. Of those, 20 papers contained a substantive part devoted to the topic of interest and were therefore analyzed further. We clustered the ethical issues and solutions around 4 themes: uncertainty, harms, autonomy/liberty, and effectiveness. Recognition of the identified ethical issues and corresponding solutions can inform and improve response efforts, public health planning, policies, and decision-making, as well as the activities of medical staff and counselors who practice before, during, or after an epidemic outbreak that affects pregnant women or those of reproductive age. The rapid review format proved to be useful despite its limited data basis and expedited review process.
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Affiliation(s)
- Patrik Hummel
- Department of Philosophy, University of St Andrews, St Andrews, United Kingdom
| | - Abha Saxena
- Ethics and Knowledge, World Health Organization, Geneva, Switzerland
| | - Corinna Klingler
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
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What methods do reviews of normative ethics literature use for search, selection, analysis, and synthesis? In-depth results from a systematic review of reviews. Syst Rev 2017; 6:261. [PMID: 29258598 PMCID: PMC5738202 DOI: 10.1186/s13643-017-0661-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 12/06/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND (Semi-)systematic approaches to finding, analysing, and synthesising ethics literature on medical topics are still in their infancy. However, our recent systematic review showed that the rate of publication of such (semi-)systematic reviews has increased in the last two decades. This is not only true for reviews of empirical ethics literature, but also for reviews of normative ethics literature. In the latter case, there is currently little in the way of standards and guidance available. Therefore, the methods and reporting strategies of such reviews vary greatly. The purpose of the follow-up study we present was to obtain deeper methodological insight into the ways reviews of normative literature are actually conducted and to analyse the methods used. METHOD Our search in the PubMed, PhilPapers, and Google Scholar databases led to the identification of 183 reviews of ethics literature published between 1997 and 2015, of which 84 were identified as reviews of normative and mixed literature. Qualitative content analysis was used to extract and synthesise descriptions of search, selection, quality appraisal, analysis, and synthesis methods. We further assessed quantitatively how often certain methods (e.g. search strategies, data analysis procedures) were used by the reviews. RESULTS The overall reporting quality varies among the analysed reviews and was generally poor even for major criteria regarding the search and selection of literature. For example, only 24 (29%) used a PRISMA flowchart. Also, only 55 (66%) reviews mentioned the information unit they sought to extract, and 12 (14%) stated an ethical approach as the theoretical basis for the analysis. Interpretable information on the synthesis method was given by 47 (60%); the most common methods applied were qualitative methods commonly used in social science research (83%). CONCLUSION Reviews which fail to provide sufficient relevant information to readers have reduced methodological transparency regardless of actual methodological quality. In order to increase the internal validity (i.e. reproducibility) as well as the external validity (i.e. utility for the intended audience) of future reviews of normative literature, we suggest more accurate reporting regarding the goal of the review, the definition of the information unit, the ethical approach used, and technical aspects.
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Mertz M. [Quality appraisal in systematic reviews of normative literature. A problem analysis]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2017; 127-128:11-20. [PMID: 28863987 DOI: 10.1016/j.zefq.2017.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 07/14/2017] [Accepted: 07/18/2017] [Indexed: 11/17/2022]
Abstract
Systematic reviews aim at searching, selecting, analyzing and synthesizing scientific literature in a transparent and systematic way in order to inform decision-making in the health care system on the basis of the best available evidence. In recent years, such reviews have also gained importance also in bio-, public health- and research ethics, as well as in health technology assessment. Such reviews do not only analyze ethically relevant empirical literature (e.g. on risk and benefit), but normative literature as well, i.e. literature consisting of ethical arguments. As the appraisal of the literature that should be included is paramount for a systematic review, the problem of how to appraise the quality of normative literature arises. This problem has not yet been solved satisfactorily. After developing a pragmatic definition for "normative literature", a typology of different types of systematic reviews of normative literature is presented. Based on existing approaches for quality appraisal, this paper identifies three possible strategies for solving the problem of quality appraisal of normative literature, and discusses their respective strength and weaknesses relative to the different types of systematic reviews. It becomes apparent that none of the existing approaches is able to solve the problem of quality appraisal in a general and convincing way. The paper concludes with stating minimal conditions regarding the elaboration of future strategies, and outlines a promising strategy that is theoretically acceptable and practically feasible.
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Affiliation(s)
- Marcel Mertz
- Institut für Geschichte, Ethik und Philosophie der Medizin, Medizinische Hochschule Hannover, Hannover, Deutschland.
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Seekles W, Widdershoven G, Robben P, van Dalfsen G, Molewijk B. Inspectors' ethical challenges in health care regulation: a pilot study. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2017; 20:311-320. [PMID: 28130719 PMCID: PMC5569140 DOI: 10.1007/s11019-016-9736-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
There is an increasing body of research on what kind of ethical challenges health care professionals experience regarding the quality of care. In the Netherlands the Dutch Health Care Inspectorate is responsible for monitoring and regulating the quality of health care. No research exists on what kind of ethical challenges inspectors experience during the regulation process itself. In a pilot study we used moral case deliberation as method in order to reflect upon inspectors' ethical challenges. The objective of this paper is to give an overview of the ethical challenges which health care inspectors encounter in their daily work. A thematic qualitative analysis was performed on cases (n = 69) that were collected from health care inspectors in a moral case deliberation pilot study. Eight themes were identified in health care regulation. These can be divided in two categories: work content and internal collaboration. The work of the health care inspectorate is morally loaded and our recommendation is that some form of ethics support is provided for health care inspectors.
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Affiliation(s)
- W Seekles
- Medical Humanities, VU University Medical Centre (EMGO+), Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands.
- University of Humanistic Studies, Kromme Nieuwegracht 29, 3512 HD, Utrecht, The Netherlands.
| | - G Widdershoven
- Medical Humanities, VU University Medical Centre (EMGO+), Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
| | - P Robben
- The Health Care Inspectorate (IGZ), Stadsplateau 1, 3521 AZ, Utrecht, The Netherlands
| | - G van Dalfsen
- The Health Care Inspectorate (IGZ), Stadsplateau 1, 3521 AZ, Utrecht, The Netherlands
| | - B Molewijk
- Medical Humanities, VU University Medical Centre (EMGO+), Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
- Centre for Medical Ethics, HELSAM, University of Oslo, Forskningsveien 3A, 0373, Oslo, Norway
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Ethical issues in obesity prevention for school children: a systematic qualitative review. Int J Public Health 2017; 62:981-988. [PMID: 28801690 DOI: 10.1007/s00038-017-1027-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 07/22/2017] [Accepted: 07/29/2017] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Planning and conducting preventive measures against obesity for school children is beset with ethical issues which should be known to make well-informed decisions. The goal of this study was to provide a comprehensive spectrum of these ethical issues by means of a systematic review. In this context, the study also assesses the value of different search strategies for ethical literature in public health. METHODS Literature was searched in Medline, EBSCO and others. Three different search strategies with varied scopes were applied and their output was compared. Qualitative content analysis was used for extracting and categorizing ethical issues. RESULTS 109 publications (published from 1995 to 2015) were finally included. The qualitative analysis resulted in 60 potentially relevant ethical issues. The three search strategies showed substantial differences regarding their search results. CONCLUSIONS The presented spectrum provides an initial evidence base for dealing with ethical issues adequately. The findings of the study further suggest that a broader scope is more fruitful for systematic reviews on ethical issues in the field of public health.
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Klingler C, Silva DS, Schuermann C, Reis AA, Saxena A, Strech D. Ethical issues in public health surveillance: a systematic qualitative review. BMC Public Health 2017; 17:295. [PMID: 28376752 PMCID: PMC5381137 DOI: 10.1186/s12889-017-4200-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 03/23/2017] [Indexed: 11/30/2022] Open
Abstract
Background Public health surveillance is not ethically neutral and yet, ethics guidance and training for surveillance programmes is sparse. Development of ethics guidance should be based on comprehensive and transparently derived overviews of ethical issues and arguments. However, existing overviews on surveillance ethics are limited in scope and in how transparently they derived their results. Our objective was accordingly to provide an overview of ethical issues in public health surveillance; in addition, to list the arguments put forward with regards to arguably the most contested issue in surveillance, that is whether to obtain informed consent. Methods Ethical issues were defined based on principlism. We assumed an ethical issue to arise in surveillance when a relevant normative principle is not adequately considered or two principles come into conflict. We searched Pubmed and Google Books for relevant publications. We analysed and synthesized the data using qualitative content analysis. Results Our search strategy retrieved 525 references of which 83 were included in the analysis. We identified 86 distinct ethical issues arising in the different phases of the surveillance life-cycle. We further identified 20 distinct conditions that make it more or less justifiable to forego informed consent procedures. Conclusions This is the first systematic qualitative review of ethical issues in public health surveillance resulting in a comprehensive ethics matrix that can inform guidelines, reports, strategy papers, and educational material and raise awareness among practitioners. Electronic supplementary material The online version of this article (doi:10.1186/s12889-017-4200-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Corinna Klingler
- Institute of Ethics, History and Theory of Medicine at LMU Munich, Lessingstr. 2, 80336, Munich, Germany.
| | - Diego Steven Silva
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11008, 8888 University Drive, Burnaby, B.C, V5A 1S6, Canada.,Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Christopher Schuermann
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Andreas Alois Reis
- Global Health Ethics Unit, World Health Organization, Avenue Appia 20, Geneva, GE, 1211, Switzerland
| | - Abha Saxena
- Global Health Ethics Unit, World Health Organization, Avenue Appia 20, Geneva, GE, 1211, Switzerland
| | - Daniel Strech
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Riva N, Agosta F, Lunetta C, Filippi M, Quattrini A. Recent advances in amyotrophic lateral sclerosis. J Neurol 2016; 263:1241-54. [PMID: 27025851 PMCID: PMC4893385 DOI: 10.1007/s00415-016-8091-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 02/12/2016] [Indexed: 10/28/2022]
Abstract
ALS is a relentlessly progressive and fatal disease, with no curative therapies available to date. Symptomatic and palliative care, provided in a multidisciplinary context, still remains the cornerstone of ALS management. However, our understanding of the molecular mechanisms underlying the disease has advanced greatly over the past years, giving new hope for the development of novel diagnostic and therapeutic approaches. Here, we have reviewed the most recent studies that have contributed to improving both clinical management and our understanding of ALS pathogenesis.
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Affiliation(s)
- Nilo Riva
- Neuropathology Unit, INSPE and Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy.
| | - Federica Agosta
- Neuroimaging Research Unit, Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology, San Raffaele Scientific Institute, Milan, Italy
| | - Christian Lunetta
- NEuroMuscular Omnicentre (NEMO), Niguarda Ca Granda Hospital, Milan, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology, San Raffaele Scientific Institute, Milan, Italy
| | - Angelo Quattrini
- Neuropathology Unit, INSPE and Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology, San Raffaele Scientific Institute, Via Olgettina 48, 20132, Milan, Italy
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