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Cincidda C, Pizzoli SFM, Oliveri S, Guiddi P, Pravettoni G. Toward a new personalized psycho-social approach for the support of prostate cancer and their caregivers dyads: a pilot study. Front Med (Lausanne) 2024; 11:1356385. [PMID: 38646557 PMCID: PMC11027503 DOI: 10.3389/fmed.2024.1356385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/11/2024] [Indexed: 04/23/2024] Open
Abstract
Introduction Prostate cancer patients (PCP) often struggle with a significant emotional, physical, and social burden during the care-flow pathway. Noteworthy, PCP should not be considered a standalone patient, but someone who is connected with a relevant social environment and that is usually supported by a beloved one, the caregiver. The involvement of the caregivers through the care pathway might bring significant benefits both on the psychological and the treatment and decision-making side. The present pilot study aimed at preliminarily assessing quantitatively the psychological impact of a prostate cancer diagnosis on the degree of agreement of PCPs and their caregivers on medical decisions, coping resources and psychological distress levels. Methods 16 PCP and their caregivers were enrolled in the study and fulfilled a battery of standardized questionnaires. Results Results showed low concordance in decision making styles and preferences in patients and their caregivers and that the dyads showed similar depression symptoms levels. Relevant features of the psychological needs of the analyzed dyads, such as need for information and support, also emerged. Conclusion On the basis of these preliminary results, guidelines for the construction of tailored brief psychological support interventions for PCP dyads are provided.
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Affiliation(s)
- Clizia Cincidda
- Applied Research Division for Cognitive and Psychological Science, IEO European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | | | - Serena Oliveri
- Applied Research Division for Cognitive and Psychological Science, IEO European Institute of Oncology IRCCS, Milan, Italy
- “Aldo Ravelli” Center for Neurotechnology and Brain Therapeutics, Department of Health Science, DISS, University of Milan, Milan, Italy
- Neurological Clinic, ASST-Santi Paolo e Carlo, Milan, Italy
| | - Paolo Guiddi
- Applied Research Division for Cognitive and Psychological Science, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Gabriella Pravettoni
- Applied Research Division for Cognitive and Psychological Science, IEO European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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2
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Bower KL, Shilling DM, Bonnes SL, Shah A, Lawson CM, Collier BR, Whitehead PB. Ethical Implications of Nutrition Therapy at the End of Life. Curr Gastroenterol Rep 2023; 25:69-74. [PMID: 36862286 DOI: 10.1007/s11894-023-00862-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 03/03/2023]
Abstract
PURPOSE OF REVIEW Provide an evidence-based resource to inform ethically sound recommendations regarding end of life nutrition therapy. RECENT FINDINGS • Some patients with a reasonable performance status can temporarily benefit from medically administered nutrition and hydration(MANH) at the end of life. • MANH is contraindicated in advanced dementia. • MANH eventually becomes nonbeneficial or harmful in terms of survival, function, and comfort for all patients at end of life. • Shared decision-making is a practice based on relational autonomy, and the ethical gold standard in end of life decisions. A treatment should be offered if there is expectation of benefit, but clinicians are not obligated to offer non-beneficial treatments. A decision to proceed or not should be based on the patient's values and preferences, a discussion of all potential outcomes, prognosis for given outcomes taking into consideration disease trajectory and functional status, and physician guidance provided in the form of a recommendation.
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Affiliation(s)
- Katie L Bower
- Carilion Clinic, Department of Surgery, Virginia Tech Carilion School of Medicine, 1906 Belleview Ave., Roanoke, VA, 24014, USA. .,Carilion Clinic Palliative Medicine, Virginia Tech Carilion School of Medicine, 1906 Belleview Ave, Roanoke, VA, 24014, USA.
| | - Danielle M Shilling
- Mayo Clinic, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Sara L Bonnes
- Mayo Clinic, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Apeksha Shah
- Cooper University Health Care, Cooper Medical School of Rowan University Digestive Health Institute, Camden, NJ, USA
| | - Christy M Lawson
- Division of Trauma and Critical Care Surgery, Univeristy of Tennessee, Knoxville, TN, USA
| | - Bryan R Collier
- Carilion Clinic, Department of Surgery, Virginia Tech Carilion School of Medicine, 1906 Belleview Ave., Roanoke, VA, 24014, USA
| | - Phyllis B Whitehead
- Carilion Clinic Palliative Medicine, Virginia Tech Carilion School of Medicine, 1906 Belleview Ave, Roanoke, VA, 24014, USA
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van Beinum A, Murphy N, Weijer C, Gruben V, Sarti A, Hornby L, Dhanani S, Chandler J. Family experiences with non-therapeutic research on dying patients in the intensive care unit. JOURNAL OF MEDICAL ETHICS 2022; 48:845-851. [PMID: 34261806 DOI: 10.1136/medethics-2021-107311] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 06/29/2021] [Indexed: 05/20/2023]
Abstract
Experiences of substitute decision-makers with requests for consent to non-therapeutic research participation during the dying process, including to what degree such requests are perceived as burdensome, have not been well described. In this study, we explored the lived experiences of family members who consented to non-therapeutic research participation on behalf of an imminently dying patient.We interviewed 33 family members involved in surrogate research consent decisions for dying patients in intensive care. Non-therapeutic research involved continuous physiological monitoring of dying patients prior to and for 30 min following cessation of circulation. At some study centres participation involved installation of bedside computers. At one centre electroencephalogram monitoring was used with a subset of participants. Aside from additional monitoring, the research protocol did not involve deviations from usual end-of-life care.Thematic analysis of interviews suggests most family members did not perceive this minimal-risk, non-therapeutic study to affect their time with patients during the dying process, nor did they perceive research consent as an additional burden. In our analysis, consenting for participation in perimortem research offered families of the dying an opportunity to affirm the intrinsic value of patients' lives and contributions. This opportunity may be particularly important for families of patients who consented to organ donation but did not proceed to organ retrieval.Our work supports concerns that traditional models of informed consent fail to account for possible benefits and harms of perimortem research to surviving families. Further research into consent models which integrate patient and family perspectives is needed.
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Affiliation(s)
- Amanda van Beinum
- Critical Care Research, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
- Sociology and Anthropology, Carleton University Faculty of Arts and Social Sciences, Ottawa, Ontario, Canada
| | - Nick Murphy
- Philosophy, Western University, London, Ontario, Canada
| | - Charles Weijer
- Philosophy, Western University Faculty of Arts and Humanities, London, Ontario, Canada
- Medicine, Epidemiology and Biostatistics, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Vanessa Gruben
- Common Law, University of Ottawa Faculty of Law, Ottawa, Ontario, Canada
| | - Aimee Sarti
- Medicine, Ottawa Hospital General Campus, Ottawa, Ontario, Canada
- Critical Care Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | - Laura Hornby
- Critical Care Research, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
- Deceased Donation, Canadian Blood Services Organ Donation and Transplantation, Ottawa, Ontario, Canada
| | - Sonny Dhanani
- Critical Care Research, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
- Division of Pediatric Critical Care, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Jennifer Chandler
- Common Law, University of Ottawa Faculty of Law, Ottawa, Ontario, Canada
- Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
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Jöbges S, Denke C, Seidlein AH. Optimierung der Zugehörigenbetreuung – angehörigenzentrierte Intensivmedizin. Med Klin Intensivmed Notfmed 2022; 117:575-583. [DOI: 10.1007/s00063-022-00964-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/29/2022] [Accepted: 08/18/2022] [Indexed: 12/01/2022]
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5
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Langer T, Depalo FC, Forlini C, Landini S, Mezzetti A, Previtali P, Monti G, de Toma C, Biscardi D, Giannini A, Fumagalli R, Mistraletti G. Communication and visiting policies in Italian intensive care units during the first COVID-19 pandemic wave and lockdown: a nationwide survey. BMC Anesthesiol 2022; 22:187. [PMID: 35710331 PMCID: PMC9203262 DOI: 10.1186/s12871-022-01726-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 06/09/2022] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND During the first coronavirus disease 2019 (COVID-19) pandemic wave, an unprecedented number of patients with respiratory failure due to a new, highly contagious virus needed hospitalization and intensive care unit (ICU) admission. The aim of the present study was to describe the communication and visiting policies of Italian intensive care units (ICUs) during the first COVID-19 pandemic wave and national lockdown and compare these data with prepandemic conditions. METHODS A national web-based survey was conducted among 290 Italian hospitals. Each ICU (active between February 24 and May 31, 2020) was encouraged to complete an individual questionnaire inquiring the hospital/ICU structure/organization, communication/visiting habits and the role of clinical psychology prior to, and during the first COVID-19 pandemic wave. RESULTS Two hundred and nine ICUs from 154 hospitals (53% of the contacted hospitals) completed the survey (202 adult and 7 pediatric ICUs). Among adult ICUs, 60% were dedicated to COVID-19 patients, 21% were dedicated to patients without COVID-19 and 19% were dedicated to both categories (Mixed). A total of 11,102 adult patients were admitted to the participating ICUs during the study period and only approximately 6% of patients received at least one visit. Communication with family members was guaranteed daily through an increased use of electronic devices and was preferentially addressed to the same family member. Compared to the prepandemic period, clinical psychologists supported physicians more often regarding communication with family members. Fewer patients received at least one visit from family members in COVID and mixed-ICUs than in non-COVID ICUs, l (0 [0-6]%, 0 [0-4]% and 11 [2-25]%, respectively, p < 0.001). Habits of pediatric ICUs were less affected by the pandemic. CONCLUSIONS Visiting policies of Italian ICUs dedicated to adult patients were markedly altered during the first COVID-19 wave. Remote communication was widely adopted as a surrogate for family meetings. New strategies to favor a family-centered approach during the current and future pandemics are warranted.
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Affiliation(s)
- Thomas Langer
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Francesca Carmela Depalo
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Clarissa Forlini
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Silvia Landini
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | | | - Paola Previtali
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Gianpaola Monti
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - Carolina de Toma
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
| | - Davide Biscardi
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
| | - Alberto Giannini
- Unit of Pediatric Anesthesia and Intensive Care, Children's Hospital, ASST Spedali Civili, Brescia, Italy
| | - Roberto Fumagalli
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy. .,Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy.
| | - Giovanni Mistraletti
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Jöbges S, Kumpf O, Hartog CS, Spies C, Haase U, Balzer F, Krampe H, Denke C. Presentation of ethical criteria during medical decision-making for critically ill patients: a mixed methods study. BJA OPEN 2022; 2:100015. [PMID: 37588268 PMCID: PMC10430832 DOI: 10.1016/j.bjao.2022.100015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/22/2022] [Indexed: 08/18/2023]
Abstract
Background Every medical decision is based on balancing medical knowledge, ethical considerations, and patient preferences. Previous surveys have mainly covered the ethical knowledge of medical staff. The aim of this study is to evaluate the feasibility of an innovative concept regarding how ethical criteria are applied to clinical decision-making during critical illness. Methods An online survey including a short case vignette was carried out at a university hospital among physicians specialising in intensive care medicine in Germany. After free text responses regarding further required case information, the participants were asked to rank decision criteria during the course of the case vignette. A qualitative evaluation was performed by two independent investigators, based on a transcription into categories. This was followed by a quantitative analysis of ranked criteria. Results Our analysis has shown that doctors are initially inclined to consider medical information when making treatment decisions. When complications occur, ethical values are more often included in the decision-making. The qualitative evaluation reveiled that the patient's will was consistently regarded as the leading criterion for decision-making. In the quantitative evaluation, patient's well-being, quality of life, and patient autonomy were rated as the most important decision criteria. Economic factors were ranked least important. Conclusion A mixed methods approach is able to reflect the complexity of ethical reasoning within the medical decision-making process, suggesting the feasibility of this concept. Clinical trial registration The study was registered under DRKS-ID: DKRS00011905 (April 2017).
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Affiliation(s)
- Susanne Jöbges
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Department of Anaesthesiology, Surgical Intensive Care, Pain and Palliative Medicine, Hospital Dortmund, University Hospital Witten Herdecke, Dortmund, Germany
| | - Oliver Kumpf
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Christiane S. Hartog
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Claudia Spies
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Ulrike Haase
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Felix Balzer
- Institute of Medical Informatics, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Henning Krampe
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Claudia Denke
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
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7
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Jöbges S, Mouton Dorey C, Porz R, Ricou B, Biller-Andorno N. What does coercion in intensive care mean for patients and their relatives? A thematic qualitative study. BMC Med Ethics 2022; 23:9. [PMID: 35120515 PMCID: PMC8817558 DOI: 10.1186/s12910-022-00748-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 01/21/2022] [Indexed: 01/10/2023] Open
Abstract
Background The need for an ethical debate about the use of coercion in intensive care units (ICU) may not be as obvious as in other areas of medicine, such as psychiatry. Coercive measures are often necessary to treat critically ill patients in the ICU. It is nevertheless important to keep these measures to a minimum in order to respect the dignity of patients and the cohesion of the clinical team. A deeper understanding of what patients and their relatives perceive during their ICU stay will shed different light on intensive care management. Patients' experiences of loss of control, dependency and abandonment may lead to a new approach towards a broader approach to the concept of coercion in intensive care. The aim of our research is to explore the experiences of patients and relatives in the ICU and to determine when it might be possible to reduce feelings and memories of coercion. Methods We conducted and analysed 29 semi-structured interviews with patients and relatives who had been in the ICU a few months previously. Following a coding and categorisation process in MAXQDA™, a rigorous qualitative methodology was used to identify themes relevant to our research. Results Five main themes emerged: memory issues; interviewees’ experiences of restricting measures and coercive treatment; patients’ negative perception of situational and relational dependency with the risk of informal coercion; patients’ perceptions of good care in a context of perceived dependency; progression from perception of coercion and dependency to respect for the person. All patients were grateful to have survived. However, coercion in the form of restraint, restriction of movement, and coercive treatment in the ICU was also acknowledged by patients and relatives. These included elements of informal coercion beyond restraints, such as a perceived negative sense of dependence, surrender, and asymmetrical interaction between the patient and health providers. Conclusions To capture the full range of patients' experiences of coercion, it is necessary to expand the concept of coercion to include less obvious forms of informal coercion that may occur in dependency situations. This will help identify solutions to avoid or reduce negative recollections that may persist long after discharge and negatively affect the patients' quality of life. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-022-00748-1.
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Affiliation(s)
- Susanne Jöbges
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, 8006, Zurich, Switzerland.
| | - Corine Mouton Dorey
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, 8006, Zurich, Switzerland
| | - Rouven Porz
- University Hospital Bern, 3010, FreiburgstrasseBern, Switzerland
| | - Bara Ricou
- Department of Anaesthesiology, Clinical Pharmacology, Intensive Care, and Emergency Medicine, University Hospital of Geneva, 1211, Geneva, Switzerland
| | - Nicola Biller-Andorno
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, 8006, Zurich, Switzerland
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Michalsen A, Neitzke G, Dutzmann J, Rogge A, Seidlein AH, Jöbges S, Burchardi H, Hartog C, Nauck F, Salomon F, Duttge G, Michels G, Knochel K, Meier S, Gretenkort P, Janssens U. [Overtreatment in intensive care medicine-recognition, designation, and avoidance : Position paper of the Ethics Section of the DIVI and the Ethics section of the DGIIN]. Med Klin Intensivmed Notfmed 2021; 116:281-294. [PMID: 33646332 PMCID: PMC7919250 DOI: 10.1007/s00063-021-00794-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 11/28/2022]
Abstract
Ungeachtet der sozialgesetzlichen Vorgaben existieren im deutschen Gesundheitssystem in der Patientenversorgung nebeneinander Unter‑, Fehl- und Überversorgung. Überversorgung bezeichnet diagnostische und therapeutische Maßnahmen, die nicht angemessen sind, da sie die Lebensdauer oder Lebensqualität der Patienten nicht verbessern, mehr Schaden als Nutzen verursachen und/oder von den Patienten nicht gewollt werden. Daraus können hohe Belastungen für die Patienten, deren Familien, die Behandlungsteams und die Gesellschaft resultieren. Dieses Positionspapier erläutert Ursachen von Überversorgung in der Intensivmedizin und gibt differenzierte Empfehlungen zu ihrer Erkennung und Vermeidung. Zur Erkennung und Vermeidung von Überversorgung in der Intensivmedizin erfordert es Maßnahmen auf der Mikro‑, Meso- und Makroebene, insbesondere die folgenden: 1) regelmäßige Evaluierung des Therapieziels im Behandlungsteam unter Berücksichtigung des Patientenwillens und unter Begleitung von Patienten und Angehörigen; 2) Förderung einer patientenzentrierten Unternehmenskultur im Krankenhaus mit Vorrang einer qualitativ hochwertigen Patientenversorgung; 3) Minimierung von Fehlanreizen im Krankenhausfinanzierungssystem gestützt auf die notwendige Reformierung des fallpauschalbasierten Vergütungssystems; 4) Stärkung der interdisziplinären/interprofessionellen Zusammenarbeit in Aus‑, Fort- und Weiterbildung; 5) Initiierung und Begleitung eines gesellschaftlichen Diskurses zur Überversorgung.
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Affiliation(s)
- Andrej Michalsen
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinikum Konstanz, Konstanz, Deutschland
| | - Gerald Neitzke
- Institut für Geschichte, Ethik und Philosophie der Medizin, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Jochen Dutzmann
- Universitätsklinik und Poliklinik für Innere Medizin III, Universitätsklinikum Halle (Saale), Halle (Saale), Deutschland
| | - Annette Rogge
- Geschäftsbereichs der Medizinethik, Christian-Albrechts-Universität zu Kiel, Kiel, Deutschland
| | - Anna-Henrikje Seidlein
- Institut für Ethik und Geschichte der Medizin, Universitätsmedizin Greifswald, Greifswald, Deutschland
| | - Susanne Jöbges
- Institut für Biomedizinische Ethik und Geschichte der Medizin, Universität Zürich, Zürich, Schweiz
| | | | - Christiane Hartog
- Klinik für Anästhesiologie und Intensivmedizin, Charité Universitätsmedizin Berlin, Berlin, Deutschland.,Patienten- und Angehörigenzentrierte Versorgung (PAV), Klinik Bavaria, Kreischa, Deutschland
| | - Friedemann Nauck
- Klinik für Palliativmedizin, Georg-August-Universität Göttingen, Göttingen, Deutschland
| | | | - Gunnar Duttge
- Abteilung für strafrechtliches Medizin- und Biorecht, Georg-August-Universität Göttingen, Göttingen, Deutschland
| | - Guido Michels
- Klinik für Akut- und Notfallmedizin, St.-Antonius-Hospital Eschweiler, Eschweiler, Deutschland
| | - Kathrin Knochel
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital Kinderpalliativzentrum, Klinikum der Universität München, München, Deutschland.,Ethik der Medizin und Gesundheitstechnologie, Technische Universität München, München, Deutschland
| | - Stefan Meier
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - Peter Gretenkort
- Simulations- und Notfallakademie, Helios Klinikum Krefeld, Krefeld, Deutschland
| | - Uwe Janssens
- Klinik für Innere Medizin und Internistische Intensivmedizin, St.-Antonius-Hospital Eschweiler, Dechant-Deckers-Str. 8, 52249, Eschweiler, Deutschland.
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Gómez-Vírseda C, de Maeseneer Y, Gastmans C. Relational autonomy in end-of-life care ethics: a contextualized approach to real-life complexities. BMC Med Ethics 2020; 21:50. [PMID: 32605569 PMCID: PMC7325052 DOI: 10.1186/s12910-020-00495-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 06/23/2020] [Indexed: 12/24/2022] Open
Abstract
Background Respect for autonomy is a paramount principle in end-of-life ethics. Nevertheless, empirical studies show that decision-making, exclusively focused on the individual exercise of autonomy fails to align well with patients’ preferences at the end of life. The need for a more contextualized approach that meets real-life complexities experienced in end-of-life practices has been repeatedly advocated. In this regard, the notion of ‘relational autonomy’ may be a suitable alternative approach. Relational autonomy has even been advanced as a foundational notion of palliative care, shared decision-making, and advance-care planning. However, relational autonomy in end-of-life care is far from being clearly conceptualized or practically operationalized. Main body Here, we develop a relational account of autonomy in end-of-life care, one based on a dialogue between lived reality and conceptual thinking. We first show that the complexities of autonomy as experienced by patients and caregivers in end-of-life practices are inadequately acknowledged. Second, we critically reflect on how engaging a notion of relational autonomy can be an adequate answer to addressing these complexities. Our proposal brings into dialogue different ethical perspectives and incorporates multidimensional, socially embedded, scalar, and temporal aspects of relational theories of autonomy. We start our reflection with a case in end-of-life care, which we use as an illustration throughout our analysis. Conclusion This article develops a relational account of autonomy, which responds to major shortcomings uncovered in the mainstream interpretation of this principle and which can be applied to end-of-life care practices.
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Affiliation(s)
- Carlos Gómez-Vírseda
- Centre for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35/3, 3000, Leuven, Belgium.
| | - Yves de Maeseneer
- Faculty of Theology and Religious Studies (Theological and Comparative Ethics), KU Leuven, Sint-Michielsstraat 4 - box 3101, B-3000, Leuven, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35 blok d - box 7001, 3000, Leuven, Belgium
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The patient with severe traumatic brain injury: clinical decision-making: the first 60 min and beyond. Curr Opin Crit Care 2020; 25:622-629. [PMID: 31574013 DOI: 10.1097/mcc.0000000000000671] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW There is an urgent need to discuss the uncertainties and paradoxes in clinical decision-making after severe traumatic brain injury (s-TBI). This could improve transparency, reduce variability of practice and enhance shared decision-making with proxies. RECENT FINDINGS Clinical decision-making on initiation, continuation and discontinuation of medical treatment may encompass substantial consequences as well as lead to presumed patient benefits. Such decisions, unfortunately, often lack transparency and may be controversial in nature. The very process of decision-making is frequently characterized by both a lack of objective criteria and the absence of validated prognostic models that could predict relevant outcome measures, such as long-term quality and satisfaction with life. In practice, while treatment-limiting decisions are often made in patients during the acute phase immediately after s-TBI, other such severely injured TBI patients have been managed with continued aggressive medical care, and surgical or other procedural interventions have been undertaken in the context of pursuing a more favorable patient outcome. Given this spectrum of care offered to identical patient cohorts, there is clearly a need to identify and decrease existing selectivity, and better ascertain the objective criteria helpful towards more consistent decision-making and thereby reduce the impact of subjective valuations of predicted patient outcome. SUMMARY Recent efforts by multiple medical groups have contributed to reduce uncertainty and to improve care and outcome along the entire chain of care. Although an unlimited endeavor for sustaining life seems unrealistic, treatment-limiting decisions should not deprive patients of a chance on achieving an outcome they would have considered acceptable.
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Relational autonomy: what does it mean and how is it used in end-of-life care? A systematic review of argument-based ethics literature. BMC Med Ethics 2019; 20:76. [PMID: 31655573 PMCID: PMC6815421 DOI: 10.1186/s12910-019-0417-3] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/10/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Respect for autonomy is a key concept in contemporary bioethics and end-of-life ethics in particular. Despite this status, an individualistic interpretation of autonomy is being challenged from the perspective of different theoretical traditions. Many authors claim that the principle of respect for autonomy needs to be reconceptualised starting from a relational viewpoint. Along these lines, the notion of relational autonomy is attracting increasing attention in medical ethics. Yet, others argue that relational autonomy needs further clarification in order to be adequately operationalised for medical practice. To this end, we examined the meaning, foundations, and uses of relational autonomy in the specific literature of end-of-life care ethics. METHODS Using PRESS and PRISMA procedures, we conducted a systematic review of argument-based ethics publications in 8 major databases of biomedical, philosophy, and theology literature that focused on relational autonomy in end-of-life care. Full articles were screened. All included articles were critically appraised, and a synthesis was produced. RESULTS Fifty publications met our inclusion criteria. Twenty-eight articles were published in the last 5 years; publications were originating from 18 different countries. Results are organized according to: (a) an individualistic interpretation of autonomy; (b) critiques of this individualistic interpretation of autonomy; (c) relational autonomy as theoretically conceptualised; (d) relational autonomy as applied to clinical practice and moral judgment in end-of-life situations. CONCLUSIONS Three main conclusions were reached. First, literature on relational autonomy tends to be more a 'reaction against' an individualistic interpretation of autonomy rather than be a positive concept itself. Dichotomic thinking can be overcome by a deeper development of the philosophical foundations of autonomy. Second, relational autonomy is a rich and complex concept, formulated in complementary ways from different philosophical sources. New dialogue among traditionally divergent standpoints will clarify the meaning. Third, our analysis stresses the need for dialogical developments in decision making in end-of-life situations. Integration of these three elements will likely lead to a clearer conceptualisation of relational autonomy in end-of-life care ethics. This should in turn lead to better decision-making in real-life situations.
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Vergano M, Naretto G, Elia F, Gandolfo E, Calliera CN, Gristina GR. ELS (Ethical Life Support): a new teaching tool for medical ethics. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:204. [PMID: 31171017 PMCID: PMC6554903 DOI: 10.1186/s13054-019-2474-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 05/13/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Marco Vergano
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, P.za del Donatore di Sangue, 3, 10154, Turin, Italy. .,Bioethics Working Group, Italian Society of Anesthesia and Intensive Care Medicine (SIAARTI), Rome, Italy.
| | - Giuseppe Naretto
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, P.za del Donatore di Sangue, 3, 10154, Turin, Italy.,Bioethics Working Group, Italian Society of Anesthesia and Intensive Care Medicine (SIAARTI), Rome, Italy
| | - Fabrizio Elia
- High Dependency Unit, San Giovanni Bosco Hospital, Turin, Italy
| | | | - Chiara Nebris Calliera
- Department of Public Health and Pediatrics, School of Nursing, University of Turin, Turin, Italy
| | - Giuseppe R Gristina
- Ethics Committee, Italian Society of Anesthesia and Intensive Care Medicine (SIAARTI), Rome, Italy
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