Quality of reporting on the vegetative state in Italian newspapers. The case of Eluana Englaro

Regulating liminality: Making sense of the vegetative state and defining the limits of end-of-life action

Persistently alive but unaware, vegetative state patients are stuck in the transition between life and death - that is, in a liminal hotspot. This condition raises complex ethical and legal dilemmas concerning end-of-life action. Drawing on social representations (SRs) and the liminality framework, our research investigated how the vegetative state was constructed within the Italian parliamentary debates discussing end-of-life bills (2009-2017). We aimed to understand (1) how political groups represented the vegetative state, (2) how they legitimised different end-of-life bills and (3) came to terms with the issue of liminal hotspots. By dialogically analysing three debates (No. of interventions = 98), we identified six themes and discursive aims allowing parliamentarians to differently represent the vegetative state and support different courses of action. In turn, we identified new features of the psycho-social processes generating SRs: the dialogical tensions between anchoring and de-anchoring. Results corroborated the idea that de-paradoxifying liminality relies on group sense-making and, thus, different political leanings differently addressed the liminality of the vegetative state. We also reveal a novel feature of dealing with liminal hotspots informing the psycho-social literature that applies when a decision needs to be taken, such as in the case of crafting a law: moving from the paradox.

Portrayals of narcolepsy from 1980 to 2020: a descriptive analysis of stigmatizing content in newspaper articles

STUDY OBJECTIVES

The media are the primary source of information about health for the public. The media portrayal of narcolepsy might contribute to the stigmatization of people affected by this condition. This study aimed to describe how narcolepsy is portrayed in newspapers.

METHODS

We collected 257 newspaper articles from the digital archive of "La Stampa" published between 1980 and 2020 that mentioned key search terms. The content was assessed using an ad-hoc coding schema developed to evaluate the presence of sensationalistic title, negative language, stigmatizing content, stereotypical description, disclosure of a person diagnosed with narcolepsy, person with narcolepsy described as dangerous, presence of an accurate diagnosis, identifiable symptoms, indications about diagnostic and treatment services. The Chi-squared analysis was performed to identify changes over time in the type of content.

RESULTS

In 10.9% of the articles, there was a sensationalistic title; inappropriate, negative, and outdated language appeared in 10.5% of the articles. Stigmatizing and stereotypical content were reported in 19.5% and 14.8% of the articles, respectively. In 62.3% of the articles, it was disclosed that a person has narcolepsy, and in 5.1% of the articles patients with narcolepsy are described as dangerous. 30.4% of the articles referred to the presence of an accurate diagnosis, while 16.7% described identifiable symptoms. Services for diagnosis and treatment were mentioned in 24.1% of the articles. Changes over time in the content of articles are discussed.

CONCLUSIONS

Our findings highlight areas for improvement in the media portrayal of narcolepsy and could help guide the development of new targeted antistigma campaigns.

Development and Validation of a Questionnaire investigating the Knowledge, Attitudes and Practices of Healthcare Workers in the Field of Anesthesiology concerning the Italian Law on Advance Healthcare Directives: a Pilot Study

Advance healthcare directives are legal documents, in which the patient, foreseeing a potential loss of capacity and autonomy, makes in advance decisions regarding future care and, in particular, end-of-life arrangements. In Italy, advance healthcare directives  are regulated by the Law 219 of 22 December 2017. Objectives of the study were: i) to develop and validate a questionnaire dedicated to evaluate the knowledge of the Law in a sample of 98 anesthesiologists, and ii) to shed light on the process of health-related decision-making and its determinants (age, gender, doctor/training resident, religious beliefs). A second part of the survey  not analyzed  in the present study, aimed to assess, through two simulated clinical scenarios, how patient' directives, relatives and the medical staff could influence physicians' clinical decision. Overall Cronbach's alpha coefficient of the questionnaire resulted 0.83. Three factors explaining up to 38.4% of total variance (communication and relationship with the patient; critical life-threatening situations and binding nature of the advance directive for the physician; and involvement of patients). Most of the doctors (58.7%) did not fully know the recent legislative provision. The lack of knowledge is critical in view of the specificity of the clinical area investigated (anesthesiology and intensive care), which has to cope with ethical issues. An adequate revision and implementation of the traditional curricula could help medical students and trainees develop the aptitudes and skills needed in their future profession.

Analyzing the paradigmatic cases of two persons with a disorder of consciousness: reflections on the legal and ethical perspectives

BACKGROUND

Media have increasingly reported on the difficulties associated with end-of-life decision-making in patients with Disorders of Consciousness (DOC), contextualizing such dilemma in detailed accounts of the patient's life. Two of the first stories debated in the scientific community were those related to the cases of two women, one American, the other Italian, who captured attention of millions of people in the first years of this third millennium.

METHODS

Much has been written about the challenges of surrogate decision-making for patients in DOC, but less has been written comparing these challenges across legal systems and cultures. In our paper, we propose a systematic analysis of the final legal documents written by the American and Italian Courts in relation to the two cases, developing our discussion around three areas: the level of certainty/reliability of diagnosis and prognosis, the reconstruction of self-expression, time of illness and time of care. They are examples of the typical issues discussed by legal authors and allow us to understand the link and the difference between the legal and ethical perspectives.

RESULTS

The legal approach to the two cases has some common elements: the need to be certain about the diagnosis and prognosis and the fact that the clinical criteria are necessary in determining the most appropriate treatments, although these criteria are not sufficient unless they are supplemented by the patient's will. The issue of relations takes on importance both from a legal and an ethical point of view, but from two different perspectives. While ethics safeguards relationships by guaranteeing their differences and makes them reconcilable, law safeguards relationships by guaranteeing the cold forms of respect, equality, impartiality, symmetry, reciprocity, and irreversibility. In this perspective, the link between the time of care and the decision of the family members assumes importance.

CONCLUSIONS

The most interesting point that emerges from our analysis is the issue of relationships and how they affect decisions, both from a legal and ethical point of view. For this reason, during the patients' hospitalization, it is necessary to identify ways in which they might give their opinion about the moral issues underlying their choices.

Knowledge, Opinion, and Attitude About the Italian Law on Advance Directives: A Population-Based Survey

CONTEXT

Advance directives are legal documents which individuals draw up to declare their treatment preferences and to appoint well-informed proxies to safeguard patient autonomy in critical situations when that individual is temporarily or no longer able to communicate these preferences. On December 22, 2017, the Italian Parliament approved the first law on end of life ("Provisions for informed consent and advance directives" L.219/2017), after a heated public and political debate lasting almost 20 years.

OBJECTIVE

The aim of this study was to investigate the awareness, knowledge, opinions, and attitudes regarding Italian Law 219/2017 and advance directives among the Italian population 15 months after its entry into force.

METHODS

A nationwide population-based survey was conducted by a certified public opinion survey company. A sample size of 2000 interviews was planned. A structured questionnaire was developed to investigate awareness, opinions, and attitudes concerning the law by a multiprofessional research team. The agreed-on version was pretested on a sample of 70 selected participants.

RESULTS

The sample included 2000 valid interviews; 70.1% of respondents declared they had heard about the law on informed consent and advance directives. Respondents were asked to express their overall opinion on the law's utility and importance: 88% declared that the law was quite or very important and 76% had a positive attitude toward making/registering advance directives.

CONCLUSION

The principles of Italian Law 219/2017 are aligned with the ethical sentiment of the vast majority of the Italian population. It is crucial to stimulate discussion to increase knowledge and awareness to increase the number of advance directives.

Longitudinal changes in functioning and disability in patients with disorders of consciousness: the importance of environmental factors

Disorders of consciousness are neurological conditions associated with low levels of functioning which pose a serious challenge to public health systems. The current study aimed to examine longitudinal changes in functioning in patients with disorders of consciousness and to identify associated biopsychosocial factors using the International Classification of Functioning, Disability, and Health. An Italian sample of 248 patients was assessed longitudinally. Differences in relative variability (an index of change that controls for baseline levels) between acute and chronic patients and predictors of relative variability in "Activities & Participation" were examined. Results showed that there were subgroups of patients whose functioning improved over time. The number of problems in "Activities & Participation" decreased in acute patients over time, whereas in chronic patients, an increase was found. The significant difference in relative variability for the environmental factor "support and relationships" reflects the increase in facilitators in acute patients, whereas the number of facilitators in chronic patients remained unchanged over time. Age at event, time from event, and relative variability in "Environmental Factors" were significant predictors of relative variability in "Activities & Participation". It is of clinical relevance that patients with disorders of consciousness are kept in a supportive and facilitative environment, in order to prevent a decline in their functioning. Moreover, caregivers should receive tailored support in order to enhance and facilitate appropriate care of patients with disorders of consciousness.

Reporting consciousness in coma: media framing of neuro-scientific research, hope, and the response of families with relatives in vegetative and minimally conscious states

This paper examines the public representation of, and family responses to, scientific studies into consciousness in coma-like states. We examine the publicity surrounding high-profile studies using functional Magnetic Resonance Imaging (fMRI) on 'vegetative' or 'minimally conscious' patients and compare this with family views. Our findings show how, with a few notable exceptions, the research was presented as an amazing breakthrough offering a potential 'voice' and choice for patients and hope and comfort for their families. We argue that such representations ignored key limitations, evoked unrealistic visions of recovery, and promoted very narrow representations of family reactions. The comparison between public representations of the science and responses from families with experience of this issue highlights the complex social/medical world into which neurotechnologies intervene, and points to the absence of a range of patient/family perspectives in public discourse. We conclude with suggestions for how those promoting the research, and the journalists reporting its implications, could act to ensure more responsible coverage and enhance public debate.

Disorders of consciousness: responding to requests for novel diagnostic and therapeutic interventions

Severe brain injury can leave patients with chronic disorders of consciousness. Because of impaired responsiveness, many of these patients have traditionally been regarded as unaware. However, findings from recent clinical studies herald a potential paradigm shift: functional imaging and neurophysiological studies have identified ways to assess awareness and have revealed astounding cases of awareness despite clinical unresponsiveness. Hence, diagnostic classifications have been rewritten, prognostic knowledge is improving, and therapeutic studies have regained momentum, showing for the first time some therapeutic effects on responsiveness. Clinicians must increasingly respond to requests by patients' families and surrogate decision makers to use novel techniques for diagnosis, prognosis, and treatment, and in doing so several ethical and social issues need to be considered. Such requests provide an opportunity for clinicians to learn about patients' values and preferences and to maintain clinical acumen for changes in patient status with the patients' best interests in mind.