BackgroundThe Covid-19 pandemic caused situations where, in some hospitals, there were more patients in need of urgent treatment in intensive care units (ICU) than were available. In particular, there were not sufficient ventilators or critical care resources for all patients in danger of dying from respiratory failure or other organ failures.DiscussionAs the “first come, first served” criterion was not considered adequate, more nuanced and fairer clinical criteria were proposed to assess whom to treat first. One type of patients that (...) has not been considered in the literature so far is that of “important patients”, individuals that many people might consider worthy of priority treatment for the contribution they made or might make to society as a whole.SummaryIn this article, we discuss the moral insights behind the possible treatment of “important patients” and suggest a supererogatory solution of voluntary renunciation/withdrawal. Details of the proposal are explained, and potential objections are addressed. (shrink)

The COVID-19 virus is severely testing the Italian healthcare system, as the requests for intensive treatment are greater than the real capacity of the system to receive patients. Given this emergency situation, it follows that citizens are limited in their freedom of movement in order to limit infection, and that in hospitals a significant number of critical situations must be faced. This brief contribution aims to offer a reflection on the public and clinical role of the bioethicist: (...) a figure able to promote dialogue between the world of medicine and the community, and to face ethical dilemmas even in emergent clinical settings. (shrink)

The evidence-based practice and evidence-based medicine movements have promoted standardization through guideline development methodologies based on systematic reviews and meta-analyses of best available research. EBM has challenged clinicians to question their reliance on practical reasoning and clinical judgement. In this paper, we argue that the protagonists of EBM position their mission as reducing uncertainty through the use of standardized methods for knowledge evaluation and use. With this drive towards uniformity, standardization and control comes a suspicion towards intuition, creativity and (...) uncertainty as integral parts of medical practice. We question the appropriateness of attempts to standardize professional practice through a discussion of the importance of uncertainty. Greenhalgh’s taxonomy of uncertainty is used to inform an analysis of the clinical reasoning occurring in a potentially life threatening emergency situation with a young patient. The case analysis is further developed by the use of the Canadian philosopher Bernard Lonergan’s theory about understanding and objective knowing. According to Lonergan it is not by getting rid of or even by reducing uncertainty, but by attending systematically to it and by relating to it in a self-conscious way, that objective knowledge can be obtained. The paper concludes that uncertainty is not a regrettable and unavoidable aspect of decision making but a productive component of clinical reasoning. (shrink)

BackgroundOver the past two decades, Uganda has experienced a significant increase in clinical research driven by both academia and industry. This has been combined with a broader spectrum of research proposals, with respect to methodologies and types of intervention that need evaluation by Research Ethics Committees (RECs) with associated increased requirement for expertise. We assessed the competencies of REC members regarding review of research protocols with complex and emerging research study designs. The aim was to guide development of a (...) training curriculum to improve the quality of scientific and ethical review.MethodsThis was a cross-sectional study design, with quantitative data collection methods. Research Ethics Committee members completed a structured pre-coded questionnaire on current competence with complex and emerging study design. REC members were asked to outline a list of additional topics for which they needed training. Data from coded questions were entered into Epidata Version 3.1 and then exported to STATA Version14.1 for analysis. Descriptive analysis was performed and findings are presented using percentages and frequencies.ResultsWe enrolled 55 REC members from 6 RECs who have a total of 97 members. The majority of whom were males (56.4%, n = 31/55). The level of competence for review of selected study design was lowest for Controlled Human Infection Model (10.9%, n = 6) and reverse pharmacology design (10.9%, n = 6), and highest for cluster randomized study design (52.7%, n = 29) and implementation science research (52.7%, n = 29).ConclusionCompetence for review of research protocols with complex and emerging study design was low among participating REC members. We recommend prioritising training of REC members on complex and emerging study designs to enhance quality of research protocol review. (shrink)

Cardiopulmonary resuscitation of a patient with an uncertain resuscitation status, and a discharging implantable cardiac defibrillator, presents a significant ethical challenge to healthcare professionals in the emergency department. Presently, no literature discusses these challenges or their implications for ethical healthcare delivery. This report will discuss the issues that arose during the management of such a case and attempt to raise awareness among healthcare professionals to ensure better preparation for similar situations.

In emergency research, obtaining informed consent can be problematic. Research to develop and improve treatments for patients admitted to hospital with life-threatening and debilitating conditions is much needed yet the issue of research without consent (RWC) raises concerns about unethical practices and the loss of individual autonomy. Consistent with the policy and practice turn towards greater patient and public involvement in health care decisions, in the US, Canada and EU, guidelines and legislation implemented to protect patients and facilitate acute (...) research with adults who are unable to give consent have been developed with little involvement of the lay public. This paper reviews research examining public opinion regarding RWC for research in emergency situations, and whether the rules and regulations permitting research of this kind are in accordance with the views of those who ultimately may be the most affected. (shrink)

Background The ambulance service provides emergency care to meet the patient’s medical and nursing needs. Based on professional nursing values, this should be done within a caring relationship with a holistic approach as the opposite would risk suffering related to disengagement from the patient’s emotional and existential needs. However, knowledge is sparse on how ambulance personnel can meet caring needs and avoid suffering, particularly in conjunction with urgent and emergency situations. Aim The aim of the study was to (...) explore ambulance nurses’ experiences of relationships with patients in urgent and emergency situations. Methods Data collection was performed using individual open-ended interviews with six ambulance nurses. The data were analyzed using a thematic analysis. Results Relationships with patients during urgent and emergency assignments emerged as three themes: “ Ambiguous silence,” “ Professional competence” and “ Challenging inadequacy” comprising eight sub-themes in total. The result shows that the ambulance nurses found it difficult to prioritize between medical care and establishing a caring relationship with the patient. However, sometimes a wordless relationship was perceived sufficient and considered a first step towards a verbal relationship. Conclusions Ambulance nurses experience that a caring relationship cannot and does not need to be prioritized in the acute stage. This uncovers a dichotomy approach to medical care versus caring relationships that exclude a holistic approach. Thus, patients’ emotional, existential and physical needs are not considered as equally important. Clinical relevance: It is important to stimulate reflection on core ethical nursing values, in training and simulation exercises among clinically active ambulance nurses. (shrink)

In December 2006 there was an amendment to the Medicines for Human Use (Clinical Trials) Regulations 2004, the statutory instrument that translated the European directive into UK law. I will demonstrate how the European directive stifled much needed clinical research in urgent critical states whilst there is an international consensus that research in these situations be allowed. The amendments to the UK Medicines for Human Use (Clinical Trials) Regulations 2004 in allowing such exception have failed to preserve (...) the high degree of respect and protection of the participants' interest as reflected in the spirit of the numerous guidelines, conventions and laws appertaining to the ethics of research in clinical emergencies. (shrink)

Clinical trials in emergency situations present unique challenges, because they involve enrolling individuals who lack capacity to consent in the context of acute illness or injury. The US Department of Health and Human Services and Food and Drug Administration regulations allowing an Exception from Informed Consent in these circumstances contain requirements for community consultation, public disclosure and restrictions on study risks and benefits. In this paper, we analyse an issue raised in the regulations that has received little attention (...) or analysis but is ethically complex. This challenge is when to solicit and honour objections to EFIC trial enrolment, including from non-legally appointed representatives. We address novel questions involving whose objections should be honoured, what level of understanding is necessary for objections to be considered valid and how hard investigators should work to offer an opportunity to object. We present a set of criteria that provide conceptual and practical guidance. We argue that objections should be honoured if they undermine one of the key assumptions that allows for the permissibility of EFIC trials: that individuals would likely not object to enrolment based on their values or preferences. We then clarify the practical implications of this approach through examination of three cases of refusal in an EFIC study. (shrink)

Bioethics laws in France have just undergone a revision process. The bioethics debate is often cast in terms of ethical principles and norms resisting emerging social and technological practices. This leads to the expression of confrontational attitudes based on widely differing interpretations of the same principles and values, and ultimately results in a deadlock. In this paper I would like to argue that focusing on values, as opposed to norms and principles, provides an interesting perspective on the evolution of norms. (...) As Joseph Raz has convincingly argued, “life-building” values and practices are closely intertwined. Precisely because values have a more indeterminate meaning than norms, they can be cited as reasons for action by concerned stakeholders, and thus can help us understand how controversial practices, e.g. surrogate motherhood, can be justified. Finally, norms evolve when the interpretations of the relevant values shift and cause a change in the presumptions implicit in the norms. Thus, norms are not a prerequisite of the ethical solution of practical dilemmas, but rather the outcome of the decision-making process itself. Struggling to reach the right decision in controversial clinical ethics situations indirectly causes social and moral values to change and principles to be understood differently. (shrink)

_Seeing and Being Seen: Emerging from a Psychic Retreat_ examines the themes that surface when considering clinical situations where patients feel stuck and where a failure to develop impedes the progress of analysis. This book analyses the anxieties and challenges confronted by patients as they begin to emerge from the protection of psychic retreats. Divided into three parts, areas of discussion include: embarrassment, shame, and humiliation helplessness, power, and dominance mourning, melancholia, and the repetition compulsion. As well as offering (...) fresh ideas, Steiner bases his creative and integrative efforts on previous contributions by psychoanalysts including Freud, Klein, Rosenfeld, and Bion. As such, this book will be of interest to psychoanalysts, clinical psychotherapists, and all those with an interest in the psychoanalytic field. (shrink)

In clinical practice, decision-making is not performed by individual knowers but by an assemblage of people and instruments in which no one member has full access to every piece of evidence. This is due to decision making teams consisting of members with different kinds of expertise, as well as to organisational and time constraints. This raises important questions for the epistemology of medicine, which is inherently social in this kind of setting, and implies epistemic dependence on others. Trust in (...) these contexts is a highly complex social practice, involving different forms of relationships between trust and reasons for trust: based on reasons, and not based on reasons; based on reasons that are easily accessible to reflection and others that are not. In this paper, we focus on what it means to have reasons to trust colleagues in an established clinical team, collectively supporting or carrying out every day clinical decision-making. We show two important points about these reasons, firstly, they are not sought or given in advance of a situation of epistemic dependence, but are established within these situations; secondly they are implicit in the sense of being contained or nested within other actions that are not directly about trusting another person. The processes of establishing these reasons are directly about accomplishing a task, and indirectly about trusting someone else’s expertise or competence. These processes establish a space of reasons within which what it means to have reasons for trust, or not, gains a meaning and traction in these team-work settings. Based on a qualitative study of decision-making in image assisted diagnosis and treatment of a complex disease called pulmonary hypertension, we show how an intersubjective framework, or ‘space of reasons’ is established through team members forging together a common way of identifying and dealing with evidence. In dealing with images as a central diagnostic tool, this also involves a common way of looking at the images, a common mode or style of perception. These frameworks are developed through many iterations of adjusting and calibrating interpretations in relation to those of others, establishing what counts as evidence, and ranking different kinds of evidence. Implicit trust is at work throughout this process. Trusting the expertise of others in clinical decision-making teams occurs while the members of the team are busy on other tasks, most importantly, building up a framework of common modes of seeing, and common ways of identifying and assessing evidence emerge. It is only in this way that trusting or mistrusting becomes meaningful in these contexts, and that a framework for epistemic dependence is established. (shrink)

In clinical practice, decision-making is not performed by individual knowers but by an assemblage of people and instruments in which no one member has full access to every piece of evidence. This is due to decision making teams consisting of members with different kinds of expertise, as well as to organisational and time constraints. This raises important questions for the epistemology of medicine, which is inherently social in this kind of setting, and implies epistemic dependence on others. Trust in (...) these contexts is a highly complex social practice, involving different forms of relationships between trust and reasons for trust: based on reasons, and not based on reasons; based on reasons that are easily accessible to reflection and others that are not. In this paper, we focus on what it means to have reasons to trust colleagues in an established clinical team, collectively supporting or carrying out every day clinical decision-making. We show two important points about these reasons, firstly, they are not sought or given in advance of a situation of epistemic dependence, but are established within these situations; secondly they are implicit in the sense of being contained or nested within other actions that are not directly about trusting another person. The processes of establishing these reasons are directly about accomplishing a task, and indirectly about trusting someone else’s expertise or competence. These processes establish a space of reasons within which what it means to have reasons for trust, or not, gains a meaning and traction in these team-work settings. Based on a qualitative study of decision-making in image assisted diagnosis and treatment of a complex disease called pulmonary hypertension (PH), we show how an intersubjective framework, or ‘space of reasons’ is established through team members forging together a common way of identifying and dealing with evidence. In dealing with images as a central diagnostic tool, this also involves a common way of looking at the images, a common mode or style of perception. These frameworks are developed through many iterations of adjusting and calibrating interpretations in relation to those of others, establishing what counts as evidence, and ranking different kinds of evidence. Implicit trust is at work throughout this process. Trusting the expertise of others in clinical decision-making teams occurs while the members of the team are busy on other tasks, most importantly, building up a framework of common modes of seeing, and common ways of identifying and assessing evidence emerge. It is only in this way that trusting or mistrusting becomes meaningful in these contexts, and that a framework for epistemic dependence is established. (shrink)

Introduction: Nurses who work in an emergency department regularly care for acute patients in a fast-paced environment, being at risk of suffering high levels of burnout. This situation makes them especially vulnerable to be accountable for decisions they did not have time to consider or have been pressured into. Research objective: The objective of this study was to find which factors influence ethical, legal and professional accountability in nursing practice in an emergency department. Research design: Data were (...) analysed, codified and triangulated using qualitative ethnographic content analysis. Participants and research context: This research is set in a large emergency department in the Midlands area of England. Data were collected from 186 nurses using participant observation, 34 semi-structured interviews with nurses and ethical analysis of 54 applicable clinical policies. Ethical considerations: Ethical approval was granted by two research ethics committees and the National Health Service Health Research Authority. Results: The main result was the clinical nursing accountability cycle model, which showed accountability as a subjective concept that flows between the nurse and the healthcare institution. Moreover, the relations among the clinical nursing accountability factors are also analysed to understand which factors affect decision-making. Discussion: The retrospective understanding of the factors that regulate nursing accountability is essential to promote that both the nurse and the healthcare institution take responsibility not only for the direct consequences of their actions but also for the indirect consequences derived from previous decisions. Conclusion: The decision-making process and the accountability linked to it are affected by several factors that represent the holistic nature of both entities, which are organised and interconnected in a complex grid. This pragmatic interpretation of nursing accountability allows the nurse to comprehend how their decisions are affected, while the healthcare institution could act proactively to avoid any problems before they happen. (shrink)

Although Directive 2001/20/EC of the European Parliament and of Council of 4 April 2001 on the approximation of the laws regulations and administrative provisions of the Member States relating to the implementation of good clinical practice in the conduct of clinical trials on medicinal products for human use does not contain an exception for emergency situations, and requires the informed consent of a legal representative in all cases where research is conducted on legally competent individuals who are (...) unable to give informed consent, in Poland, emergency research can be conducted without consent. Polish regulations on emergency research can hardly be treated as a result of intentional legislative policy. Our provisions arise from multiple and sophisticated interpretations of different regulations that govern medical experiments on human subjects and clinical trials. These interpretations can be summarized as follows: There are two categories of medical experiments: therapeutic and non-therapeutic experiments. Emergency research without consent may be conducted in the category of therapeutic experiment only.. Emergency research may be conducted without consent if there is a situation of great urgency in which the research subject’s life is in danger and there is no possibility of obtaining immediate consent from the research subject him or herself, or from his or her legal representative or guardianship court, and the research subject has not refused to give consent for the participation in an emergency therapeutic experiment. The legal representative or guardianship court shall be provided with all the relevant information concerning subject’s participation in an experiment as soon as possible. All projects of emergency research with intent to be done without the research subject’s consent must be approved by an independent bioethics committee. Because these five requirements seem to provide insufficient protection for a subject’s autonomy and rights it is necessary to add to them two other conditions: the emergency research could not be conducted using other research participants capable of giving informed consent; and informed consent for continued participation in the emergency research shall be obtained from either the participant him or herself or the legally authorized representative as soon as possible. A consolidated single Act that will govern all aspects of medical experiments on human subjects, including emergency research, should be prepared and enacted as soon as possible. (shrink)

During the first outbreak of COVID-19, the F rench governmental advisory council on bioethics suggested the need to support healthcare providers with ad hoc “ethical support units.” Several units engaged in such endeavors across the country. This article outlines some methodological considerations made by the Cochin Hospital Clinical Ethics Center (the Cec). The Cec was founded in 2002 to provide clinical ethics support services. While its approach was inspired by North American models, it was shaped by and adapted (...) to the French context. This approach is called the “Commitment Model,” as it draws upon societal engagement in all phases of its service and places the perspectives of individual patients at its core. During the first outbreak of COVID-19 pandemic, the Cec received a greater number of requests about recurring care practices or ethical guidelines and recommendations than single clinical ethics dilemmas. Through the presentation of an illustrative consultation, this article describes how, while the Cec made some adjustments to its service for the emergency situation, it preserved its case-by-case approach rather than engaging in what it calls organizational and institutional ethics. Such an approach allowed the Cec to refocus attention to individual patients and their unique circumstances and to support decision makers by the use of case-by-case, problematized, ethical reflections. (shrink)

Clinical ethics literature typically presents ethics consultations as having clear beginnings and clear ends. Experience in actual clinical ethics practice, however, reflects a different characterization, particularly when the moral experiences of ethics consultants are included in the discussion. In response, this article emphasizes listening and learning about moral experience as core activities associated with clinical ethics consultation. This focus reveals that responsibility in actual clinical ethics practice is generated within the moral scope of an ethics consultant's (...) activities as she or he encounters the unique and specific features that emerge from interactions with a specific patient, or family, or practitioner within a given situation and over time. A long-form narrative about an ethics consultant's interactions is interwoven with a more didactic discussion to highlight the theme of responsibility and to probe questions that arise regarding follow-up within the practice of clinical ethics consultation. (shrink)

Triage is a widespread principle for prioritizing patients in emergency departments. The purpose of triage is to ensure that in emergency situations, whenever medical demand exceeds medical supply, limited resources should be directed to the case with the greatest clinical need. Triage fulfills this purpose by ranking patients according to how acute their condition is and then giving priority to the most acute ones. In this paper, I argue that this current practice of triage needs to be (...) supplemented. Contemporary triage is based on a principle of preserving patients’ core capabilities, which is relevant when it comes to prioritizing acute patients above sub‐acute ones, but not for prioritizing among sub‐acute patients, which is the largest group of emergency patients. Henceforth, I propose to supplement triage with what I term the real dialogue model, a framework that, when combined with enhanced professional autonomy for clinical decision‐makers, enables fair prioritizing among sub‐acute patients. (shrink)

This commentary reflects on twelve stories of participants in clinical ethics consultations from the perspective of family members, some of whom are ethics consultants, and healthcare professionals. Together they reveal expectations of ethics consultations and suggest descriptions of the service. Some common themes emerge, including the role of the clinical ethics consultant in navigating complex situations, assuring all stake-holder voices are heard, attending to moral distress, addressing issues that seem beyond medical practice, and being accessible. They are almost (...) uniformly positive about the experience, with criticism primarily about lack of access to the service. (shrink)

Hundreds of clinical trials of potential treatments and vaccines for the “coronavirus 19 disease” (COVID-19) have been set up in record time. This is a remarkable reaction to the global pandemic, but the absence of a global coordination of clinical research efforts raises serious ethical concerns. Some COVID-19 patients might carry the burden of clinical trial involvement even though their trial cannot be completed as researchers are competing for patients. A shortage of medicines can occur when existing (...) drugs are diverted for clinical trials. Research ethics committees are overburdened with multiple applications. A multitude of trials can also overstretch medical staff and risk neglecting non-COVID-19 patients. And finally, conflicting conclusions from a multitude of heterogeneous trials might lead to delays in public health decisions about life-saving issues. These challenges are made worse by the unpredictable evolution of epidemics, the active involvement of political decision-makers in scientific issues and the pressure of social media globally. While freedom to conduct research must be safeguarded, global health emergency situations would greatly benefit from effective international coordination mechanisms for clinical research. (shrink)

This article is about the recent and profound changes in the conceptualization of dementia, especially the turn towards prevention. The main argument is that more attention needs to be paid to “situated prevention” — the framing of internationally circulating data on the “new dementia” in different contexts. After introducing some of the more problematic issues related to the “new dementia,” a first comparison of major preventive clinical trials in Europe and in North America will be provided. The major insight (...) stemming from situating the global message of preventing dementia is recognition of the responsibility researchers and policy makers bear with respect to the implicit and potential moral narratives in emerging scientific landscapes. (shrink)

Different ethical principles conflict in research conducted in emergency research. Clinical care and its development should be based on research. Patients in critical clinical condition are in the greatest need of better medicines. The critical condition of the patient and the absence of a patient representative at the critical time period make it difficult and sometimes impossible to request an informed consent before the beginning of the trial. In an emergency, care decisions must be made in (...) a short period of time, and the more time is wasted, the more the risk of death or severe tissue damage and incapacity increases. Consent requests take time, and so the time period before treatment might put the patient’s life in jeopardy. Not requesting consent before a trial is also contradictory. A person should not be forced to participate in a trial against his or her will. Due to the dark history of medical research previously, international declarations and conventions have set up ethical principles for medical research. They emphasize the autonomy of the research participant—or his or her legal representative—to give a free and informed consent prior to the initiation of research. In the case of a critical emergency, the unconscious state of the patient, the emotional stress of family members or the lack of time to start life-sustaining measures may often restrict the possibilities of communicating with the patient or his/her representative. Therefore, written informed consent is difficult to achieve, and its voluntariness in emergency situations is, at best, open to question. The mortality of patients is high without clinical interventions in emergency research. Random selection of patients is difficult and requires extra work from personnel in the emergency rooms. Recruitment, information and asking for consent may also take time, postpone the initiation of treatment and increase the risk of death and irreversible tissue and organ damage, and therefore be risky for the patient. It is therefore essential that the health care professionals recruiting suitable research participants are well motivated and well trained. Medical research in an emergency setting should always be regarded as an exceptional situation requiring special provisions. Only such research should be done as cannot be done in other conditions. An independent body must approve the research protocol and the ways in which the consent of the participant or proxy are to be sought. In addition, the trial must be expected to result in direct and significant benefit for the research participants. If research without prior consent is not approved, the development of emergency care is threatened. On the other hand, if prior consent is not required, a person could be recruited into a clinical trial against his or her will. Doing good and avoiding harm, and respecting the autonomy of the patient are in conflict in the context of emergency medical research. To develop better medicines for patients experiencing acute medical emergencies, research into such conditions should be allowed. Research participants should have the possibility to participate or refuse to participate in research that may benefit them and other patients. The risk of irreversible damage occurring as the consequence of time delays for seeking consent is unacceptable. A prior wish about participation in clinical trials should be respected, if known. The conditions under which medical research in emergencies can be considered acceptable can be determined and agreed upon nationally and internationally. (shrink)

In recent decades there has been a significant increase in community rehabilitation programs for people with mental health conditions. One such nationwide programs is Amitim in Israel whose mission is to foster the psychosocial rehabilitation of people with mental health conditions in the community. Amitim’s flagship program consists of arts-based groups that integrate participants with mental health conditions and non-clinical community members. To better understand the experiences of participants in these arts-based groups, five focus groups were conducted with participants (...) from 15 integrated arts-based groups. In total, 17 people with mental health conditions and 21 non-clinical community members were interviewed for this qualitative study. Three main themes emerged from the thematic analysis: creation and expression through the arts promote well-being, self-disclosure in a safe space encourages a sense of belonging, and “we are all in the same boat.” The participants underscored the role of creation and expression through the arts in facilitating emotional expression, self-discovery, interpersonal communication, and spiritual elevation. The findings suggest that the facilitators should instill a sense of equality by enabling intergroup acquaintances without labeling participants’ mental health status. Integrated arts-based groups should be accompanied by a mental health professional who can contain and work through complex emotional situations when needed. Arts therapists who specialize in both arts and mental health are particularly suitable for this role. Overall, the interviewees reported that participation in the integrated arts-based groups positively impacted their personal recovery processes by providing a corrective experience of equality as well as enhancing a sense of belonging to the community and social relationships. The participants also reported being empowered by the final artistic event that not only enhanced their sense of visibility, competence, and aspirations for future development in personal, interpersonal, and artistic realms, but also helped to combat both self- and public stigma. (shrink)

BackgroundRespect for confidentiality is important to safeguard the well-being of patients and ensure the confidence of society in the doctor-patient relationship. The aim of our study is to examine real situations in which there has been a breach of confidentiality, by means of direct observation in clinical practice.MethodsBy means of direct observation, our study examines real situations in which there has been a breach of confidentiality in a tertiary hospital. To observe and collect data on these situations, we recruited (...) students enrolled in the Medical Degree Program at the University of Cordoba. The observers recorded their entries on standardized templates during clinical internships in different departments: Internal Medicine; Gynecology and Obstetrics; Pediatrics; Emergency Medicine; General and Digestive Surgery; Maxillofacial Surgery; Plastic Surgery; Orthopedics and Traumatology; Digestive; Dermatology; Rheumatology; Mental Health; Nephrology; Pneumology; Neurology; and Ophthalmology.ResultsFollowing 7138 days and 33157 h of observation, we found an estimated Frequency Index of one breach per 62.5 h. As regards the typology of the observed breaches, the most frequent were related to the consultation and/or disclosure of clinical and/or personal data to medical personnel not involved in the patient’s clinical care, as well as people external to the hospital. As regards their severity, severe breaches were the most frequent, accounting for 46.7 % of all incidents. Most of the reported incidents were observed in public areas, such as corridors, elevators, the cafeteria, stairs, and locker rooms.ConclusionsIn addition to aspects related to hospital organization or infrastructure, we have shown that all healthcare personnel are involved in confidentiality breaches, especially physicians. While most are committed unintentionally, a non-negligible number are severe, repeated breaches, thus suggesting a certain carelessness, perhaps through ignorance about certain behaviors that can jeopardize patient confidentiality. (shrink)

Focusing on the largest and, arguably, the least visible disability group, the hearing impaired, this paper explores present-day views and understandings of hearing impairment and rehabilitation in a Danish context, with particular focus on working-age adults with late onset of hearing impairment. The paper shows how recent changes in perception of the hearing impaired patient relate to the introduction of a new health care reform that turns audiological rehabilitation into a consumer issue. Ethnographic and interview data from hearing clinics provides (...) evidence that the hearing technologies that are on offer stabilise in specific forms through processes of negotiation among a variety of social actors representing the interests of science, industry, government, and hearing-impaired people. The discussion critically considers the emergence of an “informed consumer” in audiological practices. (shrink)

The emergency department (ED) is a fast-paced, highly stressful environment where clinicians function with little or suboptimal information and where time is measured in minutes and hours. In addition, death and dying are phenomena that are often experienced in the ED. Current end-of-life care models, based on chronic illness trajectories, may be difficult to apply in the ED. A philosophical approach examining end-of-life care may help us understand how core medical and nursing values are embodied as care practices and (...) as ethical comportment. The integration of Aristotle's notions of phronesis and praxis with Merleau-Ponty's ontological notions of intentional arc and maximum grip in the context of the culture and practices of the ED offers a unique view of clinical and ethical practice at the end-of-life in the emergency setting. Caring for people at the end-of-life calls us to act virtuously based on previous experience, meanings and local practices. The maximum grip of the ultimate particulars of the situation combined with one's experiential and theoretical knowledge opens up situated possibilities for the expert clinician. (shrink)

ABSTRACT Although considerable attention has been given to ethical issues related to clinical research in developing countries, in particular related to HIV therapy, there has been limited focus on health systems research, despite its increasing importance in the light of current trends in development assistance. This paper examines ethical issues related to health systems research in ‘post’‐conflict situations, addressing both generic issues for developing countries and those issues specific to ‘post’‐conflict societies, citing examples from the author’s Cambodian experience. It (...) argues that the destruction of health infrastructure results in a loss of structures and processes that would otherwise protect prospective research subjects who are part of vulnerable populations. It identifies the growth of health systems research as part of a trend towards sectoral and programmatic development assistance, the emergence of ‘knowledge generation’ as a form of research linked to development, and the potential for conflict where multilateral and bilateral donors are both primary funders and users of health systems research. It also examines the position of the health system researcher in relation to the sponsors of this research, and the health system being analysed. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:To Be or Not to Be:Waiving Informed Consent in Emergency ResearchCharles R. McCarthy (bio)The requirements for prior, legally authorized informed consent constitute a necessary condition for recruiting subjects into biomedical or behavioral research. However, informed consent requirements pose a serious problem for most research conducted in emergency care settings. For this reason, the Food and Drug Administration's (FDA) regulations governing investigational devices and the Department of Health (...) and Human Services' (HHS) regulations for the protection of human subjects allow narrow exceptions to the general requirements of informed consent. In a joint effort to clarify the applicability of the current FDA regulations and to better understand the intent of the HHS regulations as they apply to emergency research, the FDA and the National Institutes of Health (NIH) cosponsored a public forum on the ethical conduct of emergency research in January 1995.Although the forum was not designed as a consensus conference and participants vigorously disagreed on some of the details, a broad consensus emerged on several major points: (1) both HHS and FDA regulations should, in the immediate future, be interpreted to allow for randomized clinical trials in emergency situations so long as the subjects are carefully protected; and (2) consideration should be given to producing new, closely harmonized regulations from both agencies that will provide greater clarity concerning what kinds of emergency research may be allowed without obtaining prior informed consent.The FDA-NIH forum in January was occasioned primarily by controversy about the hypothermia research protocol described below, but it is obvious that many other kinds of emergency research also await the outcome of deliberations concerning waiver of informed consent in emergency situations. These include research into the care and treatment of: occlusive stroke; subarachnoid hemorrhage due to intracranial aneurysm; metabolic coma; status epilepticus; cardiac arrest; myocardial infarction; cardiac arrhythmia; hemorrhagic shock; pulmonary embolism; acute asthmatic attack; and poisoning. All of these conditions [End Page 155] are encountered in emergency settings where obtaining informed consent from the patient-subjects to participate in research is seldom possible, and obtaining consent from legally authorized representatives of the subjects is either not feasible, or, if obtained, is of doubtful validity.The Hypothermia Research Case and HHS RegulationsA $7.2 million grant for research on the use of hypothermia in the treatment of severe head trauma, the largest award ever made to the University of Texas Health Sciences Center at Houston, is in danger of expiring before the study is completed. The protocol, which involves the use of cooling blankets to induce hypothermia in patients suffering from severe head injuries, is designed to test the hypothesis that: "Early lowering of the body temperature of patients suffering from severe head trauma to approximately 91 degrees Fahrenheit will slow patients' metabolism and will/will not, as a consequence, reduce the rates of both morbidity and mortality in these patients." The protocol was approved by seven Institutional Review Boards (IRBs), each of which waived the requirement to obtain informed consent from research subjects in accordance with Sec. 46. 116(d) of the HHS Regulations for the Protection of Human Subjects.1However, NIH's Office for Protection from Research Risks (OPRR), which is responsible for assuring compliance with the HHS regulations, has taken a controversial regulatory position by requiring informed consent from a legally authorized representative of each subject to be entered in the hypothermia trial. Because the obtaining of surrogate consent has proved to be very difficult, OPRR's position has slowed the research to a point where it may have to be terminated.At issue in the controversy is a fundamental question of ethics and public policy. Is it ever permissible to involve incompetent subjects in research without either their consent, or the consent of their legally authorized representatives? Pertinent HHS regulations for the protection of human subjects seem to answer the question affirmatively by allowing local IRBs to waive some or all of the elements of informed consent under carefully limited circumstances (45 CFR 46 116(d)). Nevertheless, OPRR has signalled the research community that use of the informed consent waiver provision for the Houston hypothermia study is not permitted under the regulations. OPRR judged that the risks... (shrink)

Background Professional ethics in nursing exist to guide care and allow for decision-making to be patient-centered. In the current medicolegal landscape post-Roe and in light of bans on gender-affirming care, the decision-making processes of emergency nurses in the clinical environment of care as informed by both professional and personal ethics are an important area of inquiry. Aim The aim of this study was to examine the contribution of moral courage to decision-making by emergency nurses. Research Design A (...) mixed-methods exploratory sequential approach was used, using a standard demographics form and the Nurses Moral Courage Scale to collect quantitative data. These data were used to inform an interview guide for qualitative data collection. Situational analysis was used to analyze the interview data. Ethical Considerations Prior to recruitment, this study was reviewed and approved by the University of Massachusetts IRB (#00003909). Participants were provided with an informed consent document at the time of registration and at the time of interview; participants provided both signed consent and verbal assent. Participants were assigned study codes to maintain anonymity and data were maintained in a secure University cloud. Participants and Research Context US-based emergency nurses working in environments with care limitations. Results 70% of respondents reported that they would speak up if they were aware of a situation that was ethically challenging. Respondents reported that it was fairly easy or very easy to defend their values when addressing ancillary staff, coworkers, authorities outside the organization, patients, and patient families. Respondents reported challenges in defending their professional values to charge nurses, physicians, or administrators. In response to a serious ethical problem, 65.8% of respondents answered that they would bring up the problem for discussion, 21.1% would file an internal report, and 13.2% would report externally. Interview participants reported significant social and professional barriers to acting in response to an ethical violation. Willingness to act centered on personal values and not professional codes of ethics. Conclusions While emergency nurses in this study reported high perceived levels of moral courage, they also reported low willingness to act directly, citing burnout and significant social and professional barriers. Adherence to professional codes of ethics is not the primary driver of moral courage. (shrink)

Between December 2020 and March 2021, the US Food and Drug Administration and the European Medicines Agency issued Emergency Use Authorizations and Conditional Marketing Authorizations for the distribution of the first COVID-19 vaccines. Although these vaccines were thoroughly assessed before their approval, regulators required companies to continue ongoing placebo-controlled clinical trials in order to gather further reliable scientific information on their safety and efficacy, as well as to start new studies to evaluate additional candidates. The aim of this (...) paper is to present and discuss the ethical issues raised by the tension between the need to continue these types of clinical trials and the obligations related to the protection of the rights and well-being of research participants. Specifically, we question whether—how, and to what extent—fundamental principles governing research involving human beings can be applied to the current pandemic situation. We argue that continuing ongoing placebo-controlled clinical trials can be considered ethically justifiable only if all participants are adequately informed of any developments that may affect their willingness to remain enrolled, including the current situation of resource scarcity and the prioritization criteria established for vaccination. However, we also argue that currently approved vaccines, which are considered safe and effective enough to be administered to millions of people as part of the vaccination campaign, necessarily represent the “best proven intervention” currently available and, therefore, should be used as comparators in future studies instead of placebo. (shrink)

To avoid misinterpretations one should substitute the ambiguous notion of 'new disease' with 'emerging disease'. A disease can be classified emergent in at least five dif férent historical situations; 1) it existed before it could be first identified but was overlooked from a médical point of view because it could not be conceptualized as a nosological entity; 2) it existed but was not noticed until a quantitative and/or qualitative change in its mani festations; 3) it did not exist in a (...) particular région of the world before its introduction from other régions; 4) it never existed in a human population but only in an animal population; 5) it is completely new - the triggering germ and/or necessary environmental conditions did not exist prior to the first clinical manifestations. A sériés of historical examples illustrate this classification. (shrink)

The study presented in this article is based on field observations over one year on a critical care unit in Norway. Data were analysed according to Glaser’s grounded theory and generated a theory of hidden and emerging drama in the context of ambiguity while the nurses routinized the handling of complex technology. To the untrained eye the unit presented a picture of calm competence, while under the surface one finds hidden drama full of difficult interacting clinical and ethical problems. (...) The nurses identified six ethical dilemmas: (1) end of life issues; (2) whether there should be an age limit for coronary surgery; (3) distributing limited resources; (4) resource allocation in terms of better staffing; (5) situations in which is it more harmful than beneficial to continue treatment; and (6) transferring patients to other facilities. The six problems overlap and have clinical as well as ethical components, but it was the ethical dimensions that the nurses identified and discussed. The significance for nursing is the importance of well-educated and well-qualified nurses and how they find viable solutions to complex ethical and clinical problems. (shrink)

Theoretical models for patient-physician communication in clinical practice are frequently described in the literature. Respecting patient autonomy is an ethical problem the physician faces in a medical emergency situation. No theoretical physician-patient model seems to be ideal for solving the communication problem in clinical practice. Theoretical models can at best give guidance to behavior and judgement in emergency situations. In this article the premises of autonomous treatment decisions are discussed. Based on a case-report we discuss (...) different genuine efforts the physician can do to uncover treatment refusal and respect patient autonomy in an emergency situation. Autonomy requires competence and in emergency medicine time does not allow intimate exploration of patient competence and reasons for treatment refusal. We find that the physician must base her decision on a firm theoretical base combined with a practical and realistic view of the patient's situation on a case to case basis. (shrink)

This special issue of Science, Technology, & Human Values critically explores a new stage in which the life sciences and biomedical practices have entered. This new stage is marked by postgenomic developments and an increased interest of life sciences in the everyday lives of people outside laboratories and clinical settings. Furthermore, particular attention is given to many chronic and degenerative disorders such as cardiovascular disease, Alzheimer’s disease, or developmental disorders. These developments coincide—or have become entangled—with a new set of (...) interests that an anthropologically inclined science and technology studies is bringing to the analyses of biomedical practices. An increased interest is observed in the anthropologically inclined STS in studying phenomena on different scales and in exploring fields that are not readily dominated by technoscientific rationality in practice. The introduction to the special issue examines briefly these developments and situates them in a broader genealogy of different movements that have taken place in the anthropologically inclined subfield of STS since the late 1970s and early 1980s. (shrink)

The global emergency caused by the spread of COVID-19 raises critical challenges for individuals and communities on many different levels. In particular, politicians, scientists, physicians, and other professionals may face new ethical dilemmas and cognitive constraints as they make critical decisions in extraordinary circumstances. Philosophers and cognitive scientists have long analyzed and discussed such issues. An example is the debate on moral decision making in imaginary scenarios, such as the famous “Trolley Problem”. Similarly, dramatic and consequential decisions are realized (...) daily in the current crisis. Focusing on Italy, we discuss the clinical ethical guidelines proposed by the Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care, highlighting some crucial ethical and cognitive concerns surrounding emergency decision making in the current situation. (shrink)

Anger is probably one of the mostly debated basic emotions, owing to difficulties in detecting its appearance during development, its functional and affective meaning (is it a positive or a negative emotion?), especially in human beings. Behaviors accompanied by anger and rage serve many different purposes and the nuances of aggressive behaviors are often defined by the symbolic and cultural framework and social contexts. Nonetheless, recent advances in neuroscientific and developmental research, as well as clinical psychodynamic investigation, afford a (...) new view on the role of anger in informing and guiding many aspects of human conducts. Developmental studies have confirmed the psychophysiological, cognitive and social acquisition that hesitate in the pre-determined sequence appearance of anger and rage in the first two years of life. The so-called affective neurosciences have shown the phylogenetic origin of the two circuits underlying the emergence of anger along with its evolutionary role for promoting survival. This view has been integrated by the psychodynamic theory of motivational systems that attribute a double role to anger: on the one hand, this affect works as an inwardly directed signal concerning a pressure to overcome an obstacle or an aversive situation; on the other hand, anger is also an outwardly directed communicative signal establishing differentiation and conflict within interpersonal relationships and affective bonds. Of course, human peculiar mental functioning requires the appraisal of such signals by higher cortical functions and, there is little doubt that the meaning that orientates individual behaviors is, eventually, construed on a social and cultural level. At the same time, everyday life experiences as well as clinical insights into psychopathic, narcissistic and borderline personality pathology clearly illustrate the necessity to correctly interpret and give answers to the basic questions raised around the topic of anger as a basic emotion. (shrink)

Severe Traumatic Brain Injury (TBI) remains a major cause of death and disability afflicting mostly young adult males and elderly people, resulting in high economic costs to society. Therapeutic approaches focus on reducing the risk on secondary brain injury. Specific ethical issues pertaining in clinical testing of pharmacological neuroprotective agents in TBI include the emergency nature of the research, the incapacity of the patients to informed consent before inclusion, short therapeutic time windows, and a risk-benefit ratio based on (...) concept that in relation to the severity of the trauma, significant adverse side effects may be acceptable for possible beneficial treatments. Randomized controlled phase III trials investigating the safety and efficacy of agents in TBI with promising benefit, conducted in acute emergency situations with short therapeutic time windows, should allow randomization under deferred consent or waiver of consent. Making progress in knowledge of treatment in acute neurological and other intensive care conditions is only possible if national regulations and legislations allow waiver of consent or deferred consent for clinical trials. (shrink)

Background: In Hospital Emergency Department and Emergency Medical Services professionals experience situations in which they face difficulties or barriers to know patient’s advance directives and implement them. Objectives: To analyse the barriers, facilitators, and ethical conflicts perceived by health professionals derived from the management of advance directives in emergency services. Research design, participants, and context: This is a qualitative phenomenological study conducted with purposive sampling including a population of nursing and medical professionals linked to Hospital Emergency (...) Department and Emergency Medical Services. Three focus groups were formed, totalling 24 participants. We performed an inductive-type thematic discourse analysis. Ethical considerations: This study was approved by ethical committees of Ethical Commitee of Clínic Hospital (Barcelona) and Comittee of Emergency Medical Services (Barcelona). The participants received information about the purpose of the study. Patients’ anonymity and willingness to participate in the study were guaranteed. Findings: There were four types of barriers that hindered the proper management of patients’ advance directives in Hospital Emergency Department and Emergency Medical Services: personal and professional, family members, organisational and structural, and those derived from the health system. These barriers caused ethical conflicts and hindered professionals’ decision-making. Discussion: These results are in line with those of previous studies and indicate that factors such as gender, professional category, and years of experience, in addition to professionals’ beliefs and the opinions of colleagues and family members, can also influence the professionals’ final decisions. Conclusion: The different strategies described in this study can contribute to the development of health policies and action protocols to help reduce both the barriers that hinder the correct management and implementation of advance directives and the ethical conflicts generated. (shrink)

Many therapists can attest to the fact that adolescents can be difficult and frustating clients-problems are seldom well defined, clearly delineated symptoms are more exception than the rule, and troubling situations often involve the entire family. Gestalt therapist Mark McConville draws on his more than twenty years of professional experience to offer clinicians an effective model for understanding and treating adolescents. He outlines the Developmental Tasks Model, which describes adolescents' struggles, "temporary insanity," and ultimately, triumph of development. He clearly demonstrates (...) that the Gestalt therapeutic model bridges the theoretical and clinical gap, and offers an indepth exploration of the various aspects of clinical work. _Adolescence_ offers valuable nuts-and-bolts advice on initiating therapy with adolescents who are not yet ready to do the self-reflective, exploratory work. In addition, the book examines the therapeutic method of engaging and cultivating the adolescent's emerging inner world. With perception and sensitivity, McConville explains how the clinician can guide the adolescent in the very personal and subjective process of birthing and existential self. The book details the process of the creative reorganization of the self during adolescence and explores the changes that take place in the adolescent's relationships with peers, parents, and others in the adult world. The author also tracks the interplay of intrapsychic and interpersonal boundary development and shows how this interplay manifests itself in relationships and evolves from early through late adolescence. The Gestalt model of therapy allows the clinician to make sense of the confusion of the adolescent world and map out the multiple possibilities of clinical interventions. (shrink)

This article outlines current safe harbors in the law for healthcare practitioners who work in a disaster setting. It reviews available legal protection in crisis situations with respect to the Emergency Medical Treatment and Labor Act (EMTALA), criminal liability, and licensure.

AbstractBackgroundEthical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. In prehospital emergency medicine, decision-making commonly takes place in everyday life, under time pressure, with limited information about a patient and with few possibilities of consultation with colleagues. This paper explores the ethical challenges experienced by prehospital emergency personnel. MethodsThe study was grounded in the tradition of action research related to interventions in health care. Ethical challenges were explored in three focus groups, each (...) attended by emergency medical technicians, paramedics, and prehospital anaesthesiologists. The participants, 15 in total, were recruited through an internal information network of the emergency services. Focus groups were audio-recorded and transcribed verbatim.ResultsThe participants described ethical challenges arising when clinical guidelines, legal requirements, and clinicians’ professional and personal value systems conflicted and complicated decision-making processes. The challenges centred around treatment at the end of life, intoxicated and non-compliant patients, children as patients—and their guardians, and the collaboration with relatives in various capacities. Other challenges concerned guarding the safety of oneself, colleagues and bystanders, prioritising scarce resources, and staying loyal to colleagues with different value systems. Finally, challenges arose when summoned to situations where other professionals had failed to make a decision or take action when attending to patients whose legitimate needs were not met by the appropriate medical or social services, and when working alongside representatives of authorities with different roles, responsibilities and tasks.ConclusionFrom the perspective of the prehospital emergency personnel, ethical challenges arise in three interrelated contexts: when caring for patients, in the prehospital emergency unit, and during external collaboration. Value conflicts may be identified within these contexts as well as across them. A proposed model of analysis integrating the above contexts can assist in shedding light on ethical challenges and value conflicts in other health care settings. The model emphasises that ethical challenges are experienced from a particular professional perspective, in the context of the task at hand, and in a particular, the organisational setting that includes work schedules, medical guidelines, legal requirements, as well as professional and personal value systems. (shrink)

The following text is a voice in the discussion around normative problems of innovative therapies. It refers to problems related to the amendment to the Polish Act on the Professions of Physician and Dentist, particularly to therapeutic experiment category, also discussed in this issue in the article by Maria Gutowska-Ibbs: “Off-label - practical consequences of unclear legislation.”.

In lieu of an abstract, here is a brief excerpt of the content:It Is Going to Be a Long Clinic DaySalvador Cruz-FloresIt was a routine neurology clinic day. I entered the room where one of the residents was seeing a patient that we will call Patty, a 32-year-old long-standing epilepsy patient. Patty was sitting in the chair with her husband by her side. She started screaming at me, complaining that she was tired of feeling sick and unable to do anything. (...) She had been in and out of emergency rooms with a variety of complaints, from passing out to dizziness with nausea and vomiting. She was visibly angry and started cursing me with direct expletives and blaming me for all her ailments.Her husband was quiet and, at times, would cover his face as if he was embarrassed. I felt an initial burst of anger. I felt my face getting red. I made a great effort to stay quiet, leaned on the exam table facing them, lowered my voice, and braced to take the barrage of insults that were coming my way. I had to make a strong conscious effort to control my emotions and let her vent. I felt that if I responded in kind, I would inflame the situation. Moreover, a resident and a student working with me that day were also present in the room, and I felt it was my duty to behave professionally, so I sat and tried to do active listening with the idea of offering solutions to her complaints. I am not sure how long the event lasted, but it seemed like an eternity. As she slowed down, I apologized for making her feel not cared for, repeated some of her complaints, and tried to offer solutions to them, but she would not have it and did not accept anything I said. She wanted to get her prescriptions and leave the clinic. I offered to have one of my colleagues do the follow-up as she really did not want to see me anymore.Patty is one of those patients that when you see the name in the schedule, you cringe and tell yourself, it is going to be a long clinic day. She could be in the group of patients who are considered very difficult. Before me, she had been seen by several other neurologists. They likely also preferred not to see her on the schedule because she is one of the 20–30% of patients that have a type of functional psychogenic disorder that becomes more complicated because of the coexistence of epileptic seizures along with non-epileptic psychogenic events. The latter is a more problematic event because it does not respond to pharmacological treatment and causes a lot of disability. The best way to establish whether an event is a true epileptic event or a non-epileptic psychogenic event is to do continuous electroencephalographic monitoring to capture as many events as possible on video. I tried different combinations of medications to no avail and with significant side effects. I tried to set her up for electroencephalogram home monitoring to tease the epileptic and psychogenic events apart. In truth, her social circumstances, insurance coverage, and economic situation made it impossible to do so. Every time she came to the clinic, she had a multitude of complaints, and she would ask for a medication to treat the problem. Any mention of the potential psychogenic nature of her problems would result in a defensive attitude "so you are saying I am crazy." We discussed multiple times the need to be careful with the medications and the potential bad side effects. I wanted to help her, but with every visit, there seemed to be a barrier, and the visit would end on bad terms. At least, that is how I felt. I was left every time, with a feeling of frustration. I believe that she left the clinic feeling the same. That day, I left the clinic upset and depressed. I tried to convince myself I had done all I could to help her. I just could not understand why this was the result.Several years have passed since I have seen Patty in the clinic. She certainly has not... (shrink)

This article addresses the issue of the interface between public health and clinical health within the context of the search for networking approaches geared to a more integrated delivery of health services. The articulation of an operative interface is complicated by the fact that the definition of networking modalities involves complex intra- and interdisciplinary and intra- and interorganizational systems across which a new transversal dynamics of intervention practices and exchanges between service structures must be established. A better understanding of (...) the situation is reached by shedding light on the rationale underlying the organizational methods that form the bases of the interface between these two sectors of activity. The Quebec experience demonstrates that neither the structural-functionalist approach, which emphasizes remodelling establishment structures and functions as determinants of integration, nor the structural-constructivist approach, which prioritizes distinct fields of practice in public health and clinical health, adequately serves the purpose of networking and integration. Consequently, a theoretical reframing is imperative. In this regard, structuration theory, which fosters the simultaneous study of methods of inter-structure coordination and inter-actor cooperation, paves the way for a better understanding of the situation and, in turn, to the emergence of new integration possibilities. (shrink)

Background A combination of theoretical and practical approaches is required to learn and acquire ethical competencies in caring. Occasionally, reflection on practical action differs from theoretical learning. In the context of reflective learning, issues such as ethical values can be discussed since they evoke conflict among nursing students. Aim To identify ethical conflicts encountered by nursing students during clinical placements and to determine their cooperation strategies. Research design Qualitative study with a content analysis according to Elo and Kinglas framework. (...) Participants and research context Students enrolled in a nursing program at a Spanish university aged between 22 and 35, mainly women. Methodology The study includes 134 ethical reflections from nursing students in the last year of the nursing program, written during their clinical practices in a variety of learning environments. The research team analyzed the reflections using an inductive content analysis method. Ethical considerations Ethical permission was obtained by the management center according to Law 3/2028, and all the participants accepted to participate through the informed consent form. Findings Three main categories emerged from the analysis of the ethical reflections: (1) evaluation of professional performance and patient care; (2) the student as the protagonist of the dilemma; (3) student coping. Student dilemmas and concerns are related to ignorance, student-patient communication, mistakes made and self-confidence. Some situations conflict with the autonomy of patients and their rights, and can contribute to stressful situations for patients. Stress factors include hospital routines, which the patient cannot modify, and asymmetric relationships with staff, which encourage passivity. Conclusion All ethical problems detected by the students begin with the professional-patient relationship, including issues related to bad news, errors or malpractice. Reflection on the ethical values of nursing, both in the classroom and in clinical practices, allows students to develop a greater ethical awareness of care, enhancing their decision-making skills in ethical dilemmas. (shrink)

Background Ethical reasoning and sensitivity are always important in public health, but it is especially important in the sensitive and complex area of public health emergency preparedness. Here, we explored the ethical challenges, and dilemmas encountered by frontline health workers amid the coronavirus disease-19 (COVID-19) pandemic in Ethiopia. Methods A nationwide survey was conducted amongst the frontline health workers from nineteen public hospitals. Health workers were invited to respond to a self-administered questionnaire. Data were weighted and analyzed using descriptive (...) statistics. Results Of the 285 frontline health workers to whom questionnaires were distributed, 217 of them gave their responses (response rate 76.1%). Respondents frequently reported encountering rationing dilemmas on health commodities directly used for the prevention and treatment of COVID-19. Most (83.9%) of the health workers agreed that they encountered ethical challenges very frequently or frequently. Almost all [215(99.1%)] claimed that the limitation of resources was directly used for the treatment and prevention of COVID-19. The frequency of difficulty in the provision of essential clinical services varied between 77% and 98.7% for different services. More than half of the study participants reported that they had encountered difficulty in the provision of clinical care on a daily or weekly basis. Regarding rationing strategies, isolating COVID-19 treatment units and limiting admission were the most frequent rationing strategies used by two-thirds of health workers on a daily or weekly basis. Conclusion Front-line health workers encountered numerous ethically challenging situations during COVID-19. More than half of health workers reported that they encountered ethical challenges in rationing the resources and delivery of different clinical services such as family planning services, maternal and childcare, immunization, and chronic care. With limited resources such as ventilators and hospital beds, healthcare providers have been faced with the difficult task of deciding who gets access to these resources and who doesn't. Overall, the COVID-19 pandemic has presented numerous ethical challenges for healthcare providers, highlighting the importance of ethical considerations in healthcare delivery. By being aware of these dilemmas and having policies in place to address them, healthcare providers can ensure that they are providing the best possible care to their patients while upholding ethical standards. (shrink)

Distinct sources of stress have emerged during the COVID-19 pandemic. Particularly, fear is expected to generate significant psychological burden on individuals and influence on either unsafe behavior that may hinder recovery efforts or virus-mitigating behaviors. However, little is known about the properties of measures to capture them in research and clinical settings. To resolve this gap, we evaluated the psychometric properties of a novel measure of fear of illness and viruses and tested its predictive value for future development of (...) distress. We extracted a random sample of 450 Chilean adult participants from a large cross-sectional survey panel and invited to participate in this intensive longitudinal study for 35 days. Of these, 163 ended up enrolling in the study after the demanding nature of the measurement schedule was clearly explained to them. For this final sample, we calculated different Confirmatory Factor Analyses (CFA) to evaluate the preliminary proposed structure for the instrument. Complementarily, we conducted a content analysis of the items to qualitatively extract its latent structure, which was also subject to empirical test via CFA. Results indicated that the original structure did not fit the data well; however, the new proposed structure based on the content analysis did. Overall, the modified instrument showed good reliability through all subscales both by its internal consistency with Cronbach’s alphas ranging from 0.814 to 0.913, and with test–retest correlations ranging from 0.715 to 0.804. Regarding its convergent validity, individuals who scored higher in fears tended to also score higher in depressive and posttraumatic stress symptoms at baseline. Furthermore, higher fears at baseline predicted a higher score in posttraumatic stress symptomatology 7 days later. These results provide evidence for the validity, reliability, and predictive performance of the scale. As the scale is free and multidimensional potentially not circumscribed to COVID-19, it might work as a step toward understanding the psychological impact of current and future pandemics, or further life-threatening health situations of similar characteristics. Limitations, practical implications, and future directions for research are discussed. (shrink)

ObjectiveThis study aimed to better understand the current situation involving work stressors and the coping styles of outpatient and emergency nurses in 29 pediatric specialty hospitals across China. The study analyzed this correlation to provide a reference for the occupational stress management of pediatric nurses.MethodsFrom June to September 2020, 1,457 outpatient and emergency nurses in 29 pediatric specialty hospitals across China were selected as study participants, and a questionnaire survey was conducted using the Basic Information Questionnaire, the (...) Chinese version of the Work Stressor Scale for Nurses, and the Simple Coping Style Scale.ResultsThe assessed stress level of outpatient and emergency nurses in 29 tertiary pediatric specialty hospitals nationwide is lower than the results of the survey of the 2007 domestic norm, p < 0.05. The stressors related to nurses’ expectations, family conflicts, the nature of nursing work, patient factors, and workload were lower compared with the national norm. The positive coping style score on the Simple Coping Style Scale for pediatric outpatient nurses was, and work stressors were positively associated with negative coping styles. Multiple regression analysis showed that the influencing factors of work stressors among pediatric outpatient and emergency nurses correlated with the authorized size, age, working years of nurses, work department, and negative coping styles.ConclusionNegative coping styles were present among pediatric outpatient and emergency nurses and were associated with work stressors. The influencing factors of stressors mainly correlated with the clinical establishment, age, years of employment as a nurse, work department, and negative coping styles. (shrink)

Summary This paper presents and contextualizes the construct of Aesthetic Relational Knowing (ARK), as the intuitive experience of the therapist that emerges from the phenomenological field created in a meeting between therapist and client. The concept of isomorphism is considered as an epistemological turning point and a possible bridge connecting Gestalt therapy, Gestalt theory and Neurosciences. An example of the clinical consequences of this change of perspective is given. Moreover, a validation pilot study has shown that ARK is described (...) by three factors: empathy, resonance and bodily awareness. The ARK can be defined as a three-dimensional construct that supports the positive use of the therapist’s perception in terms of aesthetic knowing of the phenomenological field of the therapeutic situation. The construct of Aesthetic Relational Knowing can be considered a phenomenological, aesthetic and field-oriented contribution to psychotherapy training, supervision and research. (shrink)

The article explores the underlying reasons for patients’ self‐perception of being a burden (SPB) in family settings, including its impact on relationships when wishes to die (WTD) are expressed. In a prospective, interview‐based study of WTD in patients with advanced cancer and non‐cancer disease (organ failure, degenerative neurological disease, and frailty) SPB was an important emerging theme. In a sub‐analysis we examined (a) the facets of SPB, (b) correlations between SPB and WTD, and (c) SPB as a relational phenomenon. We (...) analyzed 248 interviews with 62 patients, their family caregivers, and professionals using grounded theory and interpretive phenomenological analysis. SPB appeared as important empathic concern in care situations. Patients expressed many sorts of concerns for others, but also perceived an altered self‐understanding that did not meet mutual expectations within relationships. In SPB associated with WTD three constellations were found: (a) WTD to unburden others; (b) patients decided against hastening death to prevent being a further burden to others (in these cases, the SPB counteracted the wish to die); and (c) both wishes for and against dying were sustained by SPB. These patients often felt paralyzed and suffered deeply. Family caregivers felt emotionally touched by SPB and tried to unburden patients by caring and compassion. We concluded that the impact of SPB on a WTD and the various meanings the facets of SPB have in balancing relationships need to be worked out individually. An early palliative and narrative approach is warranted. (shrink)