Rogelio Altisent

An International Consensus Definition of the Wish to Hasten Death and Its Related Factors

Background The desire for hastened death or wish to hasten death (WTHD) that is experienced by some patients with advanced illness is a complex phenomenon for which no widely accepted definition exists. This lack of a common conceptualization hinders understanding and cooperation between clinicians and researchers. The aim of this study was to develop an internationally agreed definition of the WTHD. Methods Following an exhaustive literature review, a modified nominal group process and an international, modified Delphi process were carried out. The nominal group served to produce a preliminary definition that was then subjected to a Delphi process in which 24 experts from 19 institutions from Europe, Canada and the USA participated. Delphi responses and comments were analysed using a pre-established strategy. Findings All 24 experts completed the three rounds of the Delphi process, and all the proposed statements achieved at least 79% agreement. Key concepts in the final definition include the WTHD as a reaction to suffering, the fact that such a wish is not always expressed spontaneously, and the need to distinguish the WTHD from the acceptance of impending death or from a wish to die naturally, although preferably soon. The proposed definition also makes reference to possible factors related to the WTHD. Conclusions This international consensus definition of the WTHD should make it easier for clinicians and researchers to share their knowledge. This would foster an improved understanding of the phenomenon and help in developing strategies for early therapeutic intervention.

Health Care Ethics Consultation. Individual Consultant or Committee Model?: Pros and Cons

The American Society for Bioethics and Humanities is to be congratulated on its updating of competency standards for ethics consultations (Tarzian and ASBH Core Competencies Update Task Force 2013). These will be of great assistance to ethics committees all over the world, given that quality assessment for this service has had extremely limited implementation in many countries. The report defines “ethics consultation” as a service that can be provided by one person or by a group. In other words, consultation can be made individually by an individual consultant or by several people together in what is traditionally known as an ethics committee. Both models are analyzed by Tarzian and colleagues from the perspective of skill competencies requiered in order to carry out this advisory function. However, it would also be very useful to consider their respective advantages and drawbacks, taking into account the repercussion that these models have in facilitating ethics consultation in health care delivery and in the quality of service. The individual consultant model, more common in the United States, offers greater ease of access and more speed and flexibility for the consultation process. For a health care professional considering making a request for assistance for an ethical problem, it is more practical to turn to a consultant, who can be located and contacted in the space of a few hours, than to think of attending a committee meeting that is held intermittently. Intuitively, this can be likened to a clinical referral situation in which assistance is requested from another specialist: Initiating a consultation process with a colleague who can provide a response within a short period of time is not the same as waiting for a diagnostic session to be held in which the team can discuss the case. However, gains in speed and flexibility can have an adverse effect on the quality of the response, which theoretically would come with greater guarantees when it is the result of the deliberation of a committee that provides a wealth of different perspectives, something that is difficult for an individual consultant to achieve.

Are Ethics Committees in Tune With the “Epidemiology of Ethical Issues”?

Health care ethics committees (ECs) have proliferated over the last 50 years as a consequence of the progressive development of academic bioethics. However, their form of operation is neither homogeneous nor fully satisfactory, and they present a great degree of variability throughout the world, rather like the children of a large family, each with different levels of growth and maturity. The article by Frolic and colleagues (2012) opens the black box to one of their traditional functions: institutional policies on ethical questions. It is a sound article that explains—to the envy of many of us—the excellent work methodology developed by this particular group, and analyzes the quality of the review process as applied to two case studies that are recognizable at any latitude because of their relevance: Advertising Policy and Pediatric Jehovahs Witness Blood Transfusion Policy. However, we should take advantage of the singular nature of both these issues in order to call attention to whether the activities of institutional review boards are in tune with the epidemiology of the ethical issues arising in the daily existence of the institutions they serve. The question we should ask is whether ECs devote their greatest efforts to the most appropriate issues, owing to their prevalence and transcendence, either in clinical cases that cause ethical doubts to arise during the decision-making process, or as ethical guidelines for common areas of clinical practice where there is a significant moral dimension, and, naturally, in the content and form of the educational activity that ECs should be leading. Many institutional review boards can be reproached for existing in a parallel universe to the daily health care provision activities of their institution, as if they were part of a failed marriage—sharing a roof but rarely sitting down to talk, and only doing so when there are serious conflicts that leave them with no choice but to make an urgent decision. In other words, ECs may be seen to be a somewhat removed from reality owing to their being out of tune with the real daily concerns of the institution. EC members often complain among themselves that they receive few consultations, although this is scarcely reflected in the literature, and then only indirectly (DuVal et al. 2004; McLean 2007). There is a perception that the activity of ECs is excessively linked to the initiatives and motivation of their members. Consultations from professionals are few, either due to the little awareness that exist about the function of these committees, or as a result of skepticism, or because of a lack of basic education in ethics and in decision-making procedures (Altisent, Batiz, and Torrubia 2008). On the other hand, special mention should also be made of the reluctance of some doctors to seek consultation because this would mean acknowledging to their teams and to EC members that they were unable to resolve a problem, which would require humility—a genuine challenge for doctors, perhaps to a greater extent than for other health care professionals. This situation has been overcome in a number of institutions through the activity of clinical ethics consultants, who may or may not be members of an EC, offering personalized attention to those calling for advice. This is a tradition with little presence in Europe (Hurst et al. 2007). Our group has had an interesting experience over the last decade arising from the activity of a primary health care EC in the Spanish region of Aragon, with a population of little more than 1 million inhabitants. We suspected that there was lack of coincidence between the activity of the EC and the ethical concerns of health care professionals in their daily practice, which led us to research the prevalence of ethical issues considered by family physicians in their practices. We found that of the top 10 most prevalent ethical problems, according to frequency and difficulty, the highest ranked were ethical issues arising in the relationship between levels of health care (Buil et al. 2009): in other words, in the coordination between the primary and secondary levels (“induced prescription”—prescription of drugs recommended by other doctors/specialists, lack of agreement in care plans, delays in interdisciplinary consultations, etc.) Surprisingly, over a period of 12 years, our EC had hardly analyzed any consultations on these types of issues, which, likewise, were barely dealt with in the literature. So, what were we doing? Who were we advising and about what? This reflection led us to adapt the educational activities we should have been leading to the real ethical concerns in primary health care. Additionally, we questioned the risks involved with an EC devoted to the interests of a minority of professionals that were particularly motivated by bioethics. This would be analogous to the intention of organizing the health care of a poor, developing country and beginning with the construction of a hospital for transplants and equipped with a huge intensive care facility, when the priority needs of that country were in fact vaccines, food, and sanitation. This is why we have proposed for our region the addition to the traditional trinity of EC functions—ethics education, case consultation, and policy work—the promotion of research into the ethical issues faced by health care professionals in their different specialities within the ECs working area. This fourth function would serve as an epidemiological observatory for ethical issues that would enable education in ethics to be directed towards the real needs of those professionals. We believe that this will create a greater understanding between the EC and professionals, and this will lead to a higher number of consultations and to the efficiency of invested resources. In some countries there are ECs that have reached the level of maturity and excellence shown by Frolic and colleagues’ target article, with experience enabling them to offer transparent and validated criteria for the ethical evaluation of policy work. However, in other places in the world, ECs are excessively focused on extreme cases, such as advising on withdrawal life support measures (Goldim et al. 2008; Orlowksi et al. 2006). Meanwhile, they barely analyze ethical problems that are present in daily life: the relationship between doctors and the drug industry, the difficulties of working in teams caused by the weak ethical commitment of their components, inadequate ways of providing information to patients’ relatives, abuse of public health resources by some patients, and so on. For the management of some health care institutions, ECs are decorative figures that have little influence on health outcomes, and they may be seen to be driven and led by a minority of professionals who are highly motivated by humanistic aspects of medicine, but with a bias that distances them from the majority. ECs need to demonstrate their efficiency in order to convince managers that they make meaningful contributions to the quality of health care. For this to occur, we need to broaden the horizons of ECs to bring them closer to the majority of health care professionals and enable them to provide direction and relevant guidance to daily decisions. In order for ECs to become aware of the “epidemiology” of the ethical issues in their environment, they will need to carry out studies and surveys using quantitative and qualitative methodologies (Larcher, Slowther, and Watson 2010; Slowther, McClimans, and Price 2012). As a consequence of having this type of knowledge, ECs should be able to produce a special kind of policy work that we could call “ethical alerts,” by means of brief statements issued to all the professionals in an institution, providing a short explanation of a current issue they may be of general interest: the abstract of a recently published article, a news item of moral significance, commentaries over the practical implications of a point of law (legal requirement), or general guidelines. In short, these would form a series of regularly released statements that would not be of a scholarly nature or related to the personal interests of EC members, but resulting from the evidence of real need. Thus, we could contribute to the appreciation of ECs by health care professionals, narrowing the gap between them and strongly defending the standing of committees as spaces that work to build awareness in an institution and contribute to the quality of its activity.

A concept analysis of professional commitment in nursing

Background: The concept of professional commitment is being widely studied at present. However, although it is considered an indicator for the most human part of nursing care, there is no clear definition for it, and different descriptors are being used indiscriminately to reference it. Objective: The aim of this study is to clarify the concept of professional commitment in nursing through the Rodgers’ evolutionary concept analysis process. Design: Systematic search using English and Spanish descriptors and concept analysis. Studies published between 2009 and June 2015, front-to-back analysis of the Nursing Ethics journal and manual check of articles cited in studies related to the Nijmegen Professionalism Scale. Research design: The procedure of concept analysis developed by Rodgers was used. Ethical considerations: Although the topic was not labeled as sensitive and subject to ethical approval, its realization was approved by the Ethical Committee of Clinical Research of Aragon (CEICA) approved the study on 18 March 2015 and also careful procedures have been followed according to ethics expressed in the Declaration of Helsinki. Findings and discussion: A total of 17 published studies. A clear definition of the concept was made, and surrogate terms, concept dimension, differential factors related to the concept, sociocultural variations and consequences for nursing practice were identified. Conclusion: There is a need for continuous advancement in the development of the concept, specific actions to encourage this and the improvement of evaluation methods for its study.

Análisis de la maduración del juicio moral en el proceso de aprendizaje de la bioética

Objetivo. Medir el razonamiento moral de los estudiantes de medicina antes y despues de recibir formacion en bioetica en dos ambitos culturales diferentes (Zaragoza y Doha) y de los residentes al inicio de su residencia (MIR1), correlacionando el razonamiento moral con el ambito cultural y el ambiente de aprendizaje. Sujetos y metodos. Estudio observacional transversal del razonamiento moral con estudiantes de medicina y MIR1 y de intervencion con seguimiento longitudinal del razonamiento moral antes y despues de la formacion en bioetica, utilizando el test de razonamiento moral de Lind. Resultados. Se obtuvieron 273 cuestionarios iniciales de estudiantes (200 de zaragoza y 73 de Qatar) y 141 de MIR1. Se tiene informacion antes y despues de 122 estudiantes (44,7% del total), una quinta parte de Qatar. Antes de bioetica, la media del C-score era de 14,24+-8,698 (n=273). Despues, la media era de 14,30+-10,111 (n=194). La diferencia media antes-despues fue de 0,79+-12,162 (n=122). No hay diferencias del C-score por region, pero si al dicotomizarlo en pre-convencional ( =10): 49%<10 en Qatar frente a 30% en Zaragoza. Tambien hay diferencias significativas en las respuestas dadas a los dos dilemas que conforman el test de razonamiento moral entre ambas regiones. Los MIR de Zaragoza muestran el mismo patron de respuestas ante los dilemas que los estudiantes, pero su C-score es significativamente inferior (10,4 frente a 14,3). Conclusiones. Se confirman las hipotesis iniciales, aunque conviene profundizar en esta linea de investigacion durante mas cursos academicos, o incluyendo otros campus universitarios de las mismas zonas culturales.

LA ÉTICA DEL DESARROLLO PROFESIONAL CONTINUADO EN LA PROMOCIÓN DE LA CALIDAD ASISTENCIAL

Ethics has always being present in a more or less explicit way in health care quality; nevertheless, there has not been paid attention enough to the power of quality found in the ethical drive and attitudes of professionals who are leaders in improvement processes. The continuous professional development is a process which must accompany successive stages of professional life with different motivational moments and periods of crisis, for which understanding its ethical basis is convenient by reflecting about health care quality. Professionals who care patients also need attention to diagnose and overcome inertia, lack of initiative, skepticism and lack of self criticism situations. Health care quality can only be guarantee if professionals develop a satisfactory progress in their career, for which it is necessary that personal services and human resources of health care institutions devote their best energies in the promotion of their professionals.Ethics has always being present in a more or less explicit way in health care quality; nevertheless, there has not been paid attention enough to the power of quality found in the ethical drive and attitudes of professionals who are leaders in improvement processes. The continuous professional development is a process which must accompany successive stages of professional life with different motivational moments and periods of crisis, for which understanding its ethical basis is convenient by reflecting about health care quality. Professionals who care patients also need attention to diagnose and overcome inertia, lack of initiative, skepticism and lack of self criticism situations. Health care quality can only be guarantee if professionals develop a satisfactory progress in their career, for which it is necessary that personal services and human resources of health care institutions devote their best energies in the promotion of their professionals.

Correction: An International Consensus Definition of the Wish to Hasten Death and Its Related Factors

[This corrects the article DOI: 10.1371/journal.pone.0146184.].

Resident Physicians as Patients: Perceptions of Residents and Their Teaching Physicians

ObjectiveThis study aims to broaden understanding into the process by which resident physicians deal with illness and to identify areas for improvement regarding healthcare of residents and teaching physicians training to support them adequately.MethodsA qualitative study of ten semi-structured interviews with residents who had suffered a serious illness and a focus group of teaching physicians were conducted. Analysis of the interview transcripts was performed using the grounded theory approach, with information divided into five categories: Differences between residents as patients and general patients; confidentiality; feelings and attitudes; learning from illness; and impact on work and training.ResultsThere are differences between residents and the general population: In the initial stage, diagnosis is made promptly with preferential treatment shown by colleagues. Subsequently, the lack of clear guidelines can lead to poor follow-up. They accept a loss of confidentiality in the process. One of the most serious concerns felt by residents is the impact of their illness on their training as specialists, meaning that teaching physicians are charged with the important role of guaranteeing the resident’s proper recovery, return to work, and readaptation to the training program. Teaching physicians demand their own training be reinforced in these aspects.ConclusionThere is a need to assess the great diversity observed in training-related decisions made by teaching physicians when residents fall ill. Given the differences observed, more research is required to improve the care provided to sick residents and particularly the teaching physicians training to handle them.

A ÉTICA DO DESENVOLVIMENTO PROFISSIONAL CONTINUADO NA PROMOÇÃO DA QUALIDADE ASSISTENCIAL

Ethics has always being present in a more or less explicit way in health care quality; nevertheless, there has not been paid attention enough to the power of quality found in the ethical drive and attitudes of professionals who are leaders in improvement processes. The continuous professional development is a process which must accompany successive stages of professional life with different motivational moments and periods of crisis, for which understanding its ethical basis is convenient by reflecting about health care quality. Professionals who care patients also need attention to diagnose and overcome inertia, lack of initiative, skepticism and lack of self criticism situations. Health care quality can only be guarantee if professionals develop a satisfactory progress in their career, for which it is necessary that personal services and human resources of health care institutions devote their best energies in the promotion of their professionals.Ethics has always being present in a more or less explicit way in health care quality; nevertheless, there has not been paid attention enough to the power of quality found in the ethical drive and attitudes of professionals who are leaders in improvement processes. The continuous professional development is a process which must accompany successive stages of professional life with different motivational moments and periods of crisis, for which understanding its ethical basis is convenient by reflecting about health care quality. Professionals who care patients also need attention to diagnose and overcome inertia, lack of initiative, skepticism and lack of self criticism situations. Health care quality can only be guarantee if professionals develop a satisfactory progress in their career, for which it is necessary that personal services and human resources of health care institutions devote their best energies in the promotion of their professionals.

Ethics of continuous professional development in the promotion of health care quality

Ethics has always being present in a more or less explicit way in health care quality; nevertheless, there has not been paid attention enough to the power of quality found in the ethical drive and attitudes of professionals who are leaders in improvement processes. The continuous professional development is a process which must accompany successive stages of professional life with different motivational moments and periods of crisis, for which understanding its ethical basis is convenient by reflecting about health care quality. Professionals who care patients also need attention to diagnose and overcome inertia, lack of initiative, skepticism and lack of self criticism situations. Health care quality can only be guarantee if professionals develop a satisfactory progress in their career, for which it is necessary that personal services and human resources of health care institutions devote their best energies in the promotion of their professionals.Ethics has always being present in a more or less explicit way in health care quality; nevertheless, there has not been paid attention enough to the power of quality found in the ethical drive and attitudes of professionals who are leaders in improvement processes. The continuous professional development is a process which must accompany successive stages of professional life with different motivational moments and periods of crisis, for which understanding its ethical basis is convenient by reflecting about health care quality. Professionals who care patients also need attention to diagnose and overcome inertia, lack of initiative, skepticism and lack of self criticism situations. Health care quality can only be guarantee if professionals develop a satisfactory progress in their career, for which it is necessary that personal services and human resources of health care institutions devote their best energies in the promotion of their professionals.