Análisis de una experiencia de consultoría ético clínica en cuidado intensivo / Analysis of a clinical ethics consultation experience in intensive care

Background: Very few patients are presented to ethics committees, and individual ethics consultations are a response to this situation. At the intensive care unit (ICU) in Clínica Alemana, Santiago Chile, an ethics consultation system was organized coordinated with the ethics committee. Aim: To report an evaluation of this ethics consultation system. Material and Methods: Analysis of the frst 50 cases analyzed in the consultation system. Analysis of the responses of intensive care physicians to a questionnaire about the main ethical problems that they face in their work. Results: The consultation system is mainly required by the ICU staff, and reports to the ethics committee. Fifty four percent of patients subjected to consultation were aged over 80 years. The main diagnoses were neurological, oncological or cardiopulmonary problems. The ethical problems identifed were treatment limitation (62 percent), proportionality or futility (42 percent), need of a peaceful death (36 percent), lack of anticipated decisions (28 percent), disagreement between physicians and patient’s family (24 percent), undefined subrogation (14 percent), and abuse of public resources (14 percent). Twenty six of 31 ICU physicians answered the questionnaire, using a 1 (min) to 7 (max.) scale. They found that consultation is helpful for decision making (6.3), useful for improving ethical perception (6.0), supportive for staff (6.5), good for patients (6.3), supportive for families (6.7), and timely performed (5.2). Conclusions: As a complement for the ethics committee’s work, consultation is a valid alternative for ethics counselling and a support for physicians and patient’s families. Its implementation depends on the particularities of each health institution.

Subdiagnóstico de delirium en adultos mayores hospitalizados / Delirium in Chilean elderly inpatients: an overlooked problem

Background: Delirium is a common underdiagnosed and undertreated problem in elderly inpatients, associated to higher morbidity, mortality and health cost. Aim: To evaluate the prevalence of delirium at hospital admission in medically ill elderly patients and the attending physician's diagnosis and treatment of delirium. Patients and methods: In a prospective and descriptive study, consecutive patients aged 65 years or more, admitted to an internal medicine ward were evaluated by independent physicians, during the first 48 h of admission, to asses the presence of delirium. Diagnosis of delirium was based on the Confusion Assessment Method. Medical and nurse records were reviewed. Family was interviewed when necessary. Results: One hundred eight patients (52% women, age range 65-94 years) with an APACHE II score of 11.6±5, were evaluated. Fifty seven patients (53%) had delirium (32% hyperactive, 72% hypoactive and 5% mixed). Delirium prevalence was significantly higher in older patients (66% among those aged 75 years or older versus 30% in younger, p <0.05) and among patients with more severe conditions (88% among those with an APACHE score over 16 versus 47% below that value, p <0.05). Medical records of patients with delirium showed that this diagnosis was present only in 32% and cognitive deficit was described in 73%. Ten percent of patients with delirium received sedative medication and 38% were physically restricted. There were no environmental interventions to prevent or control delirium. Conclusions: Delirium in elderly inpatients at this unit is an extraordinarily prevalent problem, seriously under diagnosed (68%) and under treated. This study should alerts our medical community to improve the diagnosis and management of delirium in elderly inpatients.