Perspectiva bioética de la adecuación del esfuerzo terapéutico en pacientes adultos terminales. Revisión sistemática / Bioethical perspective of the limitation of therapeutic effort in adult terminal patients. Systematic review

Introducción: Ante la capacidad de mantenimiento de las funciones vitales de forma artificial, surgen nuevas preocupaciones éticas en los profesionales sanitarios en relación con la muerte. Se cuestiona desde la ética si el equipo asistencial debe hacer siempre todo lo necesario y posible para impedir la muerte de un paciente. Objetivo: Analizar los aspectos bioéticos de la limitación del esfuerzo terapéutico en pacientes en el final de la vida, fomentar la reflexión y contribuir a mejorar los cuidados en el final de la vida. Método: Se realizó una revisión narrativa e integradora de la literatura científica mediante la búsqueda de publicaciones en metabuscadores y bases de datos de PubMed, SciELO y la revista de Nursing Ethics. Se identificaron 6.325 estudios publicados a partir de 2018 y se incluyeron un total de 9 artículos. Resultados/Discusión: Se describen las dificultades que presentan los profesionales en relación a la toma de decisiones en el final de la vida, la necesidad de mejorar la formación en ética y en aspectos relacionados con pacientes que se encuentran en sus últimos días, los cuidados paliativos y la limitación del esfuerzo terapéutico. Solo una minoría de los estudios están enfocados en enfermería. Conclusiones: Las decisiones del profesional están influenciadas por valores, emociones, creencias y experiencias, que unidas a la dificultad que existe en ocasiones para establecer un diagnóstico clínico certero, dificulta las decisiones de limitación de esfuerzo terapéutico. Se hace necesario mejorar la formación en ética y conocimiento de los procesos de final de la vida por parte de los profesionales. (AU)

Introduction: Faced with the ability to maintenance vital functions artificially, new ethical concerns arise among health professionals regarding death. It is been questioned from ethics if the care team should always do everything necessary and possible to prevent the death of a patient. Objective: to analyze the bioethical aspects of limiting therapeutic effort in end-of-life patients, encourage reflection and contribute to improving end-of-life care. Method: a narrative and integrative review of the scientific literature was performed by searching for publications in meta-search engines and databases of PubMed, SciELO and the journal of Nursing Ethics. A total of 6,325 studies published since 2018 were identified and a total of 9 articles were included. Results/Discussion: Issues presented by professionals regarding making-decisions at the end of life, the need to improve training in ethics and aspects related to patients in their last days, palliative care and the limitation of therapeutic effort are described. Only a minority of studies are focused on nursing. Conclusions: professional's decisions are influenced by values, emotions, beliefs and experiences, which, together with the difficulty that sometimes exists to establish an accurate clinical diagnosis, makes it difficult to limit therapeutic effort. It is therefore necessary to improve training in ethics and knowledge about end-of-life processes from professionals. (AU)

Decision-making in an emergency department: A nursing accountability model.

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.

Ethical, legal and professional accountability in emergency nursing practice: An ethnographic observational study.

INTRODUCTION: Accountability in nursing practice is a concept that influences quality care, decision-making, safety standards and staff values. Therefore, understanding accountability and how it affects nursing practice could improve patient care and nurses' working conditions. AIM: The aim of this study was to find factors that influenced ethical, legal and professional accountability in emergency nursing practice. METHODS: A qualitative ethnographic approach using participant observation through convenience sampling was employed as the data collection method, while ethnographic content analysis was used for data analysis. RESULTS: The factors linked to nursing accountability found were classified into four main themes: daily dynamics, work environment evolution, customs and routines and bioethics principles' application. DISCUSSION: The long-term effect of chronic high workload and crowding, which affects nursing accountability, could promote burnout in a junior ED workforce. Changes in the nurses' working conditions need to be implemented to limit the workload to which an ED nurse is subjected to. CONCLUSION: ED nurses have to manage their accountability in difficult situations regularly, which followed patterns of four main themes across the majority of situations. Nonetheless, all those factors were influenced by nursing workload, an ever-present factor that was always considered by ED nurses during decision-making.

The development of a clinical policy ethics assessment tool.

INTRODUCTION: Clinical policies control several aspects of clinical practice, including individual treatment and care, resource management and healthcare professionals' etiquette. This article presents Clinical Policy Ethics Assessment Tool, an ethical assessment tool for clinical policies that could be used not only by clinical ethics committees but also by policy committees or other relevant groups. AIM: The aim of this study was to find or create a tool to identify ethical issues and/or confirm ethical validity in nursing practice policies, protocols and guidelines. METHODOLOGY: The development of Clinical Policy Ethics Assessment Tool involved first a literature review, followed by modification of the Research Protocol Ethics Assessment Tool, which was created to identify research protocols' ethical issues, and finally, a trial of Clinical Policy Ethics Assessment Tool to ensure its reliability and validity. ETHICAL CONSIDERATION: The policies analysed trialling Clinical Policy Ethics Assessment Tool were in the public domain and did not contain any confidential information. Despite that, Clinical Policy Ethics Assessment Tool also had the approval of a research ethics committee. RESULTS: Research Protocol Ethics Assessment Tool was chosen as the template for a Clinical Policy Ethics Assessment Tool, to which several modifications were added to adapt it to work within a nursing practice context. Clinical Policy Ethics Assessment Tool was tested twice, which resulted in a general test-retest reliability coefficient = 0.86, r = 0.84, α1 = 0.817, α2 = 0.824 and interclass correlation coefficient = 0.874. DISCUSSION: Contemporary nursing practice in a developed country is often ruled by clinical policies. The use of Clinical Policy Ethics Assessment Tool could confirm the ethical validity of those clinical practice policies, impacting on nurses' education, values and quality of care. CONCLUSION: Clinical Policy Ethics Assessment Tool has the potential to detect ethical issues and facilitate the correction and improvement of clinical policies and guidelines in a structured way. This is especially so as it has shown reliability in detecting issues in clinical policies involving human participants and in encouraging policymakers to consider common ethical dilemmas in nursing practice.