ABSTRACT
OBJECTIVES: The clinical practice guidelines published by the Renal Physicians Association (USA) recommend instituting advance care planning (ACP) for patients with end-stage renal disease. Studies on this issue are lacking in Italy. Our aim was to determine the attitudes of patients on ACP in our dialysis centre. METHODS: We performed a cross-sectional survey. We recruited patients on maintenance haemodialysis (HD) at Hemodialysis Center of Università Cattolica del Sacro Cuore, from 1 March 2014 to 31 March 2015. The only exclusion criterion was inability to give an informed consent. Patients completed a questionnaire concerning their treatment preferences in three hypothetical disease scenarios: persistent vegetative state, advanced dementia, severe terminal illness; for each patients, we also collected clinical, functional and socioeconomic data. RESULTS: Thirty-four HD outpatients completed the study questionnaire. The majority of respondents (85%) considered information about prognosis, health conditions and treatment options, including withdrawing dialysis, as very important and 94% of respondents considered treatment of uraemic/dialytic symptoms the most important issue. In the health scenarios provided, dialysis was the treatment least withheld. Dependence on instrumental activities of daily living (0.048) and higher Charlson Comorbidity Index scores (p=0.035) were associated with continuing dialysis in at least one scenario. CONCLUSIONS: ACP should be tailored to patients' value, culture and preferences. A significant proportion of patients, however, do not want to be involved in end of life decisions. Frail elderly patients, in particular, are not inclined to interrupt dialysis, despite poor quality of life or a poor prognosis.
Subject(s)
Advance Care Planning , Health Knowledge, Attitudes, Practice , Outpatients/psychology , Renal Dialysis/psychology , Aged , Decision Making , Female , Humans , Italy , Male , Middle Aged , Quality of Life , Surveys and Questionnaires , Terminal CareABSTRACT
Although existing clinical evidence shows that the transfusion of blood components is becoming increasingly safe, the risk of transmission of known and unknown pathogens, new pathogens or re-emerging pathogens still persists. Pathogen reduction technologies may offer a new approach to increase blood safety. The study is the output of collaboration between the Italian National Blood Centre and the Post-Graduate School of Health Economics and Management, Catholic University of the Sacred Heart, Rome, Italy. A large, multidisciplinary team was created and divided into six groups, each of which addressed one or more HTA domains.Plasma treated with amotosalen + UV light, riboflavin + UV light, methylene blue or a solvent/detergent process was compared to fresh-frozen plasma with regards to current use, technical features, effectiveness, safety, economic and organisational impact, and ethical, social and legal implications. The available evidence is not sufficient to state which of the techniques compared is superior in terms of efficacy, safety and cost-effectiveness. Evidence on efficacy is only available for the solvent/detergent method, which proved to be non-inferior to untreated fresh-frozen plasma in the treatment of a wide range of congenital and acquired bleeding disorders. With regards to safety, the solvent/detergent technique apparently has the most favourable risk-benefit profile. Further research is needed to provide a comprehensive overview of the cost-effectiveness profile of the different pathogen-reduction techniques. The wide heterogeneity of results and the lack of comparative evidence are reasons why more comparative studies need to be performed.
Subject(s)
Blood Safety/methods , Blood Transfusion , Plasma/microbiology , Plasma/virology , Animals , Bacteria/isolation & purification , Blood Transfusion/methods , Disinfection/methods , Humans , Transfusion Reaction , Viruses/isolation & purificationABSTRACT
The contribution describes a case report addressed in 2011 by the clinical ethics consultation service team of the Institute of Bioethics and Medical Humanities at the "Agostino Gemelli" School of Medicine of the Università Cattolica del Sacro Cuore, Rome (Italy). The clinical case regards ethical dilemmas about the patient's prospects for receiving an orthotopic liver transplant, because she was a non-resident and lacked a caregiver to assist her during the follow-up period, as well as a place to stay after liver transplant surgery.
El artículo presenta un caso clínico, dirigido en el año 2011 por el equipo de servicio de consulta ética clínica del Instituto de Bioética y Humanidades Médicas de la Facultad "Agostino Gemelli" de Medicina de la Universidad Católica del Sacro Cuore en Roma (Italia). El caso clínico se refiere a los dilemas éticos sobre las perspectivas del paciente para recibir un trasplante hepático ortotópico porque no era residente del país y carecía de un cuidador para asistirlo durante el periodo de seguimiento, así como de un lugar para quedarse después de la cirugía.
Este artigo apresenta um caso clínico dirigido em 2011 pela equipe de serviço de consulta ética clínica do Instituto de Bioética e Humanidades Médicas da Faculdade de Medicina Agostino Gemelli, da Università Cattolica del Sacro Cuore (Roma, Itália). O caso clínico se refere aos dilemas éticos sobre as perspectivas da paciente para receber um transplante hepático ortotópico porque não era residente do país, carecia de um cuidador para assisti-la durante o período de observação e de um lugar para ficar depois da respectiva cirurgia.
Subject(s)
Humans , General Surgery , Bioethics , Liver Transplantation , Caregivers , EthicsABSTRACT
Since chronic hepatitis C has mostly become curable, issues concerning choice and allocation of treatment are of major concern. We assessed the foremost ethical issues in hepatitis C virus therapy with 1st generation protease inhibitors using the personalist ethical framework within the health technology assessment methodology. Our aim was to identify values at stake/in conflict and to support both the physicians' choices in hepatitis C therapy and social (macro-) allocation decision-making. The ethical assessment indicates that: (1) safety/effectiveness profile of treatment is guaranteed if its use is restricted to the patients subgroups who may benefit from it; (2) patients should be carefully informed, particularly on treatment deferral, and widespread information on these therapies should be implemented; (3) since treatment was proven to be cost-effective, its use is acceptable respecting resource macro-allocation. Concerning individual (micro-) location criteria: (a) criteria for eligibility to treatment should be clearly identified and updated periodically; (b) information on criteria for eligibility/deferral to treatment for specific patients' subgroups should be made widely known. Interferon-based regimens will disappear from use within the next year, with the introduction of highly effective/tolerable combination regimens of direct-acting antivirals, thus profoundly changing social choices. Nonetheless, our model could support future ethical assessment since the evaluation pertaining ethical domains remains generally applicable.
Subject(s)
Cost-Benefit Analysis/ethics , Drug Therapy, Combination/ethics , Ethics, Medical , Hepacivirus/drug effects , Hepatitis C/drug therapy , Protease Inhibitors/therapeutic use , Adult , Aged , Antiviral Agents/administration & dosage , Antiviral Agents/economics , Antiviral Agents/therapeutic use , Cost-Benefit Analysis/economics , Decision Making , Drug Therapy, Combination/methods , Female , Hepacivirus/pathogenicity , Hepatitis C/virology , Humans , Male , Middle Aged , Protease Inhibitors/administration & dosage , Protease Inhibitors/economicsABSTRACT
Con la expresión contracepción de emergencia, también llamada contracepción postcoital, se indica un conjunto de prácticas a las que se recurre luego de una relación sexual presuntamente fecundante, con el fin de impedir el desarrollo de un embarazo cuando ya se ha iniciado. La reciente comercialización en Italia de la pildora Norlevo ha suscitado un debate abierto ya en el ámbito internacional, donde se realizan estas estrategias, en las que se ven implicadas adolescentes y víctimas de violencia. Después de haber descrito los diversos protocolos y productos en uso para tal fin, a la luz de los datos encontrados en la literatura internacional, las autoras han puesto en evidencia cómo -no obstante un efecto de inhibición de la ovulación, en realidad en gran parte entre el 70 y el 100 por ciento de los casos- el mecanismo de acción de estos productos es abortivo y no contraceptivo. En efecto, tales productos impiden la continuación del embarazo mediante su acción sobre el cuerpo lúteo, la trompa y, en particular, el endometrio: tres efectos que interfieren con la fase postfertilización; por lo tanto, evitan el desarrollo del embrión, ya presente si la relación sexual ha sido fecunda. En suma, las autoras evidencian la manipulación semántica aplicada ya en el ámbito científico o en el institucional, para mejorar la aceptabilidad por parte de la opinión pública, de lo cual surge la necesidad de dar a las mujeres información clara y objetiva sobre el real mecanismo de acción de estos productos, respecto al eventual desarrollo de un embarazo.
