Prevalence of ethical dilemmas in advanced cancer patients (secondary analysis of the PALCOM study).

PURPOSE: The main aim of this study was to determine the prevalence of ethical dilemmas in the end-of-life process in advanced cancer patients. METHODS: We carried out a multicenter, cross-sectional, observational, prospective study in a cohort of cancer patients whose life expectancy was ≤ 6 months. We recorded sociodemographic characteristics, diagnosis of cancer, symptom burden, cognitive and functional status, emotional impact, and sociofamilial risk factors. The main outcome measure was the detection of ethical dilemmas, based on the following definition: conflict in decision-making during the end-of-life process that involves the need to choose between morally acceptable opposing options, where none is clearly preferable to another. RESULTS: We included 324 patients (mean age, 69 years; 58% men). We identified 117 dilemmas in 90 patients (27.8%). The dilemmas detected were as follows: (a) conflicts of information (adaptive denial, conspiracy of silence, information exceeding patient's desired limit), 15.7%; (b) discrepancies in proportionality (discussion on futility, rejection of treatment, withdrawal of life support measures), 16.7%; (c) unrealistic expectations about the outcome of clinical trials, 2.5%; and (d) request for euthanasia or medically assisted suicide, 1.2%. We observed a greater prevalence of ethical dilemmas in men, in patients receiving active cancer treatment, and in patients with emotional distress (p < 0.05). CONCLUSIONS: The prevalence of ethical dilemmas during the end-of-life process in cancer patients is relevant. Most dilemmas were associated directly or indirectly with respect for patient autonomy. In this context, the communication skills of the health professionals and advanced care planning take on a key role.

The workers opinions have a value in the Code of Ethics: Analysis of the contributions of workers in virtual Forum Catalan Institute of Health.

BACKGROUND: The Catalan Institute of Health (CIH) is the largest health services public provider in Catalonia. "CIH Code of Ethics Virtual Forum" (CEVF), was created within the Intranet of the CIH to facilitate participation among their employees. The current study aims to: a) Analyse the CIH workers' assessment of their own, their colleagues' and the organization's observance of ethical values; b) Identify the opinions, attitudes, experiences and practices related to the ethical values from the discourse of the workers that contributed voluntarily to the CEVF. METHODS: Mixed methods study with convergent parallel design: 1. Cross sectional study by means of a self-administered, ad hoc, anonymous questionnaire to assess the observance of the ethical values of the CIH according to the participants. A total of 712 workers responded to the questionnaire. A descriptive, bivariate analysis of the results was carried out. 2. Qualitative study to determine the meaning for the workers of the ethical values put forward by the organization. Their individual opinions and experiences were explored by means of a thematic contents analysis of 225 comments posted in the CEVF. The study was conducted between May and December 2008. RESULTS: The average score for observance of the CE by the respondents themselves was high (over 4/5), between 3.5-4/5 for the observance by their colleagues and close to 3/5 for the CIH management. These results do not change when we compare by gender, age group and professional discipline. The comments on the values are information-rich, they mirror the ethical environment of the institution and show various ethical dilemmas and suggestions. CONCLUSIONS: Results show that it is feasible for a publicly funded health care organization to develop a CE with the participation of employees and the support of the management. Results underscore the relevance of this strategy for the implementation, improvement and update of the CE as a responsibility shared by all workers. Practices consistent with ethical values are rewarded by social approval, enhance employee's confidence and coherence in decision-making and improve public engagement and institutional policies.

Bioethics in Mediterranean culture: the Spanish experience.

This article presents a view of bioethics in the Spanish context. We may identify several features common to Mediterranean countries because of their relatively similar social organisation. Each country has its own distinguishing features but we would point two aspects which are of particular interest: the Mediterranean view of autonomy and the importance of Catholicism in Mediterranean culture. The Spanish experience on bioethics field has been marked by these elements, trying to build a civic ethics alternative, with the law as an important support. So, Spanish bioethics has been developed in two parallel levels: in the academic and policy maker field (University and Parliament) and in clinical practice (hospitals and healthcare ethics committees), with different paces and methods. One of the most important changes in the paternalistic mentality has been promoted through the recognition by law of the patient's rights and also through the new generation of citizens, clearly aware on the exercise of autonomy. Now, the healthcare professionals have a new challenge: adapt their practice to this new paradigm.

Erythroplasia of Queyrat with urethral involvement: treatment with carbon dioxide laser vaporization.

BACKGROUND: Erythroplasia of Queyrat is an uncommon carcinoma in situ that usually arises on the mucosa of the glans penis or prepuce as red, shiny, sharply demarcated velvety plaques. The treatment is often difficult and associated with significant recurrence rates, especially in cases with urethral involvement. OBJECTIVE: To evaluate carbon dioxide laser treatment in a case of erythroplasia of Queyrat with urethral involvement. MATERIALS AND METHODS: We report a patient with erythroplasia of Queyrat involving the urethra who was treated with carbon dioxide laser vaporization. RESULTS: Treatment with carbon dioxide laser vaporization resulted in an excellent cosmetic and functional status outcome for the glans penis and urethral lesions. CONCLUSION: Carbon dioxide laser vaporization is probably the initial elective treatment for erythroplasia of Queyrat with urethral involvement in young immunocompetent patients. A follow-up is necessary, and new sessions of treatment should be quickly performed if recurrence occurs.