La bioética como faro en la instauración de la telemedicina. Tratando de evitar una medicina distante / Bioethics as a lighthouse in the establishment of telemedicine. How to avoid a distant medicine

La necesaria instauración de la telemedicina ha sido acelerada por la urgencia derivada de la crisis originada por la pandemia del SARS-CoV-2. Como todos los avances cientifico-técnicos, para evitar excesos o cursos extremos no deseables, la telemedicina también requiere un proceso de reflexión ética que acompañe su incorporación a la atención de las personas como herramienta y no como hábito. Se proponen algunas claves para la deliberación desde el objetivo esencial de la bioética que es preservar los valores, lo que hemos acordado profesionales y ciudadanos como valioso y merecedor de respeto, a pesar de las dificultades. En este caso encontrar los faros que iluminen el imprescindible cambio del formato tradicional de relación clínica, preservando sus valores esenciales, evitando el camino hacia una medicina distante, impersonal y que no responda a las necesidades de las personas. (AU)

The necessary establishment of telemedicine has been accelerated by the urgency derived from the crisis caused by the SARS-CoV-2 pandemic. Like all scientific-technical advances, to avoid excesses or undesirable extreme courses, telemedicine also requires a process of ethical reflection that accompanies its incorporation into the care of people as a tool and not as a habit. Some keys for deliberation are proposed from the essential objective of bioethics to preserve values, which professionals and citizens agree on its value and deserving of respect, despite difficulties. In the case at hand, to find the lighthouse that illuminate the essential change from the traditional clinical relationship format, preserving its essential values, avoiding the path to a distant, and impersonal medicine that does not respond to people’s needs. (AU)

Tuberculosis miliar durante el tratamiento con adalimumab en enfermedad de Crohn / Miliary tuberculosis during adalimumab therapy in Crohn's disease

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Mortalidad esperable en Medicina Interna: ¿cómo son los últimos días de vida en los pacientes en los que la muerte es previsible? / Predictable mortality in Internal Medicine: How are the last days of life in patients whose death is predictable?

ANTECEDENTES: Muy pocos estudios analizan cuáles son las intervenciones médicas en los últimos días de vida. OBJETIVO: Valorar los tratamientos y cuidados proporcionados a los pacientes fallecidos en el Servicio de Medicina Interna en los que la muerte era esperable. MÉTODO: Realizamos un estudio retrospectivo de los pacientes fallecidos en el Servicio de Medicina Interna desde mayo a agosto de 2011. Definimos muerte esperable como aquella en la que el médico responsable de la asistencia comentaba en la historia clínica la posibilidad de fallecimiento. RESULTADOS: Analizamos los últimos días de vida en los 102 pacientes en los que la muerte era esperable. La edad media de los pacientes era de 80,91 años (DT 9,59), la mayoría eran varones 53 (52%), con una elevada comorbilidad. Las causas más frecuentes de muerte fueron: broncoaspiración en 20 (19,6%), enfermedad neoplásica en 18 (17,6%) e ICC en 13 (12,7%). En la mayoría de los pacientes (95; 93,1%) había algún síntoma recogido en la historia médica, y en un porcentaje elevado de casos (86,3%) se instauraba tratamiento para control de estos síntomas. Las órdenes de no reanimación cardiopulmonar aparecían recogidas en 80 pacientes (78,4%). En 35 pacientes (34,3%) se realizó sedación paliativa. CONCLUSIONES: La mayoría de los pacientes que fallecían en nuestro servicio eran personas mayores, con enfermedades crónicas o neoplásicas avanzadas, y con necesidad de atención paliativa, en los que la muerte era esperable. Aunque había un porcentaje alto de pacientes que recibía tratamiento sintomático paliativo y se registraba la indicación de no reanimación cardiopulmonar, existían otros aspectos claramente mejorables, como es la sedación paliativa (AU)

BACKGROUND: Very few studies analyze the medical interventions performed in the last days of life. OBJECTIVE: To assess the treatments and care provided to dying patients in Internal Medicine Service in whom the death was expected. Method: A retrospective study was conducted on patients who died in the Internal Medicine Service from May to August 2011. Expected death was defined as when the doctor responsible for the care had made a note of the possibility of death in the medical history. RESULTS: The last days of life were analyzed in 102 patients whose death was expected. The mean age of the patients was 80.91 (SD 9.59), the majority (53; 52%) being males, with high comorbidity. The most frequent causes of death were: bronchoaspiration in 20 (19.6%), neoplastic disease in 18 (17.6%), and congestive heart failure in 13 (12.7%). In the majority of patients (95; 93.1%) at least one symptom was noted in the medical history and a treatment to control the symptoms was ruled in a high percentage of patients (86.3%). Do not resuscitate orders were written for 80 patients (78.4%). Palliative sedation was administered in 35 (34.3%) PATIENTS: CONCLUSIONS: The majority of patients who died in Internal Medicine were elderly, who suffered end-stage chronic or neoplastic diseases, needed palliative care, in whom the death was expected. Although there were a high percentage of patients who received symptomatic palliative treatment, and do not resuscitate orders were written, there were other aspects that could be improved, such as palliative sedation

Conocimientos y actitudes sobre las instrucciones previas de los médicos de Atención Primaria y Especializada del área sanitaria de Ferrol / Knowledge and attitudes as regards living wills between primary and specialised care doctors in the Ferrol health area

Objetivo. Evaluar los conocimientos, la experiencia y las actitudes de los profesionales sanitarios de Atención Primaria (AP) y Especializada (AE) de nuestra área sanitaria respecto a las instrucciones previas (IP). Material y método. Estudio descriptivo, transversal, por medio de una encuesta dirigida a los médicos de AP y AE del área sanitaria de Ferrol. Resultados. Respondieron 120 médicos (42,85% de respuestas). Los profesionales autopuntuaron su nivel de conocimientos con una media de 3,83 (rango de 0 a 10). Solo 21 (17,5%) tenían conocimientos objetivos sobre las IP, es decir, cumplían las siguientes premisas: habían leído alguna de las leyes sobre IP, habían leído un documento de IP y conocían los elementos que podían quedar recogidos en este. Había diferencias que rozaban la significación estadística en los conocimientos objetivos entre AP y AE (11,7 vs 23,3%, p: 0,093) y entre los profesionales con < de 10 años de ejercicio profesional y aquellos con más de 10 años (6,9 vs 21,1%, p:,081). Estas diferencias alcanzaban la significación estadística en algunos de los ítems que valoraban los conocimientos objetivos. Fueron muy pocos los profesionales que habían expuesto a sus pacientes la conveniencia de tener redactado un documento de IP, solo 28 (23,3%) y menos aún los que habían ayudado al paciente en su redacción, solo 8 (6,7%). En cambio la mayoría de ellos 109 (90,8%) estaban convencidos de su utilidad. Conclusiones. Los conocimientos de los profesionales sanitarios son muy mejorables. El déficit mayor se encontró en los profesionales de AP y aquellos con menos experiencia. Sin embargo, su actitud hacia las mismas es favorable(AU)

Objectives. To evaluate the knowledge, the experience and the attitudes of the health professionals of Primary (PC) and Specialized (SC) Carein our Health Area with respect to Living Wills (LW). Material and method. Descriptive, cross-sectional study, by means of a survey addressed to PC and SC doctors Ferrol (Galicia, Spain) Health Area Results. A total of 120 (42.85%) doctors completed the questionnaire.The professionals self-assessed their level of knowledge with a mean of 3.83 (rank from 0 to 10). Only 21 professionals (17.5%) had objective knowledge of LW, that is to say, they fulfilled the following premises: they had read some pieces of LW legislation, had read an LW document and knew the elements that could figure in it. There were differences that verged on the statistical significance in the objective knowledge between PC and SC doctors (11.7% versus 23.3%, P= .093) and between professionals with under 10 years of professional experience and those with more than 10 years (6.9% versus 21.1%, P=.081). These differences reached statistical significance in some of the items that valued the objective knowledge. A few professionals (28 (23.3%)), had explained to their patients the convenience of having written an LW document, and even fewer (8 (6,7%)) had helped patients with writing one. Conclusions. The knowledge of health care professionals can be clearly improved. The highest deficiency was found between PC professionals and those with less experience. Nevertheless, they showed a favourable attitude towards them(AU)

[Knowledge and attitudes as regards Living Wills between Primary and Specialised Care Doctors in the Ferrol Health Area]. / Conocimientos y actitudes sobre las instrucciones previas de los médicos de Atención Primaria y Especializada del área sanitaria de Ferrol.

OBJECTIVES: To evaluate the knowledge, the experience and the attitudes of the health professionals of Primary (PC) and Specialized (SC) Carein our Health Area with respect to Living Wills (LW). MATERIAL AND METHOD: Descriptive, cross-sectional study, by means of a survey addressed to PC and SC doctors Ferrol (Galicia, Spain) Health Area RESULTS: A total of 120 (42.85%) doctors completed the questionnaire.The professionals self-assessed their level of knowledge with a mean of 3.83 (rank from 0 to 10). Only 21 professionals (17.5%) had objective knowledge of LW, that is to say, they fulfilled the following premises: they had read some pieces of LW legislation, had read an LW document and knew the elements that could figure in it. There were differences that verged on the statistical significance in the objective knowledge between PC and SC doctors (11.7% versus 23.3%, P= .093) and between professionals with under 10 years of professional experience and those with more than 10 years (6.9% versus 21.1%, P=.081). These differences reached statistical significance in some of the items that valued the objective knowledge. A few professionals (28 (23.3%)), had explained to their patients the convenience of having written an LW document, and even fewer (8 (6,7%)) had helped patients with writing one. CONCLUSIONS: The knowledge of health care professionals can be clearly improved. The highest deficiency was found between PC professionals and those with less experience. Nevertheless, they showed a favourable attitude towards them.

Predicting factors contributing to length of stay in hospitalized chronic obstructive pulmonary disease (COPD) patients: the role of the emergency room.

BACKGROUND: Exacerbation of chronic obstructive pulmonary disease (COPD) is a common cause of hospital admission and COPD patients usually have a long stay in hospital. METHODS: The objective of this study was to identify factors predicting length of stay in patients with exacerbation of COPD when seen in the emergency room. We analyzed clinical and biological variables. RESULTS: Patients with diminished breath sounds, systolic pressure higher than 140 mmHg, diastolic pressure higher than 90 mmHg and recent previous hospitalization for exacerbation of COPD had the longest hospital stay. CONCLUSIONS: Recognition of this clinical profile in the emergency room may help to increase efforts in order to diminish length of stay in these patients.

Indiscreción y derecho a la intimidad en el sistema sanitario / Indiscretion and confidentiality in health-care services

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