[The precarious balance of Gestalt change due to Franco Basaglia.] / Il precario equilibrio del cambio di Gestalt dovuto a Franco Basaglia.

Franco Basaglia's passionate battle to change the state of psychiatric care in Italy resembles the experiences we know as "Gestalt change". The health and well-being of the community, both family and social, constituted the dominant figure in the scenario of psychiatric disorders; the person of the sick person - and thus his rights, his dignity… - slipped into the background. The very health of the mentally ill person was seen as a function of social security. Health, that is, the very life of the person with psychiatric problems, became the object of our social gaze. Gestalt changes occur by slow and arduous cultural transformation. Just think of the not yet completed process of change in the relationship of male and female gender roles. However: Gestalt changes are not stable; the risk is that suddenly the figure we thought we had acquired forever becomes diluted, becoming background again. This uneasy balance suggests to exercise continuous vigilance.

[The future of palliative care.] / Il futuro delle cure palliative. God save the queer.

The future of palliative care is quite uncertain, both in terms of health economics and organisation. Among elements which affect his future development, it is mostly difficult to identify those ones operating covertly. Among these ones, the long shadow of a division within medical practice since the origins of palliative care: two models of medicine oriented in opposite directions. Adopting a symbolic terminology, we can talk about a medicine modeled in a heroic and masculine sense (according with the cliché that "men come from Mars") and a medicine that takes on the stereotype of female kindness and humanity ("women come from Venus"). Gender dualism translated into the practice of palliative care is highlighted in an all-out interventionism, which then makes way to palliation "when there is nothing left to do". Similarly to what happened in the field of gender identity, bipolar rigidity must also be questioned in medicine by a model inspired by queerness. Palliation that can fluidly integrate the two approaches can be an inspiration to the practice of medicine tout court.

[Evoking ethics in care: a pentagram of modalities.] / Evocare l'etica nella cura: un pentagramma di modalità.

The ways in which ethics is evoked in care and more generally in health policy decision-making are many and very different. Ideological ethics is based on the conviction that we know what is desirable and what is ethically reprehensible in health care. Legal-administrative ethics tends to seek legitimisation of behaviours. Exhortative ethics acts as a kind of moral suasion, while ethics of consultation tends to delegate decisions and choices on matters about which there is perplexity or uncertainty to committees of 'experts'. Finally, the author dwells on counselling ethics, which, with a three-dimensional view, calls for decisions to be made not about the sick person, but with the sick person, taking into account his or her values and conception of the quality of life, as well as the community's ability to use resources fairly and to respond to the needs not only of the wealthy, but of all those in need of care. Its starting point is listening, rather than rigid application of principles. Rather than importing ethics into clinical practice from outside, it encourages its explication by those involved, particularly clinicians.

[A medicine modeled on the needs of the citizen.] / Una medicina modellata sui bisogni del cittadino.

Medicine has (almost) always had a double face: that of scientific research and that of humanities. Finding a balance between these two aspects is the difficult task of any physician. Alessandro Liberati - Italian physician and researcher - embodied this union in himself, leaving a lesson on how it is possible to live the physician's mission coherently without neglecting one or the other aspect: reason and passion, scientificity and attention to real needs, and to the patient's freedom. And it is precisely patient associations, with the support of the community, that should be in a strong position to ask for a redefinition of the scientific research agenda.

[If narrative medicine draws inspiration from Dante.] / Se la medicina narrativa trae ispirazione da Dante.

A doctor patient relationship is made of stories. The story the patient tells the doctor and the one the physician uses to explain the patient's illness. Nowadays we call it "narrative medicine". The poet Dante can be a guide for our journey from the relationship of cure and care to the comprehension of pain and loneliness. With him we can ascent the hill of purgatory searching for healing or, it seems obvious, for paradise. We learn that we will be able to enter there only if we attribute the right meaning to the story of our life, which includes inevitably: dying. The knowledge of dying is not in contradiction to health, indeed it may be the crowning glory of a healthy life, lived in it's fullness.

[Imagine a new relationship of trust in medicine.] / Immaginare un nuovo rapporto di fiducia in medicina.

Informed consent for CoViD-19 vaccines can be considered a step that can help us focus on an increasingly burdensome problem for contemporary medicine: the difficult relationship of trust between citizens and academic medicine. Filling out forms full of useless information cannot replace the rebuilding of trust based on shared essential ethical principles. Trust needs to be protected by a transparent accountability, which can also decrease the threatening looming of lawsuits. Medicine must be safe, first and foremost, for the practitioner. He cannot practice it if he feels constantly in check, if the outcome of the treatment does not correspond to the wishes of those who request it.

[Palliative care: specialist competence or any therapist?] / Cure palliative: competenza specialistica o di qualsiasi terapeuta?

In Italy, a recent legislative decree establishes that from the 2021-22 academic year, medical graduates can specialize in palliative care. The proposal is to be greeted with enthusiasm. However, some concerns remain about how palliative care will become part of the care process. Two scenarios are of concern. First, that training in this area is reserved for specialists only, rather than being part of the competence of any therapist. Second, that palliative care is implemented sequentially rather than when necessary throughout the entire care span. The palliative intervention cannot be equivalent to the finding of "there is nothing more to be done". Because palliative care is part of the care itself and not a residual intervention.

[If help with suicide knocks on the door of medicine.] / Se l'aiuto al suicidio bussa alla porta della medicina.

Most codes of ethics states that physician-assisted suicide is prohibited, mainly because it is "fundamentally incompatible with the physician's role as healer". It would also be difficult to control, and would pose serious societal risks. Physician-assisted suicide is contrary to the Hippocratic Oath, when it states that no doctors will give deadly medicine to anyone if asked, nor will suggest any such counsel. The push towards a change of legislation, in a permissive sense, and some acquittal judgments have led the top of professional orders to decide that, under certain conditions, disciplinary sanctions should not be imposed on doctors who facilitate a patient's death (6th February 2020). This scenario poses a challenge to the medical profession. The request for death must be evaluated in the framework of a "shared planning of care".

[The cure: a question of merit?] / La cura: una questione di merito?

A position statement published by the Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) is fostering a vibrant debate, crossed by deep fears. These are recommendations addressed to ICU doctors who must decide whether to implement intensive treatments for patients who need them to survive. Specifically, the reference is to the patients to whom the CoViD-19 epidemic has compromised respiratory capacity. We still do not have clear what positive criteria can help make clinical decisions in contexts of insufficient resources that force us to make choices.

The last week of life of nursing home residents with advanced dementia: a retrospective study.

BACKGROUND: Barriers to palliative care still exist in long-term care settings for older people, which can mean that people with advanced dementia may not receive of adequate palliative care in the last days of their life; instead, they may be exposed to aggressive and/or inappropriate treatments. The aim of this multicentre study was to assess the clinical interventions and care at end of life in a cohort of nursing home (NH) residents with advanced dementia in a large Italian region. METHODS: This retrospective study included a convenience sample of 29 NHs in the Lombardy Region. Data were collected from the clinical records of 482 residents with advanced dementia, who had resided in the NH for at least 6 months before death, mainly focusing on the 7 days before death. RESULTS: Most residents (97.1%) died in the NH. In the 7 days before death, 20% were fed and hydrated by mouth, and 13.4% were tube fed. A median of five, often inappropriate, drugs were prescribed. Fifty-seven percent of residents had an acknowledgement of worsening condition recorded in their clinical records, a median of 4 days before death. CONCLUSIONS: Full implementation of palliative care was not achieved in our study, possibly due to insufficient acknowledgement of the appropriateness of some drugs and interventions, and health professionals' lack of implementation of palliative interventions. Future studies should focus on how to improve care for NH residents.

The Impact of Nursing Homes Staff Education on End-of-Life Care in Residents With Advanced Dementia: A Quality Improvement Study.

CONTEXT: End-of-life care in nursing homes (NHs) needs improvement. We carried out a study in 29 NHs in the Lombardy Region (Italy). OBJECTIVES: The objective of this study was to compare end-of-life care in NH residents with advanced dementia before and after an educational intervention aimed to improving palliative care. METHODS: The intervention consisted of a seven-hour lecture, followed by two 3-hour meetings consisting of case discussions. The intervention was held in each NH and well attended by NH staff. This multicenter, comparative, observational study included up to 20 residents with advanced dementia from each NH: the last 10 who died before the intervention (preintervention group, 245 residents) and the first 10 who died at least three months after the intervention (postintervention group, 237 residents). Data for these residents were collected from records for 60 days and seven days before death. RESULTS: The use of "comfort hydration" (<1000 mL/day subcutaneously) tended to increase from 16.9% to 26.8% in the postintervention group. The number of residents receiving a palliative approach for nutrition and hydration increased, though not significantly, from 24% preintervention to 31.5% postintervention. On the other hand, the proportion of tube-fed residents and residents receiving intravenous hydration decreased from 15.5% to 10.5%, and from 52% to 42%, respectively. Cardiopulmonary resuscitations decreased also from 52/245 (21%) to 18/237 (7.6%) cases (P = 0.002). CONCLUSION: The short educational intervention modified some practices relevant to the quality of end-of-life care of advanced dementia patients in NHs, possibly raising and reinforcing beliefs and attitudes already largely present.

[Dying in the Three Graces' arms: when ethics dresses up as aesthetics.] / Morire in braccio alle Grazie: quando l'etica si traveste da estetica.

The many adjectives usually used to explain the desirable death - painless, decent, human… - do not include the term "graceful". However, this is a way that can be explored, too, if you imagine to die in the Three Graces' arms, namely in a mood that, according to Ugo Foscolo, is "between the exaggerated cheerfulness and the deep pain". The pathway turns out to be much more productive if we allow ourselves to be led by the original names of the Three Graces and by their symbology. Euphrosyne suggests the wisdom through which the mind guides our choices, especially those that show as palliative cures; Aglaea suggests the peace linked to the possibility to keep the death process under control; Talia lets us imagine a death seen as growth, as a pathway that ends at the peak of our own humanity. Therefore, in terms of aesthetics, dying in the Three Graces' arms seems to be a spiritual task and an ethical commitment.

Ethics in oncology: principles and responsibilities declared in the Italian Ragusa statement.

Cancer care involves many ethical issues. The need for more patient-centered healthcare together with the improved empowerment of every person diagnosed with cancer have been transposed by the Italian Association of Medical Oncology (AIOM) and eventually translated in the Ragusa statement. This position paper describes the philosophy that lies beneath this document and its fundamental principles.

Current functions of Italian ethics committees: a cross-sectional study.

BACKGROUND: The rapid pace of progress in medical research, the consequent need for the timely transfer of new knowledge into practice, and the increasing need for ethics support, is making the work of Ethics Committees (ECs) ever more complex and demanding. As a response, ECs in many countries exhibit large variation in number, mandate, organization and member competences. This cross-sectional study aims to give an overview of the different types of activities of Italian ECs and favour discussion at a European level. METHODS: A questionnaire was emailed to all Italian Ethics Committees contained in the national Registry of the Ministry of Health, enquiring whether the EC was conducting, or planning to conduct, 4 specific activities. A telephone interview was conducted to determine reasons for failure to respond. RESULTS: Response rate was 53% (101 respondents out of 191). 20% of ECs restrict their responsibilities to research protocol review, 25% also offer ethical consultation to institutions, support on individual health care decisions and promotes educational initiatives, while the remaining 50% conduct a few of the examined activities to varying degrees. Large variation was observed across different types of hosting institutions and geographical locations. CONCLUSIONS: A common European model should be developed, defining EC functions, member selection modalities, necessary member competences, decision-making criteria and measures for work verification. In the absence of sound empirical evidence, it would be interesting to study the effectiveness and efficiency of the different existing models.

[Bioethics: emerging problems and perspectives]. / Bioetica: problematiche emergenti e prospettive.

Bioethics was born in an environment of rules that have traditionally governed relationships between health care providers and patients, as an innovation based on two strong points: the ability to transcend the paternalism of doctors and the acceptance of a plurality of ethics that characterize our societies. The new relationships that were born from bioethics require recognition and respect for the autonomy of the individual, even when they are sick. Instead of sincerely resolving a request for an agreement, the actual practice of informed consent, if any information is actually consented to at all, is more of a guarantee for the health care provider. With respect to pluralism, the polarization between secular bioethics and religious bioethics (Catholic), prevalent in Italy, tends to solidify the positions. Bioethics without dialogue is reduced to BioLaw.

[Patterns of information and informed consent procedures. Study of the Ethical Commission of the ANMCO]. / Modalità di informazione ed acquisizione del consenso informato. Indiagine della Commissione Etica dell'ANMCO.

A survey on patterns of information and informed consent procedures during daily clinical practice has been performed by the Ethical Commission of ANMCO. A structured questionnaire (38 questions) was sent to the 653 cardiological units of the National Health Service in Italy. Four hundred and eighty (73.5%) were received. The following variables were considered to evaluate differences in the answers from the various cardiological units: geographical site, presence or absence of an in-patient department, a cath-lab, and of cardiac surgery facilities. Independent predictors of returning questionnaires were: geographical site (Northern Italy vs Central and Southern) and the presence of a cath-lab. Informed consent forms were provided in 53% of instances, while in 40% a free comment about the topic of informed consent was sent. Statistically significant differences in the answers were found about physicians' and nurses' role, ways of information, qualitative and quantitative risk estimates, other persons' role, models of consent forms and procedures of obtaining consent. Free comments and informed consent forms did not allow a statistical analysis. However, they still provided sufficient material to identify specific patterns of how cardiologists deal with the informed consent process. The distinction between the two phases of information and consent was rarely clear. Information or educational material was often mixed with consent forms. While some still showed a paternalistic approach, or else considered informed consent as a formal act, others demonstrated a deep understanding of the significance of the concept of informed consent. A widespread need of guidelines and standard patterns resulted.