Challenges and Opportunities in Clinical Ethics with the Implementation of Korea's End-of-Life Act / Desafíos y oportunidades en ética clínica con la implementación de la Ley de fin de vida de Corea / Desafios e oportunidades em ética clínica com a implementação do Ato de Fim-da-Vida na Córeia

Abstract: This paper examines the possible impacts of the Act on Decisions on Life-Sustaining Treatment for Patients in Hospice and Palliative Care or at the End of Life in Korea (Korea's end-of-life act), legislated in 2016, on the development of hospital ethics committees and clinical ethics consultation services in South Korea. Clinical ethics in Korea has not made much progress in comparison to other subdisciplines of biomedical ethics. While the enactment of this law may give rise to beneficial clinical ethics services, it is possible that customary practices and traditional authorities in Korean society will come into conflict with the norms of clinical ethics. This paper examines how the three main agents of Korean society—family, government, and medical professionals—may clash with end-of-life stage norms in clinical ethics, thus posing obstacles to the development of hospital committees and consultation services. A brief outline of what lies ahead for the progress of clinical ethics practice is explored.

Resumen: Este documento examina los posibles impactos de la Ley de decisiones sobre el tratamiento de soporte vital para pacientes en hospicios y cuidados paliativos, o al final de la vida en Corea (Ley de Corea del Final de la Vida), legislada en 2016, sobre el desarrollo de comités de ética hospitalaria y servicios de consulta de ética clínica en Corea del Sur. La ética clínica en Corea no ha avanzado mucho en comparación con otras subdisciplinas de la ética biomédica. Si bien la promulgación de esta ley puede dar lugar a servicios de ética clínica beneficiosos, es posible que las prácticas tradicionales y las autoridades tradicionales en la sociedad coreana entren en conflicto con las normas de ética clínica. Este documento examina cómo los tres agentes principales de la sociedad coreana —familia, gobierno y profesionales médicos— pueden chocar con las normas de ética clínica al final de la vida, lo que plantea obstáculos para el desarrollo de comités hospitalarios y servicios de consulta. Se explora un breve resumen de lo que queda por delante para el progreso de la práctica de la ética clínica.

Resumo: Este artigo examina os possíveis impactos que o Ato sobre Decisões Relacionadas a Tratamento de Manutenção da Vida para Pacientes em Casas de Idosos e de Cuidados Paliativos ou ao Fim da Vida na Coréia (ato de fim da vida da Coréia), aprovado pelo legislativo em 2016, sobre o desenvolvimento de comitês de ética de hospitais e serviços de consulta sobre ética clínica na Coréia do Sul. Ética clínica na Coréia não sofreu muito progresso em comparação com outras subdisciplinas da ética biomédica. Enquanto a promulgação desta lei pode dar origem a serviços de ética clínica proveitosos, é possível que práticas usuais e autoridades tradicionais na sociedade coreana entrarão em conflito com as normas da ética clínica. Este artigo examina como os três principais agentes da sociedade coreana - família, governo e profissionais médicos - podem se chocar com normas de estágios de fim da vida em ética clínica, colocando assim obstáculos para o desenvolvimento de comitês hospitalares e serviços de consulta. Um breve esboço do que vem pela frente para o progresso da prática de ética clínica é explorado.

The role of the nurse at the end of the life of a critically ill patient. / Rol de la enfermera en el cuidado al final de la vida del paciente crítico.

OBJECTIVE: Analyze the role of the nurse at the end of the life of a critically ill patient. METHOD: Bibliographic review from a search of the health science databases such as PubMed, CINAHL, Cuiden, Scopus, Cochrane, as well as specialized platforms, general and thematic browsers. The limits were language (English or Spanish) and publication date (2005-2015). RESULTS: 180 articles met the inclusion criteria, and 16 of them were selected for analysis. The main results were grouped into three categories of analysis: direct patient care, family-focussed care and the nurse's role within the team. CONCLUSIONS: the described roles place the nurse as a key element in humanising death in the ICU and so nurses can and must lead change, playing an active role in creating strategies that really promote the integration of a palliative care approach in ICU.

Factors related to limitation of life support within 48h of intensive care unit admission: A multicenter study.

OBJECTIVE: To determine factors related to limitations on life support within 48h of intensive care unit (ICU) admission. STUDY DESIGN: Prospective multicenter study. SETTING: Eleven ICUs. PATIENTS: All patients who died and/or had limitations on life support after ICU admission during a four-month period. VARIABLES: Patient characteristics, hospital characteristics, characteristics of limitations on life support. Time-to-first-limitation was classified as early (<48h of admission) or late (≥48h). We performed univariate, multivariate analyses and CHAID (chi-square automatic interaction detection) analysis of variables associated with limitation of life support within 48h of ICU admission. RESULTS: 3335 patients were admitted; 326 (9.8%) had limitations on life support. A total of 344 patients died; 247 (71.8%) had limitations on life support (range among centers, 58.6%-84.2%). The median (p25-p75) time from admission to initial limitation was 2 (0-7) days. CHAID analysis found that the modified Rankin score was the variable most closely related with early limitations. Among patients with Rankin >2, early limitations were implemented in 71.7% (OR=2.5; 95% CI: 1.5-4.4) and lung disease was the variable most strongly associated with early limitations (OR=12.29; 95% CI: 1.63-255.91). Among patients with Rankin ≤2, 48.8% had early limitations; patients admitted after emergency surgery had the highest rate of early limitations (66.7%; OR=2.4; 95% CI: 1.1-5.5). CONCLUSION: Limitations on life support are common, but the practice varies. Quality of life has the greatest impact on decisions to limit life support within 48h of admission.

Limitation of life-sustaining treatment in severe trauma in the elderly after admission to an intensive care unit. / Limitación del tratamiento de soporte vital en el traumatismo grave en edades avanzadas tras el ingreso en una unidad de cuidados intensivos.

OBJECTIVE: To analyze the factors associated to limitation of life-sustaining treatment (LLST) measures in elderly patients admitted to an intensive care unit (ICU) due to trauma. DESIGN: A retrospective, descriptive, observational study was carried out. SETTING: ICU. PATIENTS: A total of 149 patients aged 65 years or older admitted to the ICU due to trauma. Hospital mortality, the decision to limit life-sustaining treatment and the factors associated to these measures were analyzed. INTERVENTIONS: None. RESULTS: The mean patient age was 76.3±6.36 years. The average APACHE II and ISS scores were 15.9±7.4 and 19.6±11.4 points, respectively. LLST were used in 37 patients (24.8%). Factors associated to the use of these measures were patient age (OR 1.16; 95% CI 1.08 to 1.25], APACHE II score (OR 1.11; 95% CI 1.05-1.67), ISS score (OR 1.03; 95% CI 1.01 to 1.06), admission due to neurological impairment (OR 19.17; 95% CI 2.33 to 157.83) and traumatic brain injury (OR 2.89; 95% CI 1.05 to 7.96). CONCLUSIONS: LLST is frequently established in elderly patients admitted to the ICU due to trauma, and is associated to hospital mortality. Factors associated with the use of these measures are patient age, higher APACHE II and ISS scores, admission due to neurological impairment, and the presence of head injuries.

[Perspective of intensive care nursing staff on the limitation of life support treatment]. / Perspectiva de los profesionales de enfermería de unidades de cuidados intensivos sobre la limitación del tratamiento de soporte vital.

OBJECTIVE: To determine the perspective of intensive care nursing staff on the limitation of life support treatment (LLST) in the Intensive Care Units. METHOD: An exploratory qualitative study was carried out by applying the theory of Strauss and Corbin as the analysis tool. Constructivist paradigm. POPULATION: Nursing staff from three Intensive Care Units of Hospital Universitari de Bellvitge. Convenience sampling to reach theoretical saturation of data. Data collection through semi-structured interview recorded prior to informed consent. Rigor and quality criteria (reliability, credibility, transferability), and authenticity criteria: reflexivity. Demographic data was analysed using Excel. RESULTS: A total of 28 interviews were conducted. The mean age of the nurses was 35.6 years, with a mean seniority of 11.46 years of working in ICU. A minority of nurses (21.46%) had received basic training in bioethics. The large majority (85.7%) believe that LLST is not a common practice due to therapeutic cruelty and poor management with it. There is a correlation with the technical concepts; but among the main ethical problems is the decision to apply LLST. Nurses recognise that the decision on applying LLST depends on medical consensus with relatives, and they believe that their opinion is not considered. Their objective is trying to avoid suffering, and assist in providing a dignified death and support to relatives. CONCLUSIONS: There is still a paternalistic pattern between the doctor and patient relationship, where the doctor makes the decision and then agrees with the relatives to apply LLST. Organ failure and poor prognosis are the most important criteria for applying LLST. It is necessary to develop a guide for applying LLST, emphasising the involvement of nurses, patients, and their relatives.

Valoración ética de la craneoplastia con vendaje compresivo como forma de limitación de tratamientos de soporte vital / Valoração ética da cranioplastia com curativo compressivo como forma de limitação de tratamentos de suporte vital / Ethical value of cranioplasty with oppressive binder as a way of limiting life support treatments

Este artículo analiza, desde una postura crítica, la utilización de la craneoplastia de compresión con vendaje como método de limitación de tratamiento de soporte vital (LTSV). Con esta técnica activa, algunos autores han propuesto provocar la muerte encefálica, posibilitando la donación de órganos. Al contrastar este procedimiento con las recomendaciones del documento de consenso sobre el tratamiento al final de la vida del paciente crítico, elaborado por el grupo de bioética de la SEMICYUC, se comprueba que los medios y fines de esta técnica no encajan con las actuaciones propias de la LTSV, que se basan en la retirada de medios de soporte vital o en su no inicio, al considerar dichos medios desproporcionados o extraordinarios en algunos casos, evitando así la obstinación terapéutica. La definición de LTSV permite clarificar los límites en los que, de un modo éticamente correcto y consensuado, las actuaciones al final de la vida se circunscriben a los fines de la medicina, evitando la sospecha de que dichas actuaciones puedan ser malinterpretadas como justificación para una obtención de órganos abusiva. El artículo concluye que la provocación directa de la muerte encefálica mediante la técnica de craneoplastia con vendaje no parece cumplir los criterios propios de la LTSV.

This article analyzes, from a critical perspective, the use of cranioplasty with oppressive binder as a method to limit life support treatment (LLST). Some authors have proposed that this active technique provokes encephalic death, allowing organ donation. Contrasting this procedure with the recommendations of the consent document about treatment of critical patients at the end of life, elaborated by the bioethics group of SEMICYUC, it is shown that the means and ends of this technique do not match with the proper actions of LLST, based on the withdrawal of life support means or in not starting them, considering such means disproportionate or extraordinary in some cases, thus avoiding the therapeutic obstinacy. The definition of LLST allows to clarify the limits in which, in a way ethically fair and with a consensus, the acts at the end of life are included in the medical goals, avoiding the suspicion that these acts may be misinterpreted as justifying an abusive extraction of organs. This article concludes that the direct provocation of encephalic death by the technique of cranioplasty with binder does not appear to fulfill the criteria proper of LLST.

Este artigo analisa, a partir de uma postura crítica, a utilização da cranioplastia de compressão com curativo como método de limitação de tratamento de suporte vital (LTSV). Com esta técnica ativa, alguns autores têm proposto provocar a morte encefálica, possibilitando a doação de órgãos. Ao contrastar este procedimento com as recomendações do documento de consenso sobre o tratamento do final de vida do paciente crítico, elaborado pelo grupo de bioética da SEMICYUC, se comprova que os meios e fins desta técnica não encaixam com as atuações próprias da LTSV, que se baseiam na retirada de meios de suporte vital ou em seu não início, ao considerar os ditos meios desproporcionados ou extraordinários em alguns casos, evitando assim a obstinação terapêutica. A definição de LTSV permite esclarecer os limites nos quais, de um modo eticamente correto e aceito, as atuações ao final da vida se circunscrevem às finalidades da medicina, evitando a suspeita de que ditas atuações podem ser mal interpretadas como justificativa para uma obtenção de órgãos abusiva. O artigo conclui que a provocação direta da morte encefálica mediante a técnica da cranioplastia com curativo não parece cumprir os critérios próprios da LTSV.

Brain death organ donation potential and life support therapy limitation in neurocritical patients.

OBJECTIVE: To analyze the profile, incidence of life support therapy limitation (LSTL) and donation potential in neurocritical patients. STUDY DESIGN: A multicenter prospective study was carried out. SETTING: Nine hospitals authorized for organ harvesting for transplantation. PATIENTS: All patients consecutively admitted to the hospital with GCS < 8 during a 6-month period were followed-up until discharge or day 30 of hospital stay. STUDY VARIABLES: Demographic data, cause of coma, clinical status upon admission and outcome were analyzed. LSTL, brain death (BD) and organ donation incidence were recorded. RESULTS: A total of 549 patients were included, with a mean age of 59.0 ± 14.5 years. The cause of coma was cerebral hemorrhage in 27.0% of the cases.LSTL was applied in 176 patients (32.1%). In 78 cases LSTL consisted of avoiding ICU admission. Age, the presence of contraindications, and specific causes of coma were associated to LSTL. A total of 58.1% of the patients died (n=319). One-hundred and thirty-three developed BD (24.2%), and 56.4% of these became organ donors (n=75). The presence of edema and mid-line shift on the CT scan, and transplant coordinator evaluation were associated to BD. LSTL was associated to a no-BD outcome. Early LSTL (first 4 days) was applied in 9 patients under 80 years of age, with no medical contraindications for donation and a GCS ≤ 4 who finally died in asystole. CONCLUSIONS: LSTL is a frequent practice in neurocritical patients. In almost one-half of the cases, LSTL consisted of avoiding admission to the ICU, and on several occasions the donation potential was not evaluated by the transplant coordinator.