The COVID-19 pandemic has generated an imbalance between the clinical needs of the population and the effective availability of advanced life support (ALS) resources. Triage protocols have thus become necessary. Triage decisions in situations of scarce resources were not extraordinary in the pre-COVID-19 era; these protocols abounded in the context of organ transplantation. However, this prior experience was not considered during the COVID-19 outbreak in Spain. Lacking national guidance or public coordination, each hospital has been forced to put forth independent (...) and autonomous triage protocols, most of which were, nonetheless, based on common ethical principles and clinical criteria. However, controversial, non-clinical criteria have also been defended by Spanish scientific societies and public institutions, including setting an age cut-off value for unilaterally withholding ALS, using ‘social utility’ criteria, prioritising healthcare professionals or using ‘first come, first served’ policies. This paper describes the most common triage criteria used in the Spanish context during the COVID-19 epidemic. We will highlight our missed opportunities by comparing these criteria to those used in organ transplantation protocols. The problems posed by subjective, non-clinical criteria will also be discussed. We hope that this critical review might be of use to countries at earlier stages of the epidemic while we learn from our mistakes. (shrink)

In March 2021, the Spanish Congress approved the law regulating euthanasia, that regulates both euthanasia and physician-assisted suicide (PAS). In this article, we analyse the Spanish law regulating euthanasia and PAS, comparing it with the rest of the European laws on euthanasia and PAS (Netherlands, Belgium and Luxembourg). Identified strengths of the Spanish law, with respect to other norms, are that it is a law with many safeguards, which broadly recognises professionals’ right to conscientious objection and the specification that it (...) makes on the prior comprehensive care of the patient, including the approach to care dependency. Regarding its shortcomings, the law does not differentiate well between euthanasia and PAS; it barely assigns a role to the healthcare team as a whole (similar to other regulations); it does not clarify the functions of the different professionals involved; it does not detail the specific composition and duration of theevaluation commission; it has not been accompanied by a prior or simultaneous regulation of palliative care; and, lastly, the period of time to implement the law is too short. (shrink)

Since 2002, legislation in Spain has allowed for the creation and documentation of end-of-life decisionmaking. Over the intervening years, the actual implementation of such documents is very low. Through extensive analysis of the literature, this article explores the current status of the use of and attitudes toward advance directives in Spain and then proposes strategies for improvement in their implementation.

Eight focus groups were conducted in four public hospitals in Madrid to explore healthcare professionals’ perceptions of advance directives in order to improve the understanding of their lack of success among physicians and patients. A purposive sample of sixty healthcare professionals discussed ADs and reasons for their infrequent use. Three main themes were identified: perceptions about their meaning, appraisals of their use in clinical practice, and decision-making about them. Healthcare professionals perceived a lack of clarity about their definition and implementation. (...) There is insufficient awareness of their efficacy in improving the quality of clinical relationships and decision-making, and they are often perceived only as a bureaucratic procedure. Advance directives are not integrated in the clinical practice of Madrid’s healthcare specialist services because their application is exceedingly complex, because of insufficient education about them, and because of lack of procedural clarity. Consequently, healthcare professionals are not aware of how ADs could improve clinical decision-making, of when and for whom their use is appropriate, and of who has responsibility for providing ADs-related information to patients. These circumstances contribute to patients’ lack of interest in completing these documents and to physicians’ sceptical views about their usefulness. (shrink)

Background In Spain, there has been great effort by lawmakers to put Advance Directives into practice since 2002. At the same time, the field of bioethics has been on the rise, a discipline that has spurred debate on the right of patients to exercise their autonomy. Despite all this, the implementation of ADs can be said to have failed in Spain, because its prevalence is very low, there is a great lack of knowledge about them and they have very little (...) impact on clinical decisions. The purpose of this article is to analyze and discuss the main reasons for the failure of ADs in Spain. Main body The main reasons why ADs have no impact on clinical practice in Spain have been fundamentally four: the training of health professionals about the end of life and AD is lacking; there has been no public process to increase awareness about AD, and therefore people know little about them; the bureaucratic procedure to document and implement ADs is excessively complex and cumbersome, creating a significant barrier to their application; in Spain, the remnants of a paternalistic medical culture continue to exist, which causes shared decision-making to be difficult. Conclusion Due to the four reasons mentioned above, AD have not been a useful tool to help honor patients’ autonomous decisions about their future care and, therefore, they have not achieved their objective. However, despite the difficulties and problems identified, it has also been observed that health care professionals and the Spanish public have a very positive view of AD. Having identified the problems which have kept AD from being successful, strategies must be developed to help improve their implementation into the future. (shrink)

It is unknown whether hospital-based medical professionals in Spain educate patients about advance directives. The objective of this research was to determine the frequency of hospital-based physicians’ and nurses’ engagement in AD discussions in the hospital and which patient populations merit such efforts. A short question-and-answer-based survey of physicians and nurses taking care of inpatients was conducted at a university hospital in Madrid, Spain. In total, 283 surveys were collected from medical professionals, of whom 71 per cent were female, with (...) an average age of thirty-four years. Eighty-four per cent had never educated patients about ADs because of lack of perceived responsibility, time, or general knowledge of ADs. Patient populations that warranted AD discussions included those with terminal illnesses, chronic diseases, and elderly patients. Regarding degree of AD understanding in medical professionals: 57 per cent of medical professionals claimed sufficient general knowledge of ADs, 19 per cent understood particulars regarding AD document creation, and 16 per cent were aware of AD regulatory policies. Engagement in AD discussions was considered important by 83 per cent of medical professionals, with 79 per cent interested in participating in such discussions themselves. The majority of hospital physicians and nurses do not educate their patients about ADs, despite acknowledging their importance. Patient populations of highest priority included those with terminal diseases or chronic illness or who are of advanced age. (shrink)

Background Ethical conflicts generate difficulties in daily clinical activity. Which methods of ethical advice are most frequently used to resolve them among Spanish doctors has not been studied. The objective of this study is to describe what methods hospital internal medicine physicians in Spain use to resolve their ethical doubts and which they consider most useful. Design A cross-sectional observational study was conducted through a voluntary and anonymous survey and distributed through an ad hoc platform of the Spanish Society of (...) Internal Medicine. Measures We measured methods by which to resolve doubts, types of tools sought, frequency of consulting the Clinical Ethics Committees, and satisfaction with resolution of ethical issues. Results Of 261 internists surveyed, 86 per cent resolve their ethical doubts with assistance, the most frequently used method being consultation with colleagues (58.6 per cent), followed by using specific protocols or guides (11.8 per cent) and consultation with experts in bioethics (9.6 per cent). The most preferred tools are the creation of protocols (30.3 per cent) and the establishment of a consultant/expert in bioethics (27.8 per cent). Conclusions Internists in Spain usually seek assistance to resolve their ethical doubts. Consulting colleagues is the most frequently adopted method. The majority regard tools to resolve ethical conflicts as necessary, seeking above all protocols and consultants/experts in bioethics. (shrink)

Movies can serve valuable didactic purposes teaching clinical ethics to medical students. However, using film sequences as means to develop critical thinking is not a straightforward task. There is a significant gap in the literature regarding how to analyse the ethical content embedded in these clips systematically, in a way that facilitates the students’ transition from anecdotal reflections to abstract thinking. This article offers a pedagogical proposal to approach the ethical analysis of film sequences in a systematic fashion. This structured (...) stepwise method encourages students to identify the main ethical problem of a selected scene and to reflect on the theoretical principles involved, emphasizing the application of these norms and values in a contextually situated analysis. We believe this method in film studies both reinforces the students’ comprehension of the theoretical framework of an ethical topic, and casts light on its pertinence and limitations under the circumstances of the scene, thus proving a constructive tool to strengthen the bridge between the theoretical teaching of clinical ethics and clinical practice. (shrink)

Background During the first weeks of March 2020 in Spain, the cases of severe respiratory failure progressively increased, generating an imbalance between the clinical needs for advanced life support (ALS) measures and the effective availability of ALS resources. To address this problem, the creation of triage committees (TC) was proposed, whose main function is to select the best candidates to receive ALS. The main objective of our study is to describe the clinical characteristics of the patients evaluated by the TC (...) of the Alcorcón Foundation University Hospital (AFUH) during the first wave of SARS CoV-2. Other objectives are to determine if there are differences between the patients considered candidates / not candidates for ALS and to analyze the functioning of the TC. Methods Retrospective observational study of all patients assessed by the AFUH TC. Results There were 19 meetings, in which 181 patients were evaluated, 65.4% male and with a mean age of 70.1 years. 31% had some degree of functional dependence, the Barthel median was 100 and Charlson 4. 58.5% were not considered a candidate for ALS at that time. The patients considered candidates to receive ALS were younger (72 vs 66; _p_ Conclusions The patients evaluated by the TC had a mean age of 70 years, high comorbidity and almost a third had some degree of functional dependence. More than half were not considered candidates for ALS at that time, these patients being older, with more comorbidity and a worse previous functional situation. TC decisions, based on objective clinical criteria, were almost always respected. Public institutions must get involved in triage procedures, which should and in our opinion must include the creation of TC in health centers. The implementation of Anticipated Decision programs (ADP) would help enable patients affected by triage decisions to participate in them. (shrink)

Background No studies have been conducted in Mexico to ascertain what ethical problems doctors working at hospitals deal with. This article aims to describe the ethical conflicts most commonly identified by Mexican internists and the importance they attribute to each of these conflicts. Methods Voluntary survey to the members of the Internal Medicine Association of Mexico. Results Responses were submitted by 347 internists. Half of those face ethical conflicts almost always or frequently. The most commonplace and relevant conflicts are those (...) resulting from the clinical relationship (communication, confidentiality, informed consent, assessment of mental capacity, decisions involving incapacitated patients, and conflicts with family members), and secondly those problems related with the end of life (palliative care, withholding or withdrawing treatment, and “No CPR orders”). To resolve conflicts they seek support through protocols, Institutional Ethics Committees (IECs), and consultations with colleagues and, occasionally, with bioethics experts. Protocols and IECs are the tools most in demand among them. Conclusions 1) the most frequent and relevant conflicts are those caused by the clinical relationship, above all those due to doctor–patient communication, and secondly those due to problems which arise at the end of life; 2) though nearly all of them have doubts about how to resolve conflicts, the vast majority are satisfied with the way in which they do so; 3) to deal with conflicts, they seek support mainly in protocols, IECs, and consultation with colleagues; and 4) in order to resolve them better, what they most demand are protocols and IECs, but also bioethics consultants. (shrink)