9. Care of the patient who dies imminently; family and medical equipment

#### 9.1. Patient care

from information, and expect their family to take a decision-making role; this is acceptable if the intensivist perceives that the decision is taken freely and without coercion, clarifying that in

The treatment of critically ill patients has two objectives: intensive treatment, which tries to restore the health and functionality of the patient to a level acceptable to him, and the control of symptoms, which tries to reduce the burden of suffering caused by the disease and by your treatment. In certain cases, in the face of poor clinical evolution, pursuing the best interest of the patient is to change the treatment approach from intensive treatment to palliative care, rather than extending life in any way [25]. Applying the principles of palliative care means maintaining comfort and dignity, attending to psychological and spiritual

Doctors and family members must make decisions based on the wishes of the patient. He has sometimes made ACP or formal opinion heard. But those desires can also be deduced in other ways: extrapolation of how he has led his life, general statements during his life, and sometimes appointment of a substitute decision-maker (who will inform the medical team of their

ACP allows the patient to plan and make clear his preferences and to take care of his health in case he gets sick. They usually include end-of-life decisions (although not necessary). It is based on the principle of Autonomy, and on the right to be fully informed about the treatment options of their pathology, and to be treated in a way that respects their dignity and avoids their suffering. ACP improves end-of-life care, meets the preferences expressed by the patient, improves family satisfaction, and reduces anxiety depression and the post-traumatic effect on survivors. It should be reflected in writing (ACD) and included in the medical report, with an adequate alert system. The intensivists must be familiar with their inclusion in the decision-

However, the ACP may be inadequate to provide the degree of certainty necessary to support the end-of-life decision, for example, to include generic phrases such as "no reasonable possibility of cure." It can be established an order of reliability about the validity of the

• 2nd, ACP that does not mention the current situation of the patient, although it allows

• 4th, belief of the family and friends of the patient's knowledge about what the patient

• 3rd, informal discussions of the patient with his family and friends about his wishes;

8. Decision-making, advance care planning, advance care decision

addition to delegating the information, decision-making is delegated.

needs, and supporting the family.

42 Reflections on Bioethics

patient's wishes:

would like to do;

preferences regarding this point if the patient cannot).

making of patients, especially in end-of-life treatments.

• 1st, ACP that is relevant in the current situation;

conclusions to be drawn "by analogy";

The death of a patient after carrying out an LLTS plan is a very complex situation, and the way in which patients die and families coexist with it is variable. The palliative care plan should be individualized to the particular needs of each case and should include pharmacological and nonpharmacological measures. Practical and emotional support should also be offered explaining that dying could cause the presence of noisy and agonizing breathing. Attention should be paid to these signs (especially when they appear as a result of the withdrawal of respiratory support) to administer preventively sedation and analgesia; the withdrawal of renal or cardiovascular treatment does not require support measures for de-scaling. Palliative treatments will always be administered with the intention of relieving symptoms, not accelerating death. Properly document what therapies are removed such as mechanical ventilation, dialysis, inotropes, cardiopulmonary resuscitation, etc.

Some patients will die and some will leave the hospital [31]. Predicting the time of death is difficult. Several factors influence which palliative treatment measures are required:

The pharmacological control of the symptoms is extensive and includes alleviating pain, agitation, dyspnea, and excessive respiratory secretions. A prepared medication checklist can be useful to ensure immediate access to the necessary medication. Muscular relaxants have no place in palliative management, only in association with sedatives and in certain circumstances such as adult respiratory distress syndrome. After extubation, the patient may die quickly, and the cause of death is the underlying disease; Sedation ensures that there is no awareness

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45

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The dose of drugs can be increased, depending on age, the presence of multiple organ dysfunction, previous exposure to benzodiazepines or morphics, the current level of sedation, the underlying disease, and the wishes of the patient in relation to sedation in the end of life. There is no maximum dose in the relief of pain and suffering at the end of life, and the dose should be individualized for each patient and each situation. Although they have cardiodepressive effects, the proper use of opioids has been associated with longer life [36]. Morphine can be used for pain and dyspnea, midazolam for agitation and restlessness, haloperidol for delirium, and glycopyrrolate for respiratory secretions. The evaluation of the palliative treatment can vary according to the situation of the patient: in a conscious patient, we can ask him; in an unconscious patient, the signs of respiratory work and distress include restlessness, diaphoresis, high blood pressure, hyperventilation, tachycardia, grimacing or vocalizing after nursing

If patients are awake before removing ventilatory support (e.g., motor neuron disease or high spinal cord injury). Sedatives or anesthetics may be administered to make them unconscious and spare them the suffering of dying [37, 38]. A consensus must be reached that allows the patient to have control over the dying process and fulfill his desire to "not die fighting, drowning." The slow withdrawal of sedation is accumulated by increasing the dose of seda-

If death is not imminent and the patient has a very minor distress, it should be made clear to the family that it is often difficult to predict the time of death. Nonpharmacological measures are important, and the opportunity for the family to spend time with the patient before he or she dies must be emphasized. The interruption of fluids and medical nutrition must be assessed individually. Oral food must be offered, although most patients reject it and reduce

All medical equipment should provide good end-of-life care. When death occurs in a short time, times are best handled in the ICU, the team being attentive to the needs of the patient and their family; if the process is longer, the patient should be transported to a palliative care area or even allowing the patient to die at home. Communication with the family must be clear, and the proper transfer of medical and nursing information is important to ensure a gradual

The patient should be supported in their pain/suffering. The loss of autonomy, control of body functions, body image, and mobility should be remembered. This one is not with the people who they would like to be with. Although communication is limited, the patient should be insisted on our commitment to comfort and dignity. Your family should be asked to think with

care, etc. Always doctor must try to preserve the dignity of the patient.

tion to achieve a respiratory frequency less than 20/minute.

during the death process [35].

its intake [35].

transition of care.


Once a decision has been made about not to initiate or suspend life support treatment, a palliative plan should be initiated. This will have to be properly documented. The ICU nurse has an essential role of caring for the patient and offering support to the family.

Nonpharmacological interventions aim to offer emotional and spiritual support through:


In some patients, noninvasive mechanical ventilation (NIMV) may be indicated. It can be used to reduce dyspnea in acute respiratory failure. Even in patients without indication of invasive mechanical ventilation (IMV), NIMV can be used to increase survival, although a clear consensus must be achieved before use [32]. No study has been made aimed at assessing the quality of death in patients with NIMV compared to patients with habitual treatment with sedoanalgesia. But it supposes greater discomfort, greater medicalization of the dying process, and ambiguity in terms of treatment, especially when removing it and initiating sedatives [33]. Therefore, its role should be evaluated patient to patient, and attention should be given above all in other aspects of palliative care.

When considering the interruption of ventilatory and circulatory support, the impact to the patient and his family must be anticipated. The patient can become dyspneic and that can be distressing for both. Prior medication should be administered to help prevent any resulting discomfort. Morphine can be administered at 5 mg/h and propofol al 50 mg/h. An important fact: the withdrawal of respiratory support followed by programmed extubation has been associated with higher rates of family satisfaction during the end-oflife process [34].

The pharmacological control of the symptoms is extensive and includes alleviating pain, agitation, dyspnea, and excessive respiratory secretions. A prepared medication checklist can be useful to ensure immediate access to the necessary medication. Muscular relaxants have no place in palliative management, only in association with sedatives and in certain circumstances such as adult respiratory distress syndrome. After extubation, the patient may die quickly, and the cause of death is the underlying disease; Sedation ensures that there is no awareness during the death process [35].

Some patients will die and some will leave the hospital [31]. Predicting the time of death is difficult. Several factors influence which palliative treatment measures are required:

Once a decision has been made about not to initiate or suspend life support treatment, a palliative plan should be initiated. This will have to be properly documented. The ICU nurse

In some patients, noninvasive mechanical ventilation (NIMV) may be indicated. It can be used to reduce dyspnea in acute respiratory failure. Even in patients without indication of invasive mechanical ventilation (IMV), NIMV can be used to increase survival, although a clear consensus must be achieved before use [32]. No study has been made aimed at assessing the quality of death in patients with NIMV compared to patients with habitual treatment with sedoanalgesia. But it supposes greater discomfort, greater medicalization of the dying process, and ambiguity in terms of treatment, especially when removing it and initiating sedatives [33]. Therefore, its role should be evaluated patient to patient, and

When considering the interruption of ventilatory and circulatory support, the impact to the patient and his family must be anticipated. The patient can become dyspneic and that can be distressing for both. Prior medication should be administered to help prevent any resulting discomfort. Morphine can be administered at 5 mg/h and propofol al 50 mg/h. An important fact: the withdrawal of respiratory support followed by programmed extubation has been associated with higher rates of family satisfaction during the end-of-

Nonpharmacological interventions aim to offer emotional and spiritual support through:

has an essential role of caring for the patient and offering support to the family.

• the patient's wishes in relation to their care and end-of-life needs;

• what treatments are removed and which are not initiated;

• how much dependence on UCI treatment the patient has;

• what are the patient's needs for analgesia and ansiolysis;

• what are the family's treatment needs.

• offer an environment as private as possible;

• nursing care: mouth, eyes, skin, intestinal, etc.

• nasal air to relieve dyspnea in a conscious patient, etc.

attention should be given above all in other aspects of palliative care.

• consider the visit of her/his favorite pet;

• removal of tubes and monitoring devices.

• what are the treatment needs of dyspnea and other symptoms;

• the patient is conscious;

• death is imminent;

44 Reflections on Bioethics

life process [34].

The dose of drugs can be increased, depending on age, the presence of multiple organ dysfunction, previous exposure to benzodiazepines or morphics, the current level of sedation, the underlying disease, and the wishes of the patient in relation to sedation in the end of life. There is no maximum dose in the relief of pain and suffering at the end of life, and the dose should be individualized for each patient and each situation. Although they have cardiodepressive effects, the proper use of opioids has been associated with longer life [36]. Morphine can be used for pain and dyspnea, midazolam for agitation and restlessness, haloperidol for delirium, and glycopyrrolate for respiratory secretions. The evaluation of the palliative treatment can vary according to the situation of the patient: in a conscious patient, we can ask him; in an unconscious patient, the signs of respiratory work and distress include restlessness, diaphoresis, high blood pressure, hyperventilation, tachycardia, grimacing or vocalizing after nursing care, etc. Always doctor must try to preserve the dignity of the patient.

If patients are awake before removing ventilatory support (e.g., motor neuron disease or high spinal cord injury). Sedatives or anesthetics may be administered to make them unconscious and spare them the suffering of dying [37, 38]. A consensus must be reached that allows the patient to have control over the dying process and fulfill his desire to "not die fighting, drowning." The slow withdrawal of sedation is accumulated by increasing the dose of sedation to achieve a respiratory frequency less than 20/minute.

If death is not imminent and the patient has a very minor distress, it should be made clear to the family that it is often difficult to predict the time of death. Nonpharmacological measures are important, and the opportunity for the family to spend time with the patient before he or she dies must be emphasized. The interruption of fluids and medical nutrition must be assessed individually. Oral food must be offered, although most patients reject it and reduce its intake [35].

All medical equipment should provide good end-of-life care. When death occurs in a short time, times are best handled in the ICU, the team being attentive to the needs of the patient and their family; if the process is longer, the patient should be transported to a palliative care area or even allowing the patient to die at home. Communication with the family must be clear, and the proper transfer of medical and nursing information is important to ensure a gradual transition of care.

The patient should be supported in their pain/suffering. The loss of autonomy, control of body functions, body image, and mobility should be remembered. This one is not with the people who they would like to be with. Although communication is limited, the patient should be insisted on our commitment to comfort and dignity. Your family should be asked to think with the patient's perspective. Death is part of life and requires an individualized management of the situation.

10. Special situations

10.2. Chronic respiratory diseases

sensation of drowning.

12 months later [39].

10.1. Suicide

There are special end-of-life situations that involve different actions.

Suicide is the leading cause of death among young people. For every completed suicide, there are about 30 suicide attempts, and many enter the ICU. Suicide damage affects the family and

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Many patients who make a suicide attempt have expressed their rejection of the treatment prior to admission. They may be mentally ill, but also nonill people who find in suicide the solution to a delicate situation or even in the bosom of a serious progressive disease. Life support measures may be withdrawn or not started in patients with serious organ damage after attempted suicide (i.e., severe hypoxic damage). That decision will be guided by the best interest of the patient. The severities of mental illness, and the absence of response to treatment, are relevant data when considering a life support treatment. Decisions can be made with the substitute decision-maker, and you can try to answer the question "would it be reasonable to withdraw active treatment given the clinical circumstances if there were not an attempted suicide?" It is accepted that patients with capacity have the right to refuse life support treatments. When the patients lose this capacity, these options are legally reinforced by the ACD, without the need to be agreed and even without clear reasons. Some patients may have freely

society broadly. Although suicide is not illegal, helping a suicide is punishable.

decided suicide as an option. The consensus of the medical team must be achieved.

Patients with chronic respiratory diseases, such as Chronic Obstructive Pulmonary Disease (COPD), are at risk of suffering an acute exacerbation leading to admission to the ICU with mechanical ventilation or other supports. The decision-making in these patients is complicated, because of the unpredictability of their recovery, ignorance about the acceptable prognosis (unless the patient has ACD), their high levels of anxiety, depression, and fear of the

Several factors are associated with a poorer prognosis: poor lung function, exercise tolerance/ functional stage, low body mass index, use of home oxygen, comorbidities, frequency of hospital admissions due to decompensation, etc. Recent studies show that 60% of patients with COPD intubate survive and can return to an acceptable situation; the average survival after admission to the ICU due to COPD is 2 years; and among COPD patients who required prolonged IMV with tracheostomy, 78% were weaned successfully and 43% were still alive

Patients with advanced respiratory diseases ideally have a good understanding of their life history, with gradual respiratory deterioration and exacerbations that follow recovery. Based on that, they will make their ACP; however, very few patients have done so for many reasons: uncertainty of the prognosis, slightly progressive disease, difficulties of the doctors to find

#### 9.2. Care of families

Families must have everything necessary to accompany the patient and carry out their grieving process. Sometimes the family asks to delay the withdrawal of treatment "to give time to arrive on time to members of the family"; this request must be overspent with what the sustained burden of treatment implies. We must collect data on the perception of family members to improve aspects of the care of the patient who dies. The reaction of bereavement changes over time, and its absence is abnormal: it can manifest with shock, distress, anger, fear, denial, confusion, guilt, numbness, etc.; even desolation and complete isolation. Religious stereotypes should not be followed but ask your family what they think is appropriate from the spiritual point of view, according to a holistic approach.

The behavior of the ICU is also important after the death, giving support to the family. The risk of postdeath bereavement is greater, and support may be needed in several situations: sudden death, traumatic death, preventable death, death of a child, social isolation, past history of mood disorders or other significant losses, and prolonged reactions mourning. The society ends soon the death, but the duel can be a long trip with a first year with experiences without the presence of the deceased. Contact with his GP can help restore physical and emotional well-being, although additional resources may be required, especially in frail and elderly people.

### 9.3. Care of the medical team

The death of the patient can imply a reduction in the personal and professional worth of the doctor and nurse. Regular multidisciplinary discussions should be integrated into the usual practice of the ICU. These discussions will help create an open, cohesive, and flexible teamwork culture, especially during a conflictive end-of-life process. It also facilitates a greater consistency of communication with the patient and his family. During the discussions, there are no successes or mistakes, but questions are opened for dialog. This shared experience can help team cohesion and prevent the team from being divided into complex end-of-life situations.

All ICU members are vulnerable to emotional stress, with complex clinical and ethical decisions. The presence of conflict increases the risk of adverse effects on health care workers. If the conflict is prolonged, and a legal action is taken, the risk is even greater. Also taking care of the patient and the people involved (families, friends, caregivers) is exhausting, and there is little time to recover; immediately, the door opens and another patient comes into.

There are other ways to support the staff. The intensivist must be separated from the family in a conflict. There must be flexibility in the support of the staff members; nobody is immune to the conflict. Sometimes the doctor can even be relieved of his work overload, if he is involved in a prolonged conflict; and this will allow you to focus on good communication and conflict resolution, with adequate rest periods.

## 10. Special situations

There are special end-of-life situations that involve different actions.

#### 10.1. Suicide

the patient's perspective. Death is part of life and requires an individualized management of

Families must have everything necessary to accompany the patient and carry out their grieving process. Sometimes the family asks to delay the withdrawal of treatment "to give time to arrive on time to members of the family"; this request must be overspent with what the sustained burden of treatment implies. We must collect data on the perception of family members to improve aspects of the care of the patient who dies. The reaction of bereavement changes over time, and its absence is abnormal: it can manifest with shock, distress, anger, fear, denial, confusion, guilt, numbness, etc.; even desolation and complete isolation. Religious stereotypes should not be followed but ask your family what they think is appropriate from

The behavior of the ICU is also important after the death, giving support to the family. The risk of postdeath bereavement is greater, and support may be needed in several situations: sudden death, traumatic death, preventable death, death of a child, social isolation, past history of mood disorders or other significant losses, and prolonged reactions mourning. The society ends soon the death, but the duel can be a long trip with a first year with experiences without the presence of the deceased. Contact with his GP can help restore physical and emotional well-being, although additional resources may be required, especially in frail and elderly

The death of the patient can imply a reduction in the personal and professional worth of the doctor and nurse. Regular multidisciplinary discussions should be integrated into the usual practice of the ICU. These discussions will help create an open, cohesive, and flexible teamwork culture, especially during a conflictive end-of-life process. It also facilitates a greater consistency of communication with the patient and his family. During the discussions, there are no successes or mistakes, but questions are opened for dialog. This shared experience can help team cohesion and prevent the team from being divided into complex end-of-life situa-

All ICU members are vulnerable to emotional stress, with complex clinical and ethical decisions. The presence of conflict increases the risk of adverse effects on health care workers. If the conflict is prolonged, and a legal action is taken, the risk is even greater. Also taking care of the patient and the people involved (families, friends, caregivers) is exhausting, and there is little

There are other ways to support the staff. The intensivist must be separated from the family in a conflict. There must be flexibility in the support of the staff members; nobody is immune to the conflict. Sometimes the doctor can even be relieved of his work overload, if he is involved in a prolonged conflict; and this will allow you to focus on good communication and conflict

time to recover; immediately, the door opens and another patient comes into.

the spiritual point of view, according to a holistic approach.

the situation.

46 Reflections on Bioethics

people.

tions.

9.3. Care of the medical team

resolution, with adequate rest periods.

9.2. Care of families

Suicide is the leading cause of death among young people. For every completed suicide, there are about 30 suicide attempts, and many enter the ICU. Suicide damage affects the family and society broadly. Although suicide is not illegal, helping a suicide is punishable.

Many patients who make a suicide attempt have expressed their rejection of the treatment prior to admission. They may be mentally ill, but also nonill people who find in suicide the solution to a delicate situation or even in the bosom of a serious progressive disease. Life support measures may be withdrawn or not started in patients with serious organ damage after attempted suicide (i.e., severe hypoxic damage). That decision will be guided by the best interest of the patient. The severities of mental illness, and the absence of response to treatment, are relevant data when considering a life support treatment. Decisions can be made with the substitute decision-maker, and you can try to answer the question "would it be reasonable to withdraw active treatment given the clinical circumstances if there were not an attempted suicide?" It is accepted that patients with capacity have the right to refuse life support treatments. When the patients lose this capacity, these options are legally reinforced by the ACD, without the need to be agreed and even without clear reasons. Some patients may have freely decided suicide as an option. The consensus of the medical team must be achieved.

#### 10.2. Chronic respiratory diseases

Patients with chronic respiratory diseases, such as Chronic Obstructive Pulmonary Disease (COPD), are at risk of suffering an acute exacerbation leading to admission to the ICU with mechanical ventilation or other supports. The decision-making in these patients is complicated, because of the unpredictability of their recovery, ignorance about the acceptable prognosis (unless the patient has ACD), their high levels of anxiety, depression, and fear of the sensation of drowning.

Several factors are associated with a poorer prognosis: poor lung function, exercise tolerance/ functional stage, low body mass index, use of home oxygen, comorbidities, frequency of hospital admissions due to decompensation, etc. Recent studies show that 60% of patients with COPD intubate survive and can return to an acceptable situation; the average survival after admission to the ICU due to COPD is 2 years; and among COPD patients who required prolonged IMV with tracheostomy, 78% were weaned successfully and 43% were still alive 12 months later [39].

Patients with advanced respiratory diseases ideally have a good understanding of their life history, with gradual respiratory deterioration and exacerbations that follow recovery. Based on that, they will make their ACP; however, very few patients have done so for many reasons: uncertainty of the prognosis, slightly progressive disease, difficulties of the doctors to find where and how to make these ACPs. Even when the ACP is done, many patients want a "treatment trial" without clear guidance on how to make limitation decisions. Also, the health professional is afraid that this discussion "will take away his hope." These conversations are useful for patients, and they allow them to maintain a certain degree of control; they can be stated in terms of "hoping for the best, planning the worst." Anxiety and fear disproportionate to lack of air influence the efforts of weaning and tolerance to the NIMV. The family and the patient can be battling to accept the information that the doctor gives during episodes of deterioration.

The child's ability to make decisions changes over the years. The views of the child are important and should be involved in decision-making, if they have considerable experience in medical treatment and according to their ability to interfere. Sometimes families do not want to make decisions and prefer doctors to make decisions for them; but on most occasions, parents want to be involved in decision-making. The best approach is shared, with joint deliberation

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49

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Intensivists should be as safe as possible in any situation. A consensus among colleagues should be sought, a second opinion sought, information obtained from other experts, etc. Even if there is still uncertainty, the values and points of view of the parents play an important role in determining whether to administer a treatment, after being informed of all the possible benefits and associated risks. "Compassion fatigue" and caregiver frustration are not legitimate reasons to interrupt treatment, but deliberation about the end of life should be ethically

When the life of a child is endangered or there is risk of significant damage that will affect their health in a decisive way, it is not necessary to ask for consent. The decisions must ideally be agreed with the parents in situations of stability and must seek and follow the ethical princi-

When discussing the prognosis with the parents, it is necessary to define the panorama that awaits the child in his daily life, that is, if he is going to be able to communicate properly, be able to procure self-care, sit-down and mobilize himself. All these will help parents to imagine this hypothetical situation and make a wise decision. A question that arises quickly is "under what circumstances is ethical to consider the limitation of life support therapy". Here some of

• it is very unlikely that the patient will benefit from any treatment if his life is prolonged. The "additional" time we offer does not give you other option to receive treatment. As with adults, decisions at the end of life should be made with as much consensus as possible. All those involved in patient care should have one or more meeting prior to the one with the family, the intensivist and other specialist, nurses psychologists, social workers, etc., and have a "common idea" about how to approach the meeting with the family. The family should fell that all efforts from this point will be aimed at providing comfort and that does not mean leaving or

It seems logical to think that early decisions do not take place when it comes to a child, and that the substitute decision-maker is usually the parent and must always be present when decisions of this type are made. Many children suffer from chronic and limiting illnesses. The doctors who regularly monitor these children must take part and be involved in the process, providing data, both technical and personal, as they know the patient and their family well. Sometimes consensus may not be reached. When medical treatment suggests that life support benefits a child, it must be provided even if there is no agreement with your family. If there is a risk of relevant damage to a child for a treatment, without the corresponding benefit, it should

abandoning him and that the team will continue to provide excellent care to the child.

• the patient has a limiting disease and probably dies despite all efforts;

over what course of illness would be best for the child.

rigorous and robust.

them:

ples of beneficence and not maleficence.

#### 10.3. Chronic neurologic diseases

Patients with motor neuron diseases die due to progressive respiratory muscle weakness, aspiration pneumonia due to involvement of the bulbar muscles, and difficulty in coughing. Patients are aware of their poor prognosis, maintain their consciousness until advanced stages, and often have ACP (documented or not). The reasons for not using NIMV are the progressive nature of the disease that impairs their quality of life, the amount of resources required in daily care, the possibility of remaining not communicated, unable to express their treatment preferences, or having that you make a future decision to withdraw treatment. These situations are emotionally difficult, and most patients would prefer to avoid them. Weaning success of IMV is <50%, and most patients need NIMV. In these patients, IMV can only be considered in two scenarios: diagnosis of the pathology that has not given time to pose ACP, with infection or another reversible disease; and respiratory failure prior to the diagnosis of motor neuron disease.

A peculiar profile of neurological patients is the persistent vegetative states. This concept refers to patients persisting in a coma with eyes open at least 4 weeks after the initial damage. Each case must be treated individually, respecting the usual end-of-life criteria and the ACP of the patient and working with the substitute decision-maker to determine a reasonable care plan. Hydration and artificial nutrition are part of medical treatments and should be discontinued like other treatments. The belief in the sanctity of life is universal, but it can be confused with the most extreme version of vitalism. The National Health and Medical Research Council guidelines [40] make it clear: "the question is not whether the life of the patient is worthwhile, but whether it is worth the treatment".

#### 10.4. Childhood

We usually do not have clear views of the child about their treatment. Intensivists and parents are obliged to act in the best interests of the child, although it may be difficult to know with certainty which option is valid. Sometimes there may be a difference of opinion between the medical team and the parents; parents believe they know what is best for the child, but as with adults, meeting family requests is not always appropriate. Parents sometimes ask the intensivists "what would you do if I were your son?"; if answered honestly, it can improve the relationship with parents, but they may not share their values and beliefs, and care should be taken to avoid influencing parents.

The child's ability to make decisions changes over the years. The views of the child are important and should be involved in decision-making, if they have considerable experience in medical treatment and according to their ability to interfere. Sometimes families do not want to make decisions and prefer doctors to make decisions for them; but on most occasions, parents want to be involved in decision-making. The best approach is shared, with joint deliberation over what course of illness would be best for the child.

where and how to make these ACPs. Even when the ACP is done, many patients want a "treatment trial" without clear guidance on how to make limitation decisions. Also, the health professional is afraid that this discussion "will take away his hope." These conversations are useful for patients, and they allow them to maintain a certain degree of control; they can be stated in terms of "hoping for the best, planning the worst." Anxiety and fear disproportionate to lack of air influence the efforts of weaning and tolerance to the NIMV. The family and the patient can be battling to accept the information that the doctor gives during episodes of

Patients with motor neuron diseases die due to progressive respiratory muscle weakness, aspiration pneumonia due to involvement of the bulbar muscles, and difficulty in coughing. Patients are aware of their poor prognosis, maintain their consciousness until advanced stages, and often have ACP (documented or not). The reasons for not using NIMV are the progressive nature of the disease that impairs their quality of life, the amount of resources required in daily care, the possibility of remaining not communicated, unable to express their treatment preferences, or having that you make a future decision to withdraw treatment. These situations are emotionally difficult, and most patients would prefer to avoid them. Weaning success of IMV is <50%, and most patients need NIMV. In these patients, IMV can only be considered in two scenarios: diagnosis of the pathology that has not given time to pose ACP, with infection or another reversible disease; and respiratory failure prior to the diagnosis of motor neuron

A peculiar profile of neurological patients is the persistent vegetative states. This concept refers to patients persisting in a coma with eyes open at least 4 weeks after the initial damage. Each case must be treated individually, respecting the usual end-of-life criteria and the ACP of the patient and working with the substitute decision-maker to determine a reasonable care plan. Hydration and artificial nutrition are part of medical treatments and should be discontinued like other treatments. The belief in the sanctity of life is universal, but it can be confused with the most extreme version of vitalism. The National Health and Medical Research Council guidelines [40] make it clear: "the question is not whether the life of the patient is worthwhile,

We usually do not have clear views of the child about their treatment. Intensivists and parents are obliged to act in the best interests of the child, although it may be difficult to know with certainty which option is valid. Sometimes there may be a difference of opinion between the medical team and the parents; parents believe they know what is best for the child, but as with adults, meeting family requests is not always appropriate. Parents sometimes ask the intensivists "what would you do if I were your son?"; if answered honestly, it can improve the relationship with parents, but they may not share their values and beliefs, and care should

deterioration.

48 Reflections on Bioethics

disease.

10.4. Childhood

10.3. Chronic neurologic diseases

but whether it is worth the treatment".

be taken to avoid influencing parents.

Intensivists should be as safe as possible in any situation. A consensus among colleagues should be sought, a second opinion sought, information obtained from other experts, etc. Even if there is still uncertainty, the values and points of view of the parents play an important role in determining whether to administer a treatment, after being informed of all the possible benefits and associated risks. "Compassion fatigue" and caregiver frustration are not legitimate reasons to interrupt treatment, but deliberation about the end of life should be ethically rigorous and robust.

When the life of a child is endangered or there is risk of significant damage that will affect their health in a decisive way, it is not necessary to ask for consent. The decisions must ideally be agreed with the parents in situations of stability and must seek and follow the ethical principles of beneficence and not maleficence.

When discussing the prognosis with the parents, it is necessary to define the panorama that awaits the child in his daily life, that is, if he is going to be able to communicate properly, be able to procure self-care, sit-down and mobilize himself. All these will help parents to imagine this hypothetical situation and make a wise decision. A question that arises quickly is "under what circumstances is ethical to consider the limitation of life support therapy". Here some of them:


As with adults, decisions at the end of life should be made with as much consensus as possible. All those involved in patient care should have one or more meeting prior to the one with the family, the intensivist and other specialist, nurses psychologists, social workers, etc., and have a "common idea" about how to approach the meeting with the family. The family should fell that all efforts from this point will be aimed at providing comfort and that does not mean leaving or abandoning him and that the team will continue to provide excellent care to the child.

It seems logical to think that early decisions do not take place when it comes to a child, and that the substitute decision-maker is usually the parent and must always be present when decisions of this type are made. Many children suffer from chronic and limiting illnesses. The doctors who regularly monitor these children must take part and be involved in the process, providing data, both technical and personal, as they know the patient and their family well.

Sometimes consensus may not be reached. When medical treatment suggests that life support benefits a child, it must be provided even if there is no agreement with your family. If there is a risk of relevant damage to a child for a treatment, without the corresponding benefit, it should not be administered even if the parents request it forcefully. Clinicians must remain faithful to their integrity. Sometimes parents find offensive that doctors think about a subjective issue such as their child's quality of life. The task of the intensivist is to consciously determine the benefit of life, in terms of the child's pleasure to live and to face the burdens of the current treatment. This act of comparison must be carried out, and the terms "quality of life" and "futility" must be avoided.

12. Decision of not to reanimate (DNR)

consent for the benefit of the patient;

attempted in the following circumstances:

• chronic, debilitating and terminal illness,

other intervention if his condition deteriorates.

than 75 years, advanced cancer, COPD, heart failure, etc.

• permanent brain damage,

tion maneuvers.

• danger for the resuscitating team,

(CPR) are to preserve life, restore health, and limit the sequelae.

• obvious signs of biological death (rigor mortis, livicedes),

• reliable evidence that the patient doesn't want to be reanimed,

Bioethical principles apply in the general CPR situation in several aspects: • CPR should be attempted in all patients suffering from cardiac arrest;

Cardiac arrest is the immediate, unexpected and potentially reversible interruption of the circulation and spontaneous breathing. The objectives of cardiopulmonary resuscitation

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51

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• patients can accept or reject any treatment, including a CPR; in most cases, it is assumed that the patient has not carried out a previous instruction and acts under the presumed

• all patients who can benefit from resuscitation efforts should have equal access to these efforts. In an emergency, we must prioritize the common good over the protection of

CPR makes sense if recovery expectations are reasonable. On the contrary, CPR should not be

• final stage of an acute process in which all available therapeutic options have been tried,

• delay of more than 10 minutes between the start of the stop and the start of the resuscita-

A "resuscitation plan" should be prepared and visible in the patients´ medical records when appropriate. It must be completed if there is a possibility of worsening and that it is not a candidate for invasive measures. The purpose is to provide clinical guidance to the nursing staff of the general ward to avoid inappropriate activation of the Emergency Medical Team. In previous articles, this document has been named as "not-for-resuscitation form" or "decision not-to reanímate" (DNR). Recently, a "positive" designation was chosen, and it must include other global treatment decisions, such as whether the patient agrees to a subsequent surgery or

This document must be completed by the intensivist if the treatment limitation follows the best interests of the patient or if it is in accordance with the preference of the patient or his substitute decision-maker. Also nonintensivist physicians must make a resuscitation plan if the limitation of treatment is appropriate. We could consider candidates for this option: older

Age is an element that doesn't influence the decision to reanimate or not to reanimate.

individual autonomy, maximizing the number of survivors or years of life saved.

The term "allow a natural death" seems more appropriate than "not resuscitate," since it avoids giving the impression that some potential benefits of the treatment are withdrawn [41]. The discussion with the parents must include which interventions are appropriate and which are not (nasogastric tube, orotracheal intubation, aspiration, intravenous access, etc.) the result should be clearly documented in the story. ACDs have less relevance in the pediatric patient because children have no ability to communicate their treatment options and because substitute decision-makers, parents, are almost always present when treatment decisions are made. When planning the LLTS, several issues can be proposed to the parents: petting the child while extubating (maintaining the role of parent caregivers), preventing them from seeing signs of agonizing breathing but that the child will be sedated, and having a single room and withdraw monitoring. Also when possible, they should have enough time and space to say goodbye.

A follow-up to the parents is accurate even weeks after the death, this follow-up must include the doctors involved, social worker, psychologist, etc. A subsequent meeting is the opportunity to clarify doubts and eliminate misunderstandings from parents.

#### 10.5. Emergency situations

Emergency situations are outside end-of-life care. The definition of emergency is a situation in which the patient is unable to give consent for a treatment that is immediately needed to:


An authorization or a renunciation to consent is limited. The only treatments allowed are those that pursue those objectives. If the treatment carries a risk of permanent disability, it is best to obtain the informed consent if possible within a reasonable timeframe.

## 11. Organ donation

Donation is an integral part of end-of-life care and it is necessary to know how to recognize donation opportunities and to identify those situations in which death is a possibility. It is necessary to contact the local transplant organization, if such situations arise, to discuss the availability of the donation, the physiological support with active treatment of the potential donor, determine brain death, and assess the need to send information to the court and documentation of brain death. Most patients who die in the ICU are able to donate tissues.

## 12. Decision of not to reanimate (DNR)

not be administered even if the parents request it forcefully. Clinicians must remain faithful to their integrity. Sometimes parents find offensive that doctors think about a subjective issue such as their child's quality of life. The task of the intensivist is to consciously determine the benefit of life, in terms of the child's pleasure to live and to face the burdens of the current treatment. This act of comparison must be carried out, and the terms "quality of life" and

The term "allow a natural death" seems more appropriate than "not resuscitate," since it avoids giving the impression that some potential benefits of the treatment are withdrawn [41]. The discussion with the parents must include which interventions are appropriate and which are not (nasogastric tube, orotracheal intubation, aspiration, intravenous access, etc.) the result should be clearly documented in the story. ACDs have less relevance in the pediatric patient because children have no ability to communicate their treatment options and because substitute decision-makers, parents, are almost always present when treatment decisions are made. When planning the LLTS, several issues can be proposed to the parents: petting the child while extubating (maintaining the role of parent caregivers), preventing them from seeing signs of agonizing breathing but that the child will be sedated, and having a single room and withdraw monitoring. Also when possible, they should have enough time and space to say goodbye.

A follow-up to the parents is accurate even weeks after the death, this follow-up must include the doctors involved, social worker, psychologist, etc. A subsequent meeting is the opportunity

Emergency situations are outside end-of-life care. The definition of emergency is a situation in which the patient is unable to give consent for a treatment that is immediately needed to:

An authorization or a renunciation to consent is limited. The only treatments allowed are those that pursue those objectives. If the treatment carries a risk of permanent disability, it is best to

Donation is an integral part of end-of-life care and it is necessary to know how to recognize donation opportunities and to identify those situations in which death is a possibility. It is necessary to contact the local transplant organization, if such situations arise, to discuss the availability of the donation, the physiological support with active treatment of the potential donor, determine brain death, and assess the need to send information to the court and documentation of brain death. Most patients who die in the ICU are able to

to clarify doubts and eliminate misunderstandings from parents.

obtain the informed consent if possible within a reasonable timeframe.

"futility" must be avoided.

50 Reflections on Bioethics

10.5. Emergency situations

• save the patient's life, or • prevent serious damage.

11. Organ donation

donate tissues.

Cardiac arrest is the immediate, unexpected and potentially reversible interruption of the circulation and spontaneous breathing. The objectives of cardiopulmonary resuscitation (CPR) are to preserve life, restore health, and limit the sequelae.

Bioethical principles apply in the general CPR situation in several aspects:


CPR makes sense if recovery expectations are reasonable. On the contrary, CPR should not be attempted in the following circumstances:


Age is an element that doesn't influence the decision to reanimate or not to reanimate.

A "resuscitation plan" should be prepared and visible in the patients´ medical records when appropriate. It must be completed if there is a possibility of worsening and that it is not a candidate for invasive measures. The purpose is to provide clinical guidance to the nursing staff of the general ward to avoid inappropriate activation of the Emergency Medical Team. In previous articles, this document has been named as "not-for-resuscitation form" or "decision not-to reanímate" (DNR). Recently, a "positive" designation was chosen, and it must include other global treatment decisions, such as whether the patient agrees to a subsequent surgery or other intervention if his condition deteriorates.

This document must be completed by the intensivist if the treatment limitation follows the best interests of the patient or if it is in accordance with the preference of the patient or his substitute decision-maker. Also nonintensivist physicians must make a resuscitation plan if the limitation of treatment is appropriate. We could consider candidates for this option: older than 75 years, advanced cancer, COPD, heart failure, etc.

Filling that plan does not mean that the treatment is limited; in some cases, the patient can be a candidate for a full CPR.

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## 13. Clinical practice guidelines for the terminal patient


Table 4 shows the 12 "good dying" points that must be contributed in the ICU [15].

These aspects should be included in the Clinical Practice Guide for the Comprehensive Management of Palliative Care. This guide should direct the palliative care plan, in patients in whom the goal of treatment has ceased to be healing, and has become comfort and symptomatic relief. It is highly recommended to implant in hospitals, first at the academic level, and then at the training level, training in palliative care. And there is no doubt that the hospital has an important responsibility in that its health professionals know how to apply palliative care to their patients.


Table 4. Items associated with a good dying.

## Author details

#### Miguel Ángel García García<sup>1</sup> \*, María Ángeles Rosero Arenas2 and Alfonso Martínez Cornejo<sup>1</sup>

\*Address all correspondence to: mangelesymangel051003@hotmail.com


## References

Filling that plan does not mean that the treatment is limited; in some cases, the patient can be a

13. Clinical practice guidelines for the terminal patient

• know that death is coming and understand what can be expected;

• have control over the relief of pain and other symptoms;

• be able to ensure that the patient's wishes are respected;

Table 4 shows the 12 "good dying" points that must be contributed in the ICU [15].

These aspects should be included in the Clinical Practice Guide for the Comprehensive Management of Palliative Care. This guide should direct the palliative care plan, in patients in whom the goal of treatment has ceased to be healing, and has become comfort and symptomatic relief. It is highly recommended to implant in hospitals, first at the academic level, and then at the training level, training in palliative care. And there is no doubt that the hospital has an important responsibility in that its health professionals know how to apply palliative care

\*, María Ángeles Rosero Arenas2 and Alfonso Martínez Cornejo<sup>1</sup>

candidate for a full CPR.

52 Reflections on Bioethics

• Palliative care plan

to their patients.

Author details

Miguel Ángel García García<sup>1</sup>

Table 4. Items associated with a good dying.

1 ICU hospital de Sagunto, Valencia, Spain

2 Primary Care, Cheste, Valencia, Spain

\*Address all correspondence to: mangelesymangel051003@hotmail.com

• be able to leave when it is time to leave and not prolong the situation indefinitely.

• Training in palliatives

• Institutional responsibility

• have some control of what is happening;

• have sufficient information and technical skill; • have access to spiritual and emotional support; • have control over who will be with the patient;

• offer dignity and privacy;

• have time to say goodbye;

• choose where to die;


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**Chapter 3**

**Provisional chapter**

**Ethical Considerations in Research and Medical Care of**

**Ethical Considerations in Research and Medical Care of** 

Menopause is the permanent cessation of menstruation, and among the main symptoms reported have been night sweats, heat waves, increased body fat at the central level, dyslipidemia, hypertension, osteoporosis, insulin resistance, diabetes, mild cognitive impairment, depression, periodontitis, varicose veins, apnea, urinary genital discomfort, as well as dryness in the mouth and eye. The diagnosis, study, and care of menopausal or postmenopausal women have had great advances, such as recognizing the sub-inclusion of women and female animal models in basic and clinical studies and proposing in the same design of the study the analysis by sex. Subsequently, the need for specialized ethical training was identified, beginning in undergraduate, postgraduate, and clinical practice. To achieve this, several actions were carried out, such as the foundation of Women's Health Institutes, the implementation of the Institutional and Private Committees of Ethic, and the development of validated instruments to evaluate signs and symptoms. Currently, there is no consensus that meets the ethical requirements for care and research in these patients. Efforts have been made practically by pathology, without considering together the social and psychobiological condition. What is intended in this document is to present the ethical aspects related to the study and medical care of women in

**Keywords:** ethics, menopause, postmenopausal, woman, and clinical research

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

DOI: 10.5772/intechopen.74666

**Menopause**

**Abstract**

menopause.

**Menopause**

Claudia Camelia Calzada Mendoza,

Claudia Camelia Calzada Mendoza,

http://dx.doi.org/10.5772/intechopen.74666

Carlos Alberto Jiménez Zamarripa and Marta Elena Hernández Caballero

Carlos Alberto Jiménez Zamarripa and Marta Elena Hernández Caballero

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

Liliana Anguiano Robledo, Gabriela Lugo Martínez,

Liliana Anguiano Robledo, Gabriela Lugo Martínez,

#### **Ethical Considerations in Research and Medical Care of Menopause Ethical Considerations in Research and Medical Care of Menopause**

DOI: 10.5772/intechopen.74666

Claudia Camelia Calzada Mendoza, Liliana Anguiano Robledo, Gabriela Lugo Martínez, Carlos Alberto Jiménez Zamarripa and Marta Elena Hernández Caballero Claudia Camelia Calzada Mendoza, Liliana Anguiano Robledo, Gabriela Lugo Martínez, Carlos Alberto Jiménez Zamarripa and Marta Elena Hernández Caballero

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.74666

#### **Abstract**

Menopause is the permanent cessation of menstruation, and among the main symptoms reported have been night sweats, heat waves, increased body fat at the central level, dyslipidemia, hypertension, osteoporosis, insulin resistance, diabetes, mild cognitive impairment, depression, periodontitis, varicose veins, apnea, urinary genital discomfort, as well as dryness in the mouth and eye. The diagnosis, study, and care of menopausal or postmenopausal women have had great advances, such as recognizing the sub-inclusion of women and female animal models in basic and clinical studies and proposing in the same design of the study the analysis by sex. Subsequently, the need for specialized ethical training was identified, beginning in undergraduate, postgraduate, and clinical practice. To achieve this, several actions were carried out, such as the foundation of Women's Health Institutes, the implementation of the Institutional and Private Committees of Ethic, and the development of validated instruments to evaluate signs and symptoms. Currently, there is no consensus that meets the ethical requirements for care and research in these patients. Efforts have been made practically by pathology, without considering together the social and psychobiological condition. What is intended in this document is to present the ethical aspects related to the study and medical care of women in menopause.

**Keywords:** ethics, menopause, postmenopausal, woman, and clinical research

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
