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Recomendaciones Éticas Y Clínicas Para La Toma De Decisiones En El Entorno Residencial En Contexto De La Crisis De Covid-19
The pandemic caused by the SARS-CoV-2 virus has been a true health tragedy worldwide, generating serious consequences of morbidity and mortality, especially in older people. The General Defense Hospital (HGDZ) has participated in Operation Balmis of the Armed Forces (FAS) to fight against this pandemic. It has required HGDZ great flexibility and adaptability to face the high demand for admission of patients infected with this virus. To this aim, it has implemented a growing set of measures focused on strengthening the response in the health field and reducing contagion rates.
Editoriales 153 La pandemia interior 155 Re exiones desde la vulnerabilidad: no estuve solo Artículos especiales 157 Epidemiología y características de la infección por SARS-CoV-2 164 Manifestaciones sintomáticas en la infección COVID-19 171 Recomendaciones sobre los fármacos empleados en pacientes oncohematológicos afectos de COVID-19. Una aproximación a las interacciones farmacológicas entre el tratamiento sintomático y el tratamiento "anti-COVID-19" 181 Acompañamiento a los pacientes al nal de la vida durante la pandemia por COVID-19 192 Sedación paliativa: ¿ha cambiado algo durante la pandemia? 201 Impacto emocional en pacientes y familiares durante la pandemia por COVID-19. Un duelo diferente 209 Profesionales sanitarios: afrontando el impacto emocional por la COVID-19 en un centro monográ co de cáncer 217 La función del trabajo social "sanitario" durante la pandemia por COVID-19 226 Atención en domicilio a pacientes no COVID-19 en la era COVID: tres experiencias diferentes 234 La atención paliativa en las residencias durante la pandemia COVID-19 (o cuando el coronavirus llamó a la puerta del ámbito más vulnerable del sistema) 242 Organización paliativa durante la pandemia de la COVID-19 y propuestas para la adaptación de los servicios y programas de cuidados paliativos y de atención psicosocial ante la posibilidad de reactivación de la pandemia y época pos-COVID-19 255 Re exiones éticas desde la experiencia práctica de la crisis COVID-19 Cartas al Director 263 El autocuidado en los profesionales sanitarios durante la pandemia: una oportunidad para su cultivo 265 La importancia de la comunidad y el voluntariado en un estado de pandemia 267 Plani cación compartida de la atención: la COVID-19, ¿una oportunidad? Resumen Introducción: La irrupción brusca e intensa de la COVID-19 en nuestra sociedad ha provocado un elevado sufrimiento en pacientes y familias, así como una elevada presión en profesionales y servicios. Sus peculiares características han hecho emerger la atención paliativa como uno de los ejes principales de su abordaje. Este hecho ha provocado una reestructuración de equipos y servicios de cuidados paliativos y atención psicosocial. Objetivos: Describir la respuesta inicial de diversos equipos de cuidados paliativos y atención psicosocial ante la pandemia por la COVID-19, así como elaborar una serie de recomendaciones ante la posibilidad de una nueva reactivación de la pandemia. Material y métodos: Tras una revisión narrativa de la literatura se elaboró un cuestionario con los elementos organizativos más destacados. Este cuestionario se envió a diversos expertos y referentes en cuidados paliativos en España. En una segunda fase y tras el análisis de los resul-tados del cuestionario se elaboraron una serie de recomendaciones.
Abstract Background Planning population care in a specific health care setting requires deep knowledge of the clinical characteristics of the target care recipients, which tend to be country specific. Our area virtually lacks any descriptive, far-reaching publications about institutionalized older people (IOP). We aimed to investigate the demographic and clinical characteristics of institutionalized older people (IOP) ≥65 years old and compare them with those of the rest of the population of the same age. Methods Retrospective analysis (total cohort approach) of clinical and resource-use characteristics of IOP and non-IOP older than 65 years in Catalonia (North-East Spain). Variables analysed included age and sex, diagnoses, morbidity burden—using Adjusted Morbidity Groups (GMA, Grupos de Morbilidad Ajustada)—, mortality, use of resources, and medications taken. All data were obtained from the administrative database of the local healthcare system. Results This study included 93,038, 78,458, 68,545 and 67,456 IOP from 2011, 2013, 2015 and 2017, respectively. In this interval, an increase in median age (83 vs. 87 years), in women (68.64% vs. 72.11%) and in annual mortality (11.74% vs. 20.46%) was observed. Compared with non-IOP (p
Nursing homes (NH) are considered hotspots for COVID-19 given their residential environments and patient vulnerabilities. We describe the COVID-19 preparedness of NHs across the nation.
Background
Planning population care in a specific health care setting requires deep knowledge of the clinical characteristics of the target care recipients, which tend to be country specific. Our area virtually lacks any descriptive, far-reaching publications about institutionalized older people (IOP). We aimed to investigate the demographic and clinical characteristics of institutionalized older people (IOP) ≥65 years old and compare them with those of the rest of the population of the same age.
Methods
Retrospective analysis (total cohort approach) of clinical and resource-use characteristics of IOP and non-IOP older than 65 years in Catalonia (North-East Spain). Variables analysed included age and sex, diagnoses, morbidity burden—using Adjusted Morbidity Groups (GMA)—, mortality, use of resources, and medications taken. All data were obtained from the administrative database of the local healthcare system.
Results
This study included 93,038, 78,458, 68,545 and 67,456 IOP from 2011, 2013, 2015 and 2017, respectively. In this interval, an increase in mean age (82.02 vs. 85.95 years), in women (68.64% vs. 72.11%) and in annual mortality (11.74% vs. 20.46%) was observed. Compared with non-IOP (p<0.001 in all comparisons), IOP showed a higher annual mortality (20.46% vs. 3.13%), a larger number of chronic diseases (specially dementia: 46.47% vs. 4.58%), higher multimorbidity (15.2% vs. 4.2% with GMA of maximum complexity), and annual admissions to acute care (47.6% vs. 27.7%) and skilled nursing facilities (27.8% vs. 7.4%), mean length of hospital stay (10.0 vs. 7.2 days) and mean of medications taken (11.7 vs. 8.0).
Conclusions
There is a growing gap between the clinical and demographic characteristics of age-matched IOP and non-IOP, which overlaps with a higher mortality rate of IOP. The profile of resources utilization of IOP compared with non-IOP strongly suggests a deficiency of preventive actions and stresses the need to rethink the care model for IOP from a social and health care perspective.
Background
Ensuring that countries have adequate research capacities is essential for an effective and efficient response to infectious disease outbreaks. The need for ethical principles and values embodied in international research ethics guidelines to be upheld during public health emergencies is widely recognized. Public health officials, researchers and other concerned stakeholders also have to carefully balance time and resources allocated to immediate treatment and control activities, with an approach that integrates research as part of the outbreak response. Under such circumstances, research ethics preparedness constitutes an important foundation for an effective response to infectious disease outbreaks and other health emergencies.Main textA two-day workshop was convened in March 2018 by the World Health Organisation Global Health Ethics Team and the African coaLition for Epidemic Research, Response and Training, with representatives of National Ethics Committees, to identify practical processes and procedures related to ethics review preparedness. The workshop considered five areas where work might be undertaken to facilitate rapid and sound ethics review: preparing national ethics committees for outbreak response; pre-review of protocols; multi-country review; coordination between national ethics committees and other key stakeholders; data and benefit sharing; and export of samples to third countries.In this paper, we present the recommendations that resulted from the workshop. In particular, the participants recommended that Ethics Committees would develop a formal national standard operating procedure for emergency response ethical review; that there is a need to clarify the terminology and expectations of pre-review of generic protocols and agree upon specific terminology; that there is a need to explore mechanisms for multi-country emergency ethical consultation, and to establish procedures for communication between national ethics committees and other oversight bodies and public health authorities. In addition, it was suggested that ethics committees should request from researchers, at a minimum, a preliminary data sharing and sample sharing plan that outlines the benefit to the population from which data and samples are to be drawn. This should be followed in due time by a full plan.Conclusion
It is hoped that the national ethics committees, supported by the WHO, relevant collaborative research consortia and external funding agencies, will work towards bringing these recommendations into practice, for supporting the conduct of effective research during outbreaks.
Background
Ensuring that countries have adequate research capacities is essential for an effective and efficient response to infectious disease outbreaks. The need for ethical principles and values embodied in international research ethics guidelines to be upheld during public health emergencies is widely recognized. Public health officials, researchers and other concerned stakeholders also have to carefully balance time and resources allocated to immediate treatment and control activities, with an approach that integrates research as part of the outbreak response. Under such circumstances, research “ethics preparedness” constitutes an important foundation for an effective response to infectious disease outbreaks and other health emergencies.
Main text
A two-day workshop was convened in March 2018 by the World Health Organisation Global Health Ethics Team and the African coaLition for Epidemic Research, Response and Training, with representatives of National Ethics Committees, to identify practical processes and procedures related to ethics review preparedness. The workshop considered five areas where work might be undertaken to facilitate rapid and sound ethics review: preparing national ethics committees for outbreak response; pre-review of protocols; multi-country review; coordination between national ethics committees and other key stakeholders; data and benefit sharing; and export of samples to third countries.
In this paper, we present the recommendations that resulted from the workshop. In particular, the participants recommended that Ethics Committees would develop a formal national standard operating procedure for emergency response ethical review; that there is a need to clarify the terminology and expectations of pre-review of generic protocols and agree upon specific terminology; that there is a need to explore mechanisms for multi-country emergency ethical consultation, and to establish procedures for communication between national ethics committees and other oversight bodies and public health authorities. In addition, it was suggested that ethics committees should request from researchers, at a minimum, a preliminary data sharing and sample sharing plan that outlines the benefit to the population from which data and samples are to be drawn. This should be followed in due time by a full plan.
Conclusion
It is hoped that the national ethics committees, supported by the WHO, relevant collaborative research consortia and external funding agencies, will work towards bringing these recommendations into practice, for supporting the conduct of effective research during outbreaks.
Background:
Of deaths in high-income countries, 75% are caused by progressive advanced chronic conditions. Palliative care needs to be extended from terminal cancer to these patients. However, direct measurement of the prevalence of people in need of palliative care in the population has not been attempted.
Aim:
Determine, by direct measurement, the prevalence of people in need of palliative care among advanced chronically ill patients in a whole geographic population.
Design:
Cross-sectional, population-based study.
Main outcome measure:
prevalence of advanced chronically ill patients in need of palliative care according to the NECPAL CCOMS-ICO(©) tool. NECPAL+ patients were considered as in need of palliative care.
Setting/participants:
County of Osona, Catalonia, Spain (156,807 inhabitants, 21.4% > 65 years). Three randomly selected primary care centres (51,595 inhabitants, 32.9% of County's population) and one district general hospital, one social-health centre and four nursing homes serving the patients. Subjects were all patients attending participating settings between November 2010 and October 2011.
Results:
A total of 785 patients (1.5% of study population) were NECPAL+: mean age = 81.4 years; 61.4% female. Main disease/condition: 31.3% advanced frailty, 23.4% dementia, 12.9% cancer (ratio of cancer/non-cancer = 1/7), 66.8% living at home and 19.7% in nursing home; only 15.5% previously identified as requiring palliative care; general clinical indicators of severity and progression present in 94% of cases.
Conclusions:
Direct measurement of prevalence of palliative care needs on a population basis is feasible. Early identification and prevalence determination of these patients is likely to be the cornerstone of palliative care public health policies.
Planning for the next pandemic influenza outbreak is underway in hospitals across the world. The global SARS experience has taught us that ethical frameworks to guide decision-making may help to reduce collateral damage and increase trust and solidarity within and between health care organisations. Good pandemic planning requires reflection on values because science alone cannot tell us how to prepare for a public health crisis.
In this paper, we present an ethical framework for pandemic influenza planning. The ethical framework was developed with expertise from clinical, organisational and public health ethics and validated through a stakeholder engagement process. The ethical framework includes both substantive and procedural elements for ethical pandemic influenza planning. The incorporation of ethics into pandemic planning can be helped by senior hospital administrators sponsoring its use, by having stakeholders vet the framework, and by designing or identifying decision review processes. We discuss the merits and limits of an applied ethical framework for hospital decision-making, as well as the robustness of the framework.
The need for reflection on the ethical issues raised by the spectre of a pandemic influenza outbreak is great. Our efforts to address the normative aspects of pandemic planning in hospitals have generated interest from other hospitals and from the governmental sector. The framework will require re-evaluation and refinement and we hope that this paper will generate feedback on how to make it even more robust.
Background
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can spread rapidly within skilled nursing facilities. After identification of a case of Covid-19 in a skilled nursing facility, we assessed transmission and evaluated the adequacy of symptom-based screening to identify infections in residents.
Methods
We conducted two serial point-prevalence surveys, 1 week apart, in which assenting residents of the facility underwent nasopharyngeal and oropharyngeal testing for SARS-CoV-2, including real-time reverse-transcriptase polymerase chain reaction (rRT-PCR), viral culture, and sequencing. Symptoms that had been present during the preceding 14 days were recorded. Asymptomatic residents who tested positive were reassessed 7 days later. Residents with SARS-CoV-2 infection were categorized as symptomatic with typical symptoms (fever, cough, or shortness of breath), symptomatic with only atypical symptoms, presymptomatic, or asymptomatic.
Results
Twenty-three days after the first positive test result in a resident at this skilled nursing facility, 57 of 89 residents (64%) tested positive for SARS-CoV-2. Among 76 residents who participated in point-prevalence surveys, 48 (63%) tested positive. Of these 48 residents, 27 (56%) were asymptomatic at the time of testing; 24 subsequently developed symptoms (median time to onset, 4 days). Samples from these 24 presymptomatic residents had a median rRT-PCR cycle threshold value of 23.1, and viable virus was recovered from 17 residents. As of April 3, of the 57 residents with SARS-CoV-2 infection, 11 had been hospitalized (3 in the intensive care unit) and 15 had died (mortality, 26%). Of the 34 residents whose specimens were sequenced, 27 (79%) had sequences that fit into two clusters with a difference of one nucleotide.
Conclusions
Rapid and widespread transmission of SARS-CoV-2 was demonstrated in this skilled nursing facility. More than half of residents with positive test results were asymptomatic at the time of testing and most likely contributed to transmission. Infection-control strategies focused solely on symptomatic residents were not sufficient to prevent transmission after SARS-CoV-2 introduction into this facility.
Introduction
The COVID-19 pandemic is stressing healthcare systems throughout the world. Significant numbers of patients are being admitted to the hospital with severe illness, often in the setting of advanced age and underlying co-morbidities. Therefore, palliative care is an important part of the response to this pandemic. The Seattle area and UW Medicine have been on the forefront of the pandemic in the US.
Methods
UW Medicine developed a strategy to implement a palliative care response for a multi-hospital healthcare system that incorporates conventional capacity, contingency capacity, and crisis capacity. The strategy was developed by our palliative care programs with input from the healthcare system leadership.
Results
In this publication, we share our multi-faceted strategy to implement high-quality palliative care in the context of the COVID-19 pandemic that incorporates conventional, contingency, and crisis capacity and focuses on the areas of the hospital caring for the most patients: the emergency department, the intensive care units, and the acute care services. The strategy focuses on key content areas including identifying and addressing goals of care, addressing moderate and severe symptoms, and supporting family members.
Conclusions
Strategy planning for delivery of high-quality palliative care in the context of the COVID-19 pandemic represents an important area of need for our healthcare systems. We share our experiences developing such a strategy to help other institutions conduct and adapt such strategies more quickly.
The pandemic of coronavirus disease of 2019 (COVID‐19) has global impact unseen since the 1918 worldwide influenza epidemic. All aspects of life have changed dramatically for now. The group most susceptible to COVID‐19 are older adults and those with chronic underlying chronic medical disorders. The population residing in long‐term care facilities generally are those who are both old and suffering from multiple comorbidities. In this article we provide information, insights, and recommended approaches to COVID‐19 in the long‐term facility setting. Since the situation is fluid and changing rapidly, readers are encouraged to access the resources cited in this article frequently.
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What lies beneath: Clinical and resource-use characteristics of institutionalized older people. A retrospective, population-based cohort study in Catalonia
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