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    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Craneoplastia con vendaje&#46; Nuevas formas de limitaci&#243;n del tratamiento de soporte vital y donaci&#243;n de &#243;rganos"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleDisplayedQuote" id="dsq0005"><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">&#8220;<span class="elsevierStyleItalic">The fact that things are so does not mean that they have to stay that way&#8221;&#46; Bertolt Brecht&#46; The life of Galileo</span>&#46;</p></span></p><p id="par0010" class="elsevierStylePara elsevierViewall">Organ transplantation is a consolidated treatment for terminal organ failure&#46; It clearly improves patient&#39;s quality of life&#44; and in the case of vital organs constitutes the only possible treatment option&#46; Transplantation currently offers excellent results&#44; reaching a survival rate of 48&#37; after 20 years in the case of liver transplantation<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and of 53&#37; after 10 years in the case of heart transplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Spain&#44; with 35&#46;3 donors per million of population &#40;pmp&#41; in the year 2011&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> has the highest donor rate in the world&#44; while the United States has a rate of 26&#46;3<span class="elsevierStyleHsp" style=""></span>pmp and the European Union has an average donor rate of 18&#46;1<span class="elsevierStyleHsp" style=""></span>pmp&#46; Up until 1 January 2012&#44; a total of 81&#44;909 organ transplants had been carried out in Spain&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Globally&#44; the main problem facing transplantation is the scarcity of organs&#8212;a situation causing the death of about 10&#37; of all patients while on the waiting list&#46; The demand for organs moreover increases every year&#44; since transplantation has become a routine and generalized practice&#46; Approximately 90&#37; of all organs transplanted in Spain come from brain death &#40;BD&#41; donors&#44; but this source has a limited potential for producing candidate organs&#46; In order to satisfy the demand on the part of patients on the transplant waiting list&#44; the Spanish National Transplant Organization &#40;<span class="elsevierStyleItalic">Organizaci&#243;n Nacional de Trasplantes</span>&#44; ONT&#41; and other international organizations have developed strategies designed to increase the donor pool by harvesting organs from non-heart beating donors &#40;Maastricht types II and III&#41; and live donors&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The age of BD donors has gradually increased in this country&#46; In the year 2011&#44; 53&#46;7&#37; of the donors were over 60 years of age&#44; 27&#46;9&#37; were between 45 and 59 years of age&#44; and only 18&#46;4&#37; were under 45 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> This means that a large proportion of donors are of the &#8220;expanded&#8221; type&#44; resulting in a shortage of thoracic organs in particular&#44; since these are the transplants that prove most demanding in terms of donor age&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Intensive Care Units &#40;ICUs&#41; constitute a key element in any transplant program&#44; since it is in the ICU where BD is diagnosed&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and where the multiorgan donor is maintained&#46; In Spain&#44; almost 80&#37; of all transplant coordinators are intensivists&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In neurocritical patients with intracranial hypertension syndrome &#40;ICH&#41;&#44; the European Brain Injury Consortium<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and the American Association of Neurological Surgeons<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> propose decompressive craniotomy &#40;DC&#41; as a second level management measure&#46; In recent decades&#44; DC has been the subject of controversy&#44; and although it clearly reduces intracranial pressure &#40;ICP&#41; and shortens the stay in the ICU&#44; there is debate regarding the functional outcome of the technique&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;15</span></a> In any case&#44; and despite the controversies&#44; extensive DC &#40;frontal-subtemporal-parietal-occipital&#41; is increasingly being used in the ICU&#46; This in turn is one of the explanations given for the decrease in BD donors&#44; which in Spain have dropped from 32<span class="elsevierStyleHsp" style=""></span>pmp in the year 2001 to 29&#46;2<span class="elsevierStyleHsp" style=""></span>pmp in 2010&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In patients with devastating neurological injuries and an extremely poor prognosis&#44; the maintenance of DC prevents ICP from reaching levels high enough to produce cerebral circulatory arrest and therefore BD&#46; In these cases&#44; life-sustaining treatment limitation &#40;LSTL&#41; may be considered&#8212;this being a frequent practice in our ICUs and regarded as a quality standard by the Spanish Society of Intensive and Critical Care Medicine and Coronary Units &#40;<span class="elsevierStyleItalic">Sociedad Espa&#241;ola de Medicina Intensiva&#44; Cr&#237;tica y Unidades Coronarias</span>&#44; SEMICYUC&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> When LSTL is performed through terminal extubation&#44; the possibility of organ harvesting is exclusively limited to controlled non-heart beating or Maastricht type III donation&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> This type of donation is only exceptionally performed in Spain&#44; and because of its inherent limitations&#44; the harvesting of organs for grafting cannot always be guaranteed&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Based on the case of a patient admitted to the ICU of the Central University Hospital of Asturias &#40;Oviedo&#44; Spain&#41;&#44; we have postulated suppression of therapeutically futile DC involving cranioplasty with bandage as a form of LSTL&#46; All aspects related to transplantation have an important bioethical dimension&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> and despite the fact that this practice&#44; and withdrawal of ventricular drainage&#44; are performed occasionally&#44; there are no literature references in this respect&#46; Consequently&#44; <span class="elsevierStyleItalic">a posteriori</span>&#44; we commented the case with the Clinical Ethics Committee of our hospital and consulted reputed national and international experts in bioethics&#46; In order to obtain a broader range of impressions&#44; we consulted experts from different settings&#46; All of them were especially dedicated to medical ethics&#58; Dr&#46; Diego Gracia&#44; Dr&#46; Marcelo Palacios&#44; Dr&#46; Pablo Sim&#243;n and Dr&#46; Pilar Miranda&#46; Others were specifically ascribed to the world of Intensive Care Medicine&#44; as members of the SEMICYUC and experts in ethics applied to the critical patient&#58; Dr&#46; Lu&#237;s Cabr&#233;&#44; Dr&#46; I&#241;aki Saralegui&#44; Dr&#46; Koldo Mart&#237;nez and Dr&#46; Sebasti&#225;n Iribarren&#46; In turn&#44; another consulted expert&#44; likewise dedicated to medical ethics&#44; was more closely related to organ donation and transplantation&#58; Dr&#46; Miguel Casares&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The consulted experts came from different parts of the country&#59; consultation was therefore made by e-mail&#46; The authors of the present article summarized and structured all the replies obtained&#46; Posteriorly&#44; the manuscript was forwarded to all the consulted experts &#40;as co-authors&#41; for reading and approval&#46; The pertinent modifications were made&#44; and the paper was then again forwarded to the experts with a view to obtaining final consensus&#46; The paper was then submitted for publication&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Clinical case</span><p id="par0050" class="elsevierStylePara elsevierViewall">A 38-year-old male was admitted due to traumatic brain injury&#46; Upon admission&#44; the Glasgow coma score was 3&#44; with bilateral non-reactive mydriasis &#40;6<span class="elsevierStyleHsp" style=""></span>mm&#41; and the absence of corneal reflexes&#46; The brain computed tomography scan showed multiple hemorrhagic contusions&#44; massive brain edema with compression of the peri-mesencephalic cisterns&#44; and left subdural hematoma with mass effect&#46; Given the Glasgow score and the absence of brainstem reflexes&#44; Neurosurgery decided against surgical intervention&#46; After three hours without sedation&#44; the patient remained with bilateral non-reactive mydriasis &#40;6<span class="elsevierStyleHsp" style=""></span>mm&#41; but had recovered the corneal reflexes and showed decerebration rigidity motor responses&#46; Upon re-evaluation by Neurosurgery&#44; and despite the bilateral non-reactive mydriasis and dire prognosis&#44; surgery with evacuation of the subdural hematoma was carried out&#44; with left DC and ICP monitoring with a Camino<span class="elsevierStyleSup">&#174;</span> catheter&#44; in view of the age of the patient&#46; The course proved negative&#44; with a sustained ICP of over 40<span class="elsevierStyleHsp" style=""></span>mmHg&#44; refractory to all kinds of treatment &#40;deep sedation&#44; analgesia&#44; neuromuscular block&#44; controlled hyperventilation&#44; hypertonic saline infusion&#44; mannitol and DC&#41;&#46; The computed tomography scan showed ischemic areas in the brainstem&#44; territory of the right anterior cerebral artery and left brain hemisphere &#40;territory of the middle and posterior cerebral arteries&#41;&#46; After 5 days&#44; and with the suspicion of BD&#44; sedation was suspended&#46; After 48<span class="elsevierStyleHsp" style=""></span>h without sedation&#44; the patient presented a Glasgow score of 3&#44; bilateral non-reactive mydriasis and the absence of photomotor&#44; cranial&#44; oculocephalic and cough reflexes&#44; maintaining only spontaneous breathing&#46; The electroencephalogram &#40;EEG&#41; showed the absence of brain bioelectrical activity in the left brain hemisphere&#44; and minimum activity with suppression phases in the right hemisphere&#46; The neurological exploration&#44; the computed tomography findings and the EEG tracing confirmed that the patient suffered catastrophic and irreversible brain damage&#44; with no chance of recovery&#46; The supervising physician made the following assessment&#58; the natural course of these injuries is towards BD&#44; though this is impeded by DC initially intended to help save the life of the patient&#44; but which has failed and now artificially prolongs a terminal situation&#46; In this case two options were considered&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#40;A&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Decompressive craniotomy no longer improves the situation and only prolongs a terminal condition&#46; It therefore would be acceptable to cancel its effects by means of a cranioplasty with bandage&#46; In this case&#44; death would occur according to neurological criteria&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#40;B&#41;</span><p id="par0060" class="elsevierStylePara elsevierViewall">The application of LSTL through terminal extubation&#44; likewise considering that intubation and mechanical ventilation are futile and only prolong a terminal patient condition&#46; In this case&#44; death would occur according to cardiorespiratory criteria&#46;</p></li></ul></p><p id="par0065" class="elsevierStylePara elsevierViewall">The case was discussed in clinical session&#44; and since patient recovery was considered impossible&#44; all the physicians in the Department agreed to apply LSTL&#46; Of the two abovementioned options&#44; the supervising physician chose cranioplasty with bandage&#44; with the criterion that this would ensure a course more consistent with the natural evolution of the initial injury&#46; The relatives of the patient were informed in detail of the reasons for this decision and of its possible consequences&#46; Twenty-four hours later&#44; after obtaining consent from the family&#44; and in the absence of prior wills&#44; the patient donated 6 organs &#40;seventh day of admission&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical consultation</span><p id="par0070" class="elsevierStylePara elsevierViewall">All the consulted experts in medical ethics were asked the following question&#58;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In a patient with catastrophic and irreversible brain damage&#44; in which LSTL is decided&#44; is it ethically correct to perform cranioplasty with bandage in order to facilitate evolution towards BD&#63; Should this option be preferred over other forms of LSTL&#44; taking into account the possibility of organ donation&#63;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Responses</span><p id="par0080" class="elsevierStylePara elsevierViewall">The experts agreed on the following points&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0085" class="elsevierStylePara elsevierViewall">From the scientific and ethical perspective&#44; in the event of catastrophic neurological damage&#44; it is advisable to adapt treatment to the expectations for recovery and the wishes of the patient&#44; if these have been previously expressed&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Maintaining futile treatment is regarded as poor clinical practice&#44; since it goes against human dignity&#46; The physician should always avoid unwarranted insistence upon treatment&#46; Limiting life support measures that only serve to artificially prolong life without possibilities for recovery of the patient&#44; having established consensus among the attending physicians and relatives&#44; constitutes correct practice consistent with the recommendations referred to end of life care&#44; Spanish legislation&#44; and the accepted ethical standards&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> LSTL in these situations avoids undue suffering for the family and also the unnecessary consumption of healthcare resources&#46; In the present case&#44; cranioplasty with bandage is considered good medical practice&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Reverting the effect of decompressive surgery when the latter is no longer effective and indeed proves futile cannot be assumed in terms of surgical replacement of the bone flap&#44; since this would constitute an unjustified consumption of resources&#46; Reverting the effect of decompressive surgery through cranioplasty with bandage may be regarded as ethically similar to other forms of LSTL&#44; since it does not violate the principles of beneficence and non-maleficence&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#40;3&#41;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Attending the principle of autonomy&#44; it must be determined whether the patient expressed or left instructions referred to LSTL and organ donation&#46; If not so&#44; then the relatives or legal representatives should make the decisions on the basis of what they know&#46; In this respect&#44; it is necessary to provide the family with exhaustive&#44; detailed and transparent information on the entire process&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#40;4&#41;</span><p id="par0100" class="elsevierStylePara elsevierViewall">If the patient expressed a wish to donate his or her organs&#44; or in the event of family consent through delegation&#44; the implicated healthcare professionals must do everything possible to satisfy the expressed wish&#8212;preserving the principle of autonomy and abiding with the principles of social solidarity&#46; In the present case it would be indicated to apply LSTL involving cranioplasty with bandage&#44; since a fatal outcome under conditions of brain death would facilitate organ donation&#46; In this context it must be remembered that donation under non-heart beating donor conditions &#40;in cases of death according to cardiorespiratory criteria after terminal extubation&#41; is exceptional&#44; and is unable to guarantee organ harvesting for transplantation&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">From the ethical perspective&#44; we are obliged to contemplate organ donation&#44; since there are many patients on the transplant waiting list who could benefit as a result&#46; Some authors<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> have estimated that a multiorgan donation comprising 6 organs generates 55&#46;8 years of life for the different recipients&#44; and thus represents an important social benefit consistent with the principles of justice&#46; The World Health Organization&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> the Spanish national medical organization &#40;article 48 of the Code of Medical Ethics and Deontology<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#41;&#44; and the ethical code of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units &#40;SEMICYUC&#41;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> consider it an obligation of all health professionals to encourage and promote organ donation&#46; Moreover&#44; the family members of the patient can find certain consolation in donation&#44; since by doing so&#44; they are contributing to save the life or improve the quality of life of other people&#46; It must be remembered that organ donation contributes greatly to a fairer society&#44; with values such as solidarity&#44; altruism&#44; compassion&#44; or the correction of inequalities&#46; On the other hand&#44; transplantation practice has been shown to be very efficient in terms of healthcare resource utilization&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#40;5&#41;</span><p id="par0110" class="elsevierStylePara elsevierViewall">In the ICU&#44; the disconnection of mechanical ventilation and&#47;or terminal extubation is a common element in LSTL&#46; The fact that protocolized extubation is traditionally and most frequently decided does not mean that this LSTL modality should prevail over other options such as cranioplasty with bandage&#44; particularly in those cases where there is a possibility for organ donation&#46;</p></li></ul></p><p id="par0115" class="elsevierStylePara elsevierViewall">Therefore&#44; cranioplasty with bandage can be regarded as good clinical practice&#44; consistent with the general aims of medical practice as defined by the Hastings Center&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In many cases&#44; decompressive craniotomy can save the life of neurocritical patients&#44; and our obligation as intensivists is to offer our patients all possible opportunities for recovery&#46; Unfortunately&#44; in cases characterized by a very poor course and devastating injuries&#44; DC may prove futile and can moreover impede natural evolution of the patient condition towards brain death&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">After pondering this clinical case&#44; it can be concluded that cranioplasty with bandage is an ethically acceptable form of LSTL&#46; Its application is of undeniable social value&#44; since it facilitates organ donation&#46; In these cases&#44; it is necessary to know the existence of prior instructions and to adequately inform the family of the patient with a view to obtaining consent&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Social and professional practices change slowly&#44; and good reasons&#44; profound reflection and broad knowledge are needed to facilitate change&#46; We are therefore obliged to continue our research and specific training of health professionals in relation to the new forms of LSTL and organ donation&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Most of the transplanted organs are obtained from brain death &#40;BD&#41; donors&#46; In neurocritical patients with catastrophic injuries and decompressive craniectomy &#40;DC&#41;&#44; which show a dreadful development in spite of this treatment&#44; DC could be a futile tool to avoid natural progress to BD&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We propose whether cranial compressive bandage &#40;<span class="elsevierStyleItalic">cranioplasty with bandage</span>&#41; could be an ethically correct practice&#44; similar to other life-sustaining treatment limitation &#40;LSTL&#41; common methods&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Based on a clinical case&#44; we had contacted the Assistance Ethics Committee and some of the bioethics professionals and asked them two questions&#58; 1&#41; Is ethically correct to perform a <span class="elsevierStyleItalic">cranioplasty with bandage</span> in those patients with LSTL indication&#63; 2&#41; Thinking in organ donation possibility&#44; is this option preferable&#63;</p> <span class="elsevierStyleSectionTitle" id="sect0010">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#40;1&#41; <span class="elsevierStyleItalic">Cranioplasty with bandage</span> could be considered an ethically acceptable LSTL practice&#44; similar to other procedures&#46; &#40;2&#41; It facilitates organ donation for transplant&#44; which provides for value-added proposition because of its own social good&#46; &#40;3&#41; In these cases&#44; it is necessary to know previous patient&#39;s will or&#44; in absentia&#44; to obtain family consent after a detailed procedure report&#46;</p>"
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        "resumen" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La mayor&#237;a de los &#243;rganos trasplantados proceden de donantes fallecidos en muerte encef&#225;lica &#40;ME&#41;&#46; En pacientes neurocr&#237;ticos con lesiones catastr&#243;ficas y craniectom&#237;a descompresiva &#40;CD&#41; que tienen una p&#233;sima evoluci&#243;n a pesar de todo el tratamiento&#44; la CD puede llegar a ser una medida f&#250;til que impida la evoluci&#243;n <span class="elsevierStyleItalic">natural</span> hacia la ME&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Planteamos si realizar un vendaje compresivo pericraneal &#40;<span class="elsevierStyleItalic">craneoplastia con vendaje</span>&#41; puede ser una pr&#225;ctica &#233;ticamente correcta y comparable a otras formas habituales de limitaci&#243;n del tratamiento de soporte vital &#40;LTSV&#41;&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A partir de un caso cl&#237;nico&#44; realizamos una consulta al Comit&#233; de &#201;tica Asistencial y a expertos bio&#233;ticos&#44; formulando las siguientes cuestiones&#58; 1&#41; En pacientes que se decide la LTSV &#191;es &#233;ticamente correcto realizar una craneoplastia con vendaje&#63; 2&#41; &#191;Es preferible esta opci&#243;n considerando una posible donaci&#243;n de &#243;rganos&#63;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">1&#41; La <span class="elsevierStyleItalic">craneoplastia con vendaje</span> puede ser considerada una forma de LTSV &#233;ticamente aceptable y similar a otros procedimientos 2&#41; Facilita la donaci&#243;n de &#243;rganos para trasplante&#44; lo que aporta valor a&#241;adido por el bien social correspondiente 3&#41; En estos casos&#44; es necesario conocer las instrucciones previas del paciente y en su ausencia&#44; obtener el consentimiento familiar por delegaci&#243;n tras un informe detallado del procedimiento&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Escudero D&#44; et al&#46; Craneoplastia con vendaje&#46; nuevas formas de limitaci&#243;n del tratamiento de soporte vital y donaci&#243;n de &#243;rganos&#46; Med Intensiva&#46; 2013&#46; <span class="elsevierStyleInterRef" id="intr0005" href="doi:10.1016/j.medin.2012.12.008">http&#58;&#47;&#47;dx&#46;doi&#46;org&#47;10&#46;1016&#47;j&#46;medin&#46;2012&#46;12&#46;008</span></p>"
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Cranioplasty with bandaging: New forms of limitation of life support and organ donation
Craneoplastia con vendaje. Nuevas formas de limitación del tratamiento de soporte vital y donación de órganos
D. Escuderoa,
Corresponding author
, L. Cofiñoa, D. Graciab, M. Palaciosc, M. Casaresd, L. Cabrée, P. Simónf, P. Mirandag, K. Martínezh, S. Iribarreni, I. Saraleguij, R.M. Simók, B. de Leónl, V. Españolm
a Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Oviedo, Spain
b Profesor Emérito de la Universidad Complutense de Madrid, Madrid, Spain
c Presidente del Comité Científico de la Sociedad Internacional de Bioética – SIBI, Miembro del Comité de Bioética de España, Spain
d Nefrólogo, Magister en Bioética, Presidente del CEAS del Hospital Universitario de Getafe, Madrid, Spain
e Jefe Servicio Medicina Intensiva Hospital de Barcelona, SCIAS, Presidente de la Associació de Bioètica i Dret de la Universidad de Barcelona, Miembro del Comité de Bioètica de la Generalitat de Catalunya, Presidente del CEA del Hospital de Barcelona, SCIAS, Spain
f Profesor de Bioética, Escuela Andaluza de Salud Pública, Granada, Spain
g ex Jefe de Servicio de Ginecología y Obstetricia, Hospital Universitario 12 de Octubre, Madrid, Máster en Bioética, Spain
h Presidente de la Asociación de Bioética Fundamental y Clínica. Servicio de Medicina Intensiva, Hospital Navarra, Pamplona, Spain
i Jefe de Servicio Medicina Intensiva, Hospital Universitario de Araba Sede Txagorritxu, experto en Bioética, Spain
j Presidente Comité Ética Asistencial, Unidad Medicina Intensiva, Hospital Universitario Álava-Santiago, Vitoria, Spain
k Presidenta Comité de Ética Asistencial del Área Sanitaria IV, Hospital Universitario Central de Asturias, Oviedo, Spain
l Servicio de Medicina Intensiva, Instituto Nacional de Silicosis – HUCA, Miembro del Comité de Ética Asistencial del Hospital Universitario Central de Asturias, Oviedo, Spain
m Servicio de Medicina Intensiva I HUCA, Miembro del Comité de Ética Asistencial del Hospital Universitario Central de Asturias, Oviedo, Spain
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    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Craneoplastia con vendaje&#46; Nuevas formas de limitaci&#243;n del tratamiento de soporte vital y donaci&#243;n de &#243;rganos"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleDisplayedQuote" id="dsq0005"><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">&#8220;<span class="elsevierStyleItalic">The fact that things are so does not mean that they have to stay that way&#8221;&#46; Bertolt Brecht&#46; The life of Galileo</span>&#46;</p></span></p><p id="par0010" class="elsevierStylePara elsevierViewall">Organ transplantation is a consolidated treatment for terminal organ failure&#46; It clearly improves patient&#39;s quality of life&#44; and in the case of vital organs constitutes the only possible treatment option&#46; Transplantation currently offers excellent results&#44; reaching a survival rate of 48&#37; after 20 years in the case of liver transplantation<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and of 53&#37; after 10 years in the case of heart transplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Spain&#44; with 35&#46;3 donors per million of population &#40;pmp&#41; in the year 2011&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> has the highest donor rate in the world&#44; while the United States has a rate of 26&#46;3<span class="elsevierStyleHsp" style=""></span>pmp and the European Union has an average donor rate of 18&#46;1<span class="elsevierStyleHsp" style=""></span>pmp&#46; Up until 1 January 2012&#44; a total of 81&#44;909 organ transplants had been carried out in Spain&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Globally&#44; the main problem facing transplantation is the scarcity of organs&#8212;a situation causing the death of about 10&#37; of all patients while on the waiting list&#46; The demand for organs moreover increases every year&#44; since transplantation has become a routine and generalized practice&#46; Approximately 90&#37; of all organs transplanted in Spain come from brain death &#40;BD&#41; donors&#44; but this source has a limited potential for producing candidate organs&#46; In order to satisfy the demand on the part of patients on the transplant waiting list&#44; the Spanish National Transplant Organization &#40;<span class="elsevierStyleItalic">Organizaci&#243;n Nacional de Trasplantes</span>&#44; ONT&#41; and other international organizations have developed strategies designed to increase the donor pool by harvesting organs from non-heart beating donors &#40;Maastricht types II and III&#41; and live donors&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The age of BD donors has gradually increased in this country&#46; In the year 2011&#44; 53&#46;7&#37; of the donors were over 60 years of age&#44; 27&#46;9&#37; were between 45 and 59 years of age&#44; and only 18&#46;4&#37; were under 45 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> This means that a large proportion of donors are of the &#8220;expanded&#8221; type&#44; resulting in a shortage of thoracic organs in particular&#44; since these are the transplants that prove most demanding in terms of donor age&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Intensive Care Units &#40;ICUs&#41; constitute a key element in any transplant program&#44; since it is in the ICU where BD is diagnosed&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and where the multiorgan donor is maintained&#46; In Spain&#44; almost 80&#37; of all transplant coordinators are intensivists&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In neurocritical patients with intracranial hypertension syndrome &#40;ICH&#41;&#44; the European Brain Injury Consortium<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and the American Association of Neurological Surgeons<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> propose decompressive craniotomy &#40;DC&#41; as a second level management measure&#46; In recent decades&#44; DC has been the subject of controversy&#44; and although it clearly reduces intracranial pressure &#40;ICP&#41; and shortens the stay in the ICU&#44; there is debate regarding the functional outcome of the technique&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;15</span></a> In any case&#44; and despite the controversies&#44; extensive DC &#40;frontal-subtemporal-parietal-occipital&#41; is increasingly being used in the ICU&#46; This in turn is one of the explanations given for the decrease in BD donors&#44; which in Spain have dropped from 32<span class="elsevierStyleHsp" style=""></span>pmp in the year 2001 to 29&#46;2<span class="elsevierStyleHsp" style=""></span>pmp in 2010&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In patients with devastating neurological injuries and an extremely poor prognosis&#44; the maintenance of DC prevents ICP from reaching levels high enough to produce cerebral circulatory arrest and therefore BD&#46; In these cases&#44; life-sustaining treatment limitation &#40;LSTL&#41; may be considered&#8212;this being a frequent practice in our ICUs and regarded as a quality standard by the Spanish Society of Intensive and Critical Care Medicine and Coronary Units &#40;<span class="elsevierStyleItalic">Sociedad Espa&#241;ola de Medicina Intensiva&#44; Cr&#237;tica y Unidades Coronarias</span>&#44; SEMICYUC&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> When LSTL is performed through terminal extubation&#44; the possibility of organ harvesting is exclusively limited to controlled non-heart beating or Maastricht type III donation&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> This type of donation is only exceptionally performed in Spain&#44; and because of its inherent limitations&#44; the harvesting of organs for grafting cannot always be guaranteed&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Based on the case of a patient admitted to the ICU of the Central University Hospital of Asturias &#40;Oviedo&#44; Spain&#41;&#44; we have postulated suppression of therapeutically futile DC involving cranioplasty with bandage as a form of LSTL&#46; All aspects related to transplantation have an important bioethical dimension&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> and despite the fact that this practice&#44; and withdrawal of ventricular drainage&#44; are performed occasionally&#44; there are no literature references in this respect&#46; Consequently&#44; <span class="elsevierStyleItalic">a posteriori</span>&#44; we commented the case with the Clinical Ethics Committee of our hospital and consulted reputed national and international experts in bioethics&#46; In order to obtain a broader range of impressions&#44; we consulted experts from different settings&#46; All of them were especially dedicated to medical ethics&#58; Dr&#46; Diego Gracia&#44; Dr&#46; Marcelo Palacios&#44; Dr&#46; Pablo Sim&#243;n and Dr&#46; Pilar Miranda&#46; Others were specifically ascribed to the world of Intensive Care Medicine&#44; as members of the SEMICYUC and experts in ethics applied to the critical patient&#58; Dr&#46; Lu&#237;s Cabr&#233;&#44; Dr&#46; I&#241;aki Saralegui&#44; Dr&#46; Koldo Mart&#237;nez and Dr&#46; Sebasti&#225;n Iribarren&#46; In turn&#44; another consulted expert&#44; likewise dedicated to medical ethics&#44; was more closely related to organ donation and transplantation&#58; Dr&#46; Miguel Casares&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The consulted experts came from different parts of the country&#59; consultation was therefore made by e-mail&#46; The authors of the present article summarized and structured all the replies obtained&#46; Posteriorly&#44; the manuscript was forwarded to all the consulted experts &#40;as co-authors&#41; for reading and approval&#46; The pertinent modifications were made&#44; and the paper was then again forwarded to the experts with a view to obtaining final consensus&#46; The paper was then submitted for publication&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Clinical case</span><p id="par0050" class="elsevierStylePara elsevierViewall">A 38-year-old male was admitted due to traumatic brain injury&#46; Upon admission&#44; the Glasgow coma score was 3&#44; with bilateral non-reactive mydriasis &#40;6<span class="elsevierStyleHsp" style=""></span>mm&#41; and the absence of corneal reflexes&#46; The brain computed tomography scan showed multiple hemorrhagic contusions&#44; massive brain edema with compression of the peri-mesencephalic cisterns&#44; and left subdural hematoma with mass effect&#46; Given the Glasgow score and the absence of brainstem reflexes&#44; Neurosurgery decided against surgical intervention&#46; After three hours without sedation&#44; the patient remained with bilateral non-reactive mydriasis &#40;6<span class="elsevierStyleHsp" style=""></span>mm&#41; but had recovered the corneal reflexes and showed decerebration rigidity motor responses&#46; Upon re-evaluation by Neurosurgery&#44; and despite the bilateral non-reactive mydriasis and dire prognosis&#44; surgery with evacuation of the subdural hematoma was carried out&#44; with left DC and ICP monitoring with a Camino<span class="elsevierStyleSup">&#174;</span> catheter&#44; in view of the age of the patient&#46; The course proved negative&#44; with a sustained ICP of over 40<span class="elsevierStyleHsp" style=""></span>mmHg&#44; refractory to all kinds of treatment &#40;deep sedation&#44; analgesia&#44; neuromuscular block&#44; controlled hyperventilation&#44; hypertonic saline infusion&#44; mannitol and DC&#41;&#46; The computed tomography scan showed ischemic areas in the brainstem&#44; territory of the right anterior cerebral artery and left brain hemisphere &#40;territory of the middle and posterior cerebral arteries&#41;&#46; After 5 days&#44; and with the suspicion of BD&#44; sedation was suspended&#46; After 48<span class="elsevierStyleHsp" style=""></span>h without sedation&#44; the patient presented a Glasgow score of 3&#44; bilateral non-reactive mydriasis and the absence of photomotor&#44; cranial&#44; oculocephalic and cough reflexes&#44; maintaining only spontaneous breathing&#46; The electroencephalogram &#40;EEG&#41; showed the absence of brain bioelectrical activity in the left brain hemisphere&#44; and minimum activity with suppression phases in the right hemisphere&#46; The neurological exploration&#44; the computed tomography findings and the EEG tracing confirmed that the patient suffered catastrophic and irreversible brain damage&#44; with no chance of recovery&#46; The supervising physician made the following assessment&#58; the natural course of these injuries is towards BD&#44; though this is impeded by DC initially intended to help save the life of the patient&#44; but which has failed and now artificially prolongs a terminal situation&#46; In this case two options were considered&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#40;A&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Decompressive craniotomy no longer improves the situation and only prolongs a terminal condition&#46; It therefore would be acceptable to cancel its effects by means of a cranioplasty with bandage&#46; In this case&#44; death would occur according to neurological criteria&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#40;B&#41;</span><p id="par0060" class="elsevierStylePara elsevierViewall">The application of LSTL through terminal extubation&#44; likewise considering that intubation and mechanical ventilation are futile and only prolong a terminal patient condition&#46; In this case&#44; death would occur according to cardiorespiratory criteria&#46;</p></li></ul></p><p id="par0065" class="elsevierStylePara elsevierViewall">The case was discussed in clinical session&#44; and since patient recovery was considered impossible&#44; all the physicians in the Department agreed to apply LSTL&#46; Of the two abovementioned options&#44; the supervising physician chose cranioplasty with bandage&#44; with the criterion that this would ensure a course more consistent with the natural evolution of the initial injury&#46; The relatives of the patient were informed in detail of the reasons for this decision and of its possible consequences&#46; Twenty-four hours later&#44; after obtaining consent from the family&#44; and in the absence of prior wills&#44; the patient donated 6 organs &#40;seventh day of admission&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical consultation</span><p id="par0070" class="elsevierStylePara elsevierViewall">All the consulted experts in medical ethics were asked the following question&#58;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In a patient with catastrophic and irreversible brain damage&#44; in which LSTL is decided&#44; is it ethically correct to perform cranioplasty with bandage in order to facilitate evolution towards BD&#63; Should this option be preferred over other forms of LSTL&#44; taking into account the possibility of organ donation&#63;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Responses</span><p id="par0080" class="elsevierStylePara elsevierViewall">The experts agreed on the following points&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0085" class="elsevierStylePara elsevierViewall">From the scientific and ethical perspective&#44; in the event of catastrophic neurological damage&#44; it is advisable to adapt treatment to the expectations for recovery and the wishes of the patient&#44; if these have been previously expressed&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Maintaining futile treatment is regarded as poor clinical practice&#44; since it goes against human dignity&#46; The physician should always avoid unwarranted insistence upon treatment&#46; Limiting life support measures that only serve to artificially prolong life without possibilities for recovery of the patient&#44; having established consensus among the attending physicians and relatives&#44; constitutes correct practice consistent with the recommendations referred to end of life care&#44; Spanish legislation&#44; and the accepted ethical standards&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> LSTL in these situations avoids undue suffering for the family and also the unnecessary consumption of healthcare resources&#46; In the present case&#44; cranioplasty with bandage is considered good medical practice&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Reverting the effect of decompressive surgery when the latter is no longer effective and indeed proves futile cannot be assumed in terms of surgical replacement of the bone flap&#44; since this would constitute an unjustified consumption of resources&#46; Reverting the effect of decompressive surgery through cranioplasty with bandage may be regarded as ethically similar to other forms of LSTL&#44; since it does not violate the principles of beneficence and non-maleficence&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#40;3&#41;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Attending the principle of autonomy&#44; it must be determined whether the patient expressed or left instructions referred to LSTL and organ donation&#46; If not so&#44; then the relatives or legal representatives should make the decisions on the basis of what they know&#46; In this respect&#44; it is necessary to provide the family with exhaustive&#44; detailed and transparent information on the entire process&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#40;4&#41;</span><p id="par0100" class="elsevierStylePara elsevierViewall">If the patient expressed a wish to donate his or her organs&#44; or in the event of family consent through delegation&#44; the implicated healthcare professionals must do everything possible to satisfy the expressed wish&#8212;preserving the principle of autonomy and abiding with the principles of social solidarity&#46; In the present case it would be indicated to apply LSTL involving cranioplasty with bandage&#44; since a fatal outcome under conditions of brain death would facilitate organ donation&#46; In this context it must be remembered that donation under non-heart beating donor conditions &#40;in cases of death according to cardiorespiratory criteria after terminal extubation&#41; is exceptional&#44; and is unable to guarantee organ harvesting for transplantation&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">From the ethical perspective&#44; we are obliged to contemplate organ donation&#44; since there are many patients on the transplant waiting list who could benefit as a result&#46; Some authors<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> have estimated that a multiorgan donation comprising 6 organs generates 55&#46;8 years of life for the different recipients&#44; and thus represents an important social benefit consistent with the principles of justice&#46; The World Health Organization&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> the Spanish national medical organization &#40;article 48 of the Code of Medical Ethics and Deontology<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#41;&#44; and the ethical code of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units &#40;SEMICYUC&#41;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> consider it an obligation of all health professionals to encourage and promote organ donation&#46; Moreover&#44; the family members of the patient can find certain consolation in donation&#44; since by doing so&#44; they are contributing to save the life or improve the quality of life of other people&#46; It must be remembered that organ donation contributes greatly to a fairer society&#44; with values such as solidarity&#44; altruism&#44; compassion&#44; or the correction of inequalities&#46; On the other hand&#44; transplantation practice has been shown to be very efficient in terms of healthcare resource utilization&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#40;5&#41;</span><p id="par0110" class="elsevierStylePara elsevierViewall">In the ICU&#44; the disconnection of mechanical ventilation and&#47;or terminal extubation is a common element in LSTL&#46; The fact that protocolized extubation is traditionally and most frequently decided does not mean that this LSTL modality should prevail over other options such as cranioplasty with bandage&#44; particularly in those cases where there is a possibility for organ donation&#46;</p></li></ul></p><p id="par0115" class="elsevierStylePara elsevierViewall">Therefore&#44; cranioplasty with bandage can be regarded as good clinical practice&#44; consistent with the general aims of medical practice as defined by the Hastings Center&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In many cases&#44; decompressive craniotomy can save the life of neurocritical patients&#44; and our obligation as intensivists is to offer our patients all possible opportunities for recovery&#46; Unfortunately&#44; in cases characterized by a very poor course and devastating injuries&#44; DC may prove futile and can moreover impede natural evolution of the patient condition towards brain death&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">After pondering this clinical case&#44; it can be concluded that cranioplasty with bandage is an ethically acceptable form of LSTL&#46; Its application is of undeniable social value&#44; since it facilitates organ donation&#46; In these cases&#44; it is necessary to know the existence of prior instructions and to adequately inform the family of the patient with a view to obtaining consent&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Social and professional practices change slowly&#44; and good reasons&#44; profound reflection and broad knowledge are needed to facilitate change&#46; We are therefore obliged to continue our research and specific training of health professionals in relation to the new forms of LSTL and organ donation&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            0 => "&#201;tica"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Most of the transplanted organs are obtained from brain death &#40;BD&#41; donors&#46; In neurocritical patients with catastrophic injuries and decompressive craniectomy &#40;DC&#41;&#44; which show a dreadful development in spite of this treatment&#44; DC could be a futile tool to avoid natural progress to BD&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We propose whether cranial compressive bandage &#40;<span class="elsevierStyleItalic">cranioplasty with bandage</span>&#41; could be an ethically correct practice&#44; similar to other life-sustaining treatment limitation &#40;LSTL&#41; common methods&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Based on a clinical case&#44; we had contacted the Assistance Ethics Committee and some of the bioethics professionals and asked them two questions&#58; 1&#41; Is ethically correct to perform a <span class="elsevierStyleItalic">cranioplasty with bandage</span> in those patients with LSTL indication&#63; 2&#41; Thinking in organ donation possibility&#44; is this option preferable&#63;</p> <span class="elsevierStyleSectionTitle" id="sect0010">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#40;1&#41; <span class="elsevierStyleItalic">Cranioplasty with bandage</span> could be considered an ethically acceptable LSTL practice&#44; similar to other procedures&#46; &#40;2&#41; It facilitates organ donation for transplant&#44; which provides for value-added proposition because of its own social good&#46; &#40;3&#41; In these cases&#44; it is necessary to know previous patient&#39;s will or&#44; in absentia&#44; to obtain family consent after a detailed procedure report&#46;</p>"
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        "resumen" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La mayor&#237;a de los &#243;rganos trasplantados proceden de donantes fallecidos en muerte encef&#225;lica &#40;ME&#41;&#46; En pacientes neurocr&#237;ticos con lesiones catastr&#243;ficas y craniectom&#237;a descompresiva &#40;CD&#41; que tienen una p&#233;sima evoluci&#243;n a pesar de todo el tratamiento&#44; la CD puede llegar a ser una medida f&#250;til que impida la evoluci&#243;n <span class="elsevierStyleItalic">natural</span> hacia la ME&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Planteamos si realizar un vendaje compresivo pericraneal &#40;<span class="elsevierStyleItalic">craneoplastia con vendaje</span>&#41; puede ser una pr&#225;ctica &#233;ticamente correcta y comparable a otras formas habituales de limitaci&#243;n del tratamiento de soporte vital &#40;LTSV&#41;&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A partir de un caso cl&#237;nico&#44; realizamos una consulta al Comit&#233; de &#201;tica Asistencial y a expertos bio&#233;ticos&#44; formulando las siguientes cuestiones&#58; 1&#41; En pacientes que se decide la LTSV &#191;es &#233;ticamente correcto realizar una craneoplastia con vendaje&#63; 2&#41; &#191;Es preferible esta opci&#243;n considerando una posible donaci&#243;n de &#243;rganos&#63;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">1&#41; La <span class="elsevierStyleItalic">craneoplastia con vendaje</span> puede ser considerada una forma de LTSV &#233;ticamente aceptable y similar a otros procedimientos 2&#41; Facilita la donaci&#243;n de &#243;rganos para trasplante&#44; lo que aporta valor a&#241;adido por el bien social correspondiente 3&#41; En estos casos&#44; es necesario conocer las instrucciones previas del paciente y en su ausencia&#44; obtener el consentimiento familiar por delegaci&#243;n tras un informe detallado del procedimiento&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Escudero D&#44; et al&#46; Craneoplastia con vendaje&#46; nuevas formas de limitaci&#243;n del tratamiento de soporte vital y donaci&#243;n de &#243;rganos&#46; Med Intensiva&#46; 2013&#46; <span class="elsevierStyleInterRef" id="intr0005" href="doi:10.1016/j.medin.2012.12.008">http&#58;&#47;&#47;dx&#46;doi&#46;org&#47;10&#46;1016&#47;j&#46;medin&#46;2012&#46;12&#46;008</span></p>"
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Medicina Intensiva (English Edition)
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¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

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