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given that they may not be in any condition to competently make decisions&#59; in the absence of a living will&#44; consent is required of a representative&#44; either a family member or legal counsel&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Patient testimonials or initiatives such as the HU-CI blog&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a> highlight the fact that the principalist bioethics does not respond to all situations that can cause suffering to the people admitted to the ICU&#44; so new ethical view is necessary&#59; this time to try to modify the operation of the UCI and the attitude of the professionals&#44; in order to reduce as much as possible the fear and pain&#44; besides its consequences&#46; Bioethical principles and code of the Spanish Society of Intensive Care Medicine &#40;SEMICYUC&#41; can help&#44; but it is imperative a broader perspective&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Care ethics could be defined as a type of relational ethics that ensures autonomy of vulnerable persons and uses a relational and context-bound approach toward morality and decision making&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Autonomy&#44; in this case&#44; is understood in a context&#44; not self-sufficiency or independence&#44; but interdependence&#46; We live in a social framework which we need to be ourselves&#44; to make our own decisions&#46; The autonomy to which we refer is the moral ability to direct our own lives&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The ethics of care retrieves the affective and emotional supplementing a bioethics more rational as based on principles &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a> This can influence to improve the experience of patients in the ICU&#44; putting it in the foreground&#44; in the center of attention&#46; In a study that showed that admission to the ICU of patients with a limitation in life-support treatment was a common practice&#44; Rubio noted that decision-making on the futility of a treatment is an act with ethical and moral implications&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a> This alludes to the ethics of accountability&#8212;a necessary virtue for the professional who has to assume the responsibility for this decision-making&#46; To respond is to take charge&#44; to look after and care for a fragile individual&#46; The ethics of care touch upon the emotional and affective domains which may have a part to play in improving the experience of patients in the ICU&#44; placing this question at the heart of the matter&#46; It is&#44; of course&#44; fundamental to include the physician in the task of caring&#44; without restricting the work of nurses&#44; as has been the case till now&#46; Care should not be encumbered by professional or jurisdictional barriers&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">One conclusion of a study entitled &#8216;Sufrimiento y su afrontamiento en la UCI&#8217; &#40;Facing Suffering in the ICU&#41;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">13</span></a> is that the strategies for facing suffering&#44; on both parts&#44; patients and their families&#44; were based on medical information &#40;in addition to family support&#41;&#46; The fact that nursing carries care as a virtue does not mean that the physician should not provide more than technical expertise&#44; clinical practice guides&#44; and protocols&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">These strategies are necessary for the care&#44; but they are not enough to reveal the person that may be found in the patient who is under care&#46; Care requires a reciprocal relationship&#59; if the carer does not identify what makes the patient different from all others&#44; then to attend that patient&#39;s real needs will be nearly impossible&#46; It is of the utmost importance to focus diagnostic and therapeutic strategies attentively toward the singularity of each patient&#59; we are not there&#44; after all&#44; to treat illnesses&#44; but rather people who are ill&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">We all&#44; as humans&#44; require care at one time or another in our lives in order to develop as people&#44; so that our voice&#44; which makes each of us unique&#44; may be heard&#46; Caring and being cared for are indispensable parts of our survival&#44; and those in the ICU finds themselves in a situation of great vulnerability in many ways&#46; Levinas maintains that attending the Other &#40;a term he uses to refer to a human being that is suffering&#41; is a moral imperative&#44; an inescapable call&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a> When care is professionalized&#44; it acquires a normative dimension&#46; Healthcare personnel take on a moral commitment to others&#59; <span class="elsevierStyleItalic">care</span> is the internal goods of the healthcare profession and a desirable virtue in those working in the ICU&#46; In order to establish the relationship of care&#44; the carer&#44; as a professional&#44; must take on among other virtues compassion and concern for the well-being of the patient&#46; But even this is not enough&#44; if it is not accompanied by action&#44; by an attentive gaze&#44; and by the application of technical know-how&#46; Ethical care allows for an understanding of a person&#39;s needs beyond the purely biological in order to assume control over physical and psychological pain&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">New ethical points of views are necessary to humanize intensive care&#44; and physician involvement is essential in this process&#46; Care ethics is a fundamental foundation for the building of the friendly ICU that we are starting to conceive of&#44; an ICU in which patients and their families are treated well and recognize this&#46; From this point&#44; admission to the ICU can stop being a prelude to horrors&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0065" class="elsevierStylePara elsevierViewall">The preparation of this manuscript has not sought nor received funding&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict ofinterest</span><p id="par0060" class="elsevierStylePara elsevierViewall">There has been no conflict of interest in the preparation of this manuscript&#46;</p></span></span>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Non maleficence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vulnerability situation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Beneficence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good relationship &#40;caretaker&#47;patient&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Standards of guidelines&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Empathy in concrete without relativism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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Care ethics. A new bioethical approach to humanize the ICU
Ética del cuidado. Un nuevo enfoque bioético para humanizar la UCI
A. Fernández-Truilloa,
Corresponding author
af.trujillo@pssjd.org

Corresponding author at: C/Antoni Pujadas, 42 08830 Sant Boi de Llobregat, Barcelona, Spain.
, H. Vallverdú-Cartiéb, B. Román-Maestrec
a Intensive Care Unit, PSSJD Hospital General, Sant Boi de Llobregat, Barcelona, Spain
b Head of Departament of Surgery, Consorci Hospitalari de Vic, Barcelona, Spain
c Faculty of Philosophy, Barcelona University, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">To stay in an intensive care unit &#40;ICU&#41; is an experience that has a tremendous impact on the quality of life of the patients&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> In several interviews&#44; an important politician in Spain has expressed the pain and fear suffered during her ICU stay&#44; which she described as the &#8216;vestibule of hell&#8217;&#46; This perception has not left indifferent the professionals that we devote ourselves to the intensive care&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Patients in critical condition who are admitted to our units often find themselves immersed in a plethora of cables and sophisticated monitoring and life-support equipment&#46; When the medical priority is to provide diagnostic support and treatment urgently needed&#44; this tends to produce a kind of depersonalization of the patient&#46; Nevertheless&#44; the patients&#44; at some point&#44; become aware of their surroundings and later they are able to recall them&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The consequences of life-support for those who survive an ICU stay invite reflection on certain aspects of this question which have&#44; to date&#44; been relegated to the background&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">3&#44;4</span></a> The main concern in intensive care medicine&#44; from an ethical perspective&#44; has been to insure that the life support provided to each patient is consistent with that patient&#39;s needs so as to avoid therapeutic obstinacy&#44; as well as to be able to detect and attend to end-of-life situations in an appropriate manner&#46; This&#44; in terms of principle-based bioethics&#44; would correspond to non-malfeasance or beneficence&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a> Also requiring reflection is the autonomy of the critically ill patients&#44; given that they may not be in any condition to competently make decisions&#59; in the absence of a living will&#44; consent is required of a representative&#44; either a family member or legal counsel&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Patient testimonials or initiatives such as the HU-CI blog&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a> highlight the fact that the principalist bioethics does not respond to all situations that can cause suffering to the people admitted to the ICU&#44; so new ethical view is necessary&#59; this time to try to modify the operation of the UCI and the attitude of the professionals&#44; in order to reduce as much as possible the fear and pain&#44; besides its consequences&#46; Bioethical principles and code of the Spanish Society of Intensive Care Medicine &#40;SEMICYUC&#41; can help&#44; but it is imperative a broader perspective&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Care ethics could be defined as a type of relational ethics that ensures autonomy of vulnerable persons and uses a relational and context-bound approach toward morality and decision making&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Autonomy&#44; in this case&#44; is understood in a context&#44; not self-sufficiency or independence&#44; but interdependence&#46; We live in a social framework which we need to be ourselves&#44; to make our own decisions&#46; The autonomy to which we refer is the moral ability to direct our own lives&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The ethics of care retrieves the affective and emotional supplementing a bioethics more rational as based on principles &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a> This can influence to improve the experience of patients in the ICU&#44; putting it in the foreground&#44; in the center of attention&#46; In a study that showed that admission to the ICU of patients with a limitation in life-support treatment was a common practice&#44; Rubio noted that decision-making on the futility of a treatment is an act with ethical and moral implications&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a> This alludes to the ethics of accountability&#8212;a necessary virtue for the professional who has to assume the responsibility for this decision-making&#46; To respond is to take charge&#44; to look after and care for a fragile individual&#46; The ethics of care touch upon the emotional and affective domains which may have a part to play in improving the experience of patients in the ICU&#44; placing this question at the heart of the matter&#46; It is&#44; of course&#44; fundamental to include the physician in the task of caring&#44; without restricting the work of nurses&#44; as has been the case till now&#46; Care should not be encumbered by professional or jurisdictional barriers&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">One conclusion of a study entitled &#8216;Sufrimiento y su afrontamiento en la UCI&#8217; &#40;Facing Suffering in the ICU&#41;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">13</span></a> is that the strategies for facing suffering&#44; on both parts&#44; patients and their families&#44; were based on medical information &#40;in addition to family support&#41;&#46; The fact that nursing carries care as a virtue does not mean that the physician should not provide more than technical expertise&#44; clinical practice guides&#44; and protocols&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">These strategies are necessary for the care&#44; but they are not enough to reveal the person that may be found in the patient who is under care&#46; Care requires a reciprocal relationship&#59; if the carer does not identify what makes the patient different from all others&#44; then to attend that patient&#39;s real needs will be nearly impossible&#46; It is of the utmost importance to focus diagnostic and therapeutic strategies attentively toward the singularity of each patient&#59; we are not there&#44; after all&#44; to treat illnesses&#44; but rather people who are ill&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">We all&#44; as humans&#44; require care at one time or another in our lives in order to develop as people&#44; so that our voice&#44; which makes each of us unique&#44; may be heard&#46; Caring and being cared for are indispensable parts of our survival&#44; and those in the ICU finds themselves in a situation of great vulnerability in many ways&#46; Levinas maintains that attending the Other &#40;a term he uses to refer to a human being that is suffering&#41; is a moral imperative&#44; an inescapable call&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a> When care is professionalized&#44; it acquires a normative dimension&#46; Healthcare personnel take on a moral commitment to others&#59; <span class="elsevierStyleItalic">care</span> is the internal goods of the healthcare profession and a desirable virtue in those working in the ICU&#46; In order to establish the relationship of care&#44; the carer&#44; as a professional&#44; must take on among other virtues compassion and concern for the well-being of the patient&#46; But even this is not enough&#44; if it is not accompanied by action&#44; by an attentive gaze&#44; and by the application of technical know-how&#46; Ethical care allows for an understanding of a person&#39;s needs beyond the purely biological in order to assume control over physical and psychological pain&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">New ethical points of views are necessary to humanize intensive care&#44; and physician involvement is essential in this process&#46; Care ethics is a fundamental foundation for the building of the friendly ICU that we are starting to conceive of&#44; an ICU in which patients and their families are treated well and recognize this&#46; From this point&#44; admission to the ICU can stop being a prelude to horrors&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0065" class="elsevierStylePara elsevierViewall">The preparation of this manuscript has not sought nor received funding&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict ofinterest</span><p id="par0060" class="elsevierStylePara elsevierViewall">There has been no conflict of interest in the preparation of this manuscript&#46;</p></span></span>"
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