Letter to the Editor
Veteran or novice in end-of-life decision-making in intensive care medicine? Promote ethical deliberation
¿Intensivistas veteranos o noveles en la toma de decisiones al final de la vida en medicina intensiva? Promueva la deliberación ética
Á. Estella
Unidad de Cuidados Intensivos, Hospital Universitario del SAS de Jerez, Jerez, Cádiz, Spain
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Chico Carballas, S. Freita Ramos, D. Mosquera Rodriguez, E.M. Menor Fernandez, M. Piñon Esteban, R. Casais Pampin" "autores" => array:6 [ 0 => array:2 [ "nombre" => "J.I." "apellidos" => "Chico Carballas" ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Freita Ramos" ] 2 => array:2 [ "nombre" => "D." "apellidos" => "Mosquera Rodriguez" ] 3 => array:2 [ "nombre" => "E.M." "apellidos" => "Menor Fernandez" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "Piñon Esteban" ] 5 => array:2 [ "nombre" => "R." "apellidos" => "Casais Pampin" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217357272030028X?idApp=WMIE" "url" => "/21735727/0000004400000003/v1_202003270001/S217357272030028X/v1_202003270001/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Veteran or novice in end-of-life decision-making in intensive care medicine? Promote ethical deliberation" "tieneTextoCompleto" => true "saludo" => "To the Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "201" "paginaFinal" => "202" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Á. Estella" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Á." "apellidos" => "Estella" "email" => array:1 [ 0 => "litoestella@hotmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Cuidados Intensivos, Hospital Universitario del SAS de Jerez, Jerez, Cádiz, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Intensivistas veteranos o noveles en la toma de decisiones al final de la vida en medicina intensiva? Promueva la deliberación ética" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">I have read with great interest the study published by Blazquez et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> paying special attention to their statement that limitation of life-support treatment (LLST) decisions are related to centers where over 60% of their health providers have 10+ years of experience. In their discussion, the authors suggest that this may have to do with better communication skills with the patients and their families. If so, this has more to do with the acquisition of competences than it has to do with experience.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">It is interesting in the sense that there is a very similar scenario in the actual staff of most intensive care units with more veterans than novices. Two questions have come to my mind after reading this statement: Does experience really lead to making more earlier LLST decisions? Would it then be alright to assume that the more LLST decisions made the better the decision-making process that led to them really was?</p><p id="par0015" class="elsevierStylePara elsevierViewall">There is no doubt that experience is something to take into account in the complex decision-making process of a specialty like intensive medicine. In the Nicomachean Ethics,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Aristotle defines caution or phronesis [Φρόνησιζ, <span class="elsevierStyleItalic">phronēsis</span>] as practical wisdom, and in Book IV he says that young people cannot be prudent precisely because of their lack of experience: «A sign of what has been said is that the young can be geometricians and mathematicians, and wise in both fields, but they do not seem to be prudent. The reason for this is that the objective of prudence is also particular, but becomes familiar through experience, and the young do not have experience because it requires a lot of time».</p><p id="par0020" class="elsevierStylePara elsevierViewall">In my own opinion, in intensive medicine it can take us months to learn a new technique, years to know its indication, and unfortunately decades to know when it was not indicated. The vision of experience is a degree <span class="elsevierStyleItalic">per se</span> in the indication of procedures, resolution of diagnostic challenges, and therapeutic decision-making process. Still, I don’t know if this is the case with conflict resolution.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In end-of-life decisions we should promote ethical deliberation at the ICU setting away from individual decisions or biased decisions by this or that group of professionals. The veterans should not be the ones who make these decisions based on their own experience and novices should not make these decisions either just because they have more updated knowledge. Let us avoid individual decisions made from the head of the department or the expert in bioethics. The prudent thing to do is to promote collective deliberation including these professionals. The more different perspectives we have, the fewer biases. The difficulty of deliberation is modifying different points of view by applying a methodology that analyzes clinical facts. Also, deliberating on conflicting values while taking into consideration the opinion of the treating physician and the rest of the team, and the patient’s values as expressed by himself or his relatives.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Standing on this ground, facts and values, a deliberative environment should be established from which team decisions should arise by reducing individual biases and gaining specific weight after being communicated to the patient and/or his relatives.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The finding that correlates belonging to a transplant center with LLST decisions is controversial since these clinical decisions should be independent from transplant activity <span class="elsevierStyleItalic">per se</span>.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The high participation from the nursing team is obviously a remarkable fact that varies with the trend reported in former series<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> where its involvement was marginal.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declared they received no funding whatsoever while conducting this study.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Estella Á. ¿Intensivistas veteranos o noveles en la toma de decisiones al final de la vida en medicina intensiva? Promueva la deliberación ética. Med Intensiva. 2020;44:201–202.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Factors related to limitation of life support within 48h of intensive care unit admission: a multicenter study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "V. Blazquez" 1 => "A. Rodríguez" 2 => "A. Sandiumenge" 3 => "E. Oliver" 4 => "B. Cancio" 5 => "M. Ibañez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medin.2018.03.010" "Revista" => array:6 [ "tituloSerie" => "Med Intensiva" "fecha" => "2019" "volumen" => "43" "paginaInicial" => "352" "paginaFinal" => "361" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29747939" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fellows’ communication skills" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.M. Arnold" 1 => "A.L. Back" 2 => "A.E. Barnato" 3 => "T.J. Prendergast" 4 => "L.L. Emlet" 5 => "I. 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Estella" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medin.2018.11.006" "Revista" => array:5 [ "tituloSerie" => "Med Intensiva" "fecha" => "2020" "volumen" => "44" "paginaInicial" => "60" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30670291" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "End of life decision making and quality of ICU performance: an observational study in 84 Italian unit" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Bertolini" 1 => "S. Bofelli" 2 => "P. Malacarne" 3 => "M. Peta" 4 => "M. Marchesi" 5 => "C. Barbisan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00134-010-1910-9" "Revista" => array:6 [ "tituloSerie" => "Intensive Care Med" "fecha" => "2010" "volumen" => "36" "paginaInicial" => "1495" "paginaFinal" => "1504" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20464541" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735727/0000004400000003/v1_202003270001/S2173572720300060/v1_202003270001/en/main.assets" "Apartado" => array:4 [ "identificador" => "64604" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735727/0000004400000003/v1_202003270001/S2173572720300060/v1_202003270001/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572720300060?idApp=WMIE" ]
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