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Palliative medicine represents the holistic multiprofessional treatment of severely and incurably ill people and their relatives, addressing their complex physical, psychological, social and spiritual needs. The central therapeutic goals are the quality of life and alleviation of suffering. In the course of many neurological diseases, high symptom burden, long and variable trajectories and unfavorable prognosis at times create a need for palliative care even at an early stage, which is currently still inadequately met. This can be countered by qualified neuropalliative care. In addition to intensifying interdisciplinary collaboration, this requires neurologists to have core competencies in palliative care. These include a team-oriented attitude, communication skills, expertise in symptom control and knowledge of biomedical ethics including palliative options at the end of life., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Competing Interests: Declaration of competing interest None.

The psychologist working in an institution plays a specific role within a multidisciplinary team, where skills are multiple but complementary. As part of a holistic approach, the psychologist's position in relation to other team members, the different functions he or she occupies and his or her ethical responsibility are essential elements in the support provided. Whether supporting professionals or caring for patients, the psychologist brings unique resources to the relational space., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Aim: To give an insight into areas for future development and suggestions in the complexities of incorporation of AI into human colorectal cancer (CRC) care while bringing into focus the importance of clinicians' roles in patient care., Methods: Existing literature around AI use in CRC care is reviewed and potential regulatory issues and medicolegal implications around its implementation in CRC multidisciplinary team meetings (MDTs) are identified., Results: Challenges with patient privacy and confidentiality, patient consent, inequity and bias, patient autonomy, as well as AI system transparency and the liability and accountability issues arising from complications that arise from AI-aided clinical decisions are important focusses associated with the use of AI in CRC MDTs., Conclusion: Consideration of various medicolegal aspects of the use of AI in CRC MDTs is warranted to ensure its safe and smooth incorporation into CRC MDTs. AI function as a clinical decision support system and does not replace professional expertise., (© 2024 Association of Coloproctology of Great Britain and Ireland.)

Objectives: In the province of Quebec, Canada, interdisciplinary support groups (ISGs) are mandated to support those who are involved in the clinical, administrative, legal and ethical aspects of medical assistance in dying (MAiD). This article presents the results of a mixed-method, multi-phase study carried out in 2021 on ISGs with the aim to describe current ISG practices, critically analyze them and make recommendations on promising practices for provincial implementation., Method: Semi-structured interviews (42) and focus groups (7) with coordinators of 24 ISGs were used to identify promising practices and confirm their utility with participants., Results: We have distributed the ISGs along what we coined an "ISG continuum." Between teams' accountability (decentralization) and ISGs' assumption of responsibility for MAiD requests (centralization), a middle ground approach, focused on the value of support, should be favored., Conclusion: The structuring of ISGs and their practices is intimately linked to their values. Harmonization of ISGs and their practices, while considering their specific values and contexts, can contribute to the equity and quality of services intended for those who request MAiD and those who support them., Competing Interests: The authors declare that they do not have any conflicts of interest., (Copyright © 2024 Perron, Racine and Bouthillier.)

Purpose of Review: This review explores the intricacies of ethical anesthesia, exploring the necessity for precision anesthesia and its impact on patient-reported outcomes. The primary objective is to advocate for a defined aim, promoting the implementation of rules and feedback systems. The ultimate goal is to enhance precision anesthesia care, ensuring patient safety through the implementation of a teamwork and the integration of feedback mechanisms., Recent Findings: Recent strategies in the field of anesthesia have evolved from intraoperative monitorization to a wider perioperative patient-centered precision care. Nonetheless, implementing this approach encounters significant obstacles. The article explores the evidence supporting the need for a defined aim and applicable rules for precision anesthesia's effectiveness. The implementation of the safety culture is underlined. The review delves into the teamwork description with structured feedback systems., Summary: Anesthesia is a multifaceted discipline that involves various stakeholders. The primary focus is delivering personalized precision care. This review underscores the importance of establishing clear aims, defined rules, and fostering effective and well tolerated teamwork with accurate feedback for improving patient-reported outcomes. The Safe Brain Initiative approach, emphasizing algorithmic monitoring and systematic follow-up, is crucial in implementing a fundamental and standardized reporting approach within patient-centered anesthesia care practice., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

The purpose of this paper is to delve into the ethical aspects experienced by the healthcare team when they receive the directive to limit therapeutic effort or a do-not-resuscitate order. From an interpretative, qualitative paradigm with a content analysis approach, a process based on three phases was conducted: pre-analysis in which categories were identified, the projection of the analysis, and inductive analysis. During 2023, interviews were conducted in the clinical setting of a high-complexity hospital in Chile with 56 members of the healthcare teams from critical and emergency units, from which four categories emerged: a) the risk of violating patients' rights by using do-not-resuscitate orders and limiting therapeutic effort; b) the gap in the interpretation of the legal framework addressing the care and attention of patients at the end of life or with terminal illnesses by the healthcare team; c) ethical conflicts in end-of-life care; and d) efficient care versus holistic care in patients with terminal illness. There are significant gaps in bioethics training and aspects of a good death in healthcare teams facing the directive to limit therapeutic effort and not resuscitate. It is suggested to train personnel and work on a consensus guide to address the ethical aspects of a good death.

Purpose: To identify meanings of and challenges to enacting equitable diversification of genomics research, and specifically precision medicine research (PMR), teams., Methods: We conducted in-depth interviews with 102 individuals involved in three U.S.-based precision medicine research consortia and conducted over 400 observation hours of their working group meetings, consortium-wide meetings, and conference presentations. We also reviewed published reports on genomic workforce diversity (WFD), particularly those relevant to the PMR community., Results: Our study finds that many PMR teams encounter challenges as they strive to achieve equitable diversification on scientific teams. Interviewees articulated that underrepresented team members were often hired to increase the study's capacity to recruit diverse research participants, but are limited to on-the-ground staff positions with little influence over study design. We find existing hierarchies and power structures in the academic research ecosystem compound challenges for equitable diversification., Conclusion: Our results suggest that meaningful diversification of PMR teams will only be possible when team equity is prioritized as a core value in academic research communities., Competing Interests: The authors have declared that no competing interests exist.

Cardiovascular disease is the leading cause of death globally. While pharmacological advancements have improved the morbidity and mortality associated with cardiovascular disease, non-adherence to prescribed treatment remains a significant barrier to improved patient outcomes. A variety of strategies to improve medication adherence have been tested in clinical trials, and include the following categories: improving patient education, implementing medication reminders, testing cognitive behavioral interventions, reducing medication costs, utilizing healthcare team members, and streamlining medication dosing regimens. In this review, we describe specific trials within each of these categories and highlight the impact of each on medication adherence. We also examine ongoing trials and future lines of inquiry for improving medication adherence in patients with cardiovascular diseases., Competing Interests: Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: STS reports none, AEL reports none, VK reports unrelated research grants from the NIH and Greenwall Foundation, PMH reports research grants from Department of Veterans Affairs, NHLBI, and University of Colorado School of Medicine. His NHLBI grant is focused on medication adherence. He has a research agreement with Bristol Myers Squibb unrelated to medication adherence. He serves as a deputy editor for Circulation: Cardiovascular Quality and Outcomes., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Integrated behavioral health models of care offer many benefits for patient experience and outcomes. However, multidisciplinary teams are comprised of professionals who each may have different professional norms and ethical obligations, which may at times be in conflict. This article offers a framework for negotiating potential conflicts between professional norms and expectations across disciplines involved in integrated behavioral health teams., Competing Interests: Disclosure No financial or relationship conflicts of interest relevant to this publication., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: The overall aim of this study was to describe perceptions of the decision-making process in relation to participation/non-participation in ethics discussions among healthcare professionals in paediatric oncology., Methods: Healthcare professionals, working at three paediatric units where ethics discussions where performed answered a study-specific questionnaire focusing on perceptions of involvement, influence, responsibility and understanding of ethics decision-making. Statistical analyses included descriptive statistics, non-parametric paired t-tests and correlation tests., Results: Participation in ethics discussions was related to perceptions of greater involvement and the possibility of influencing decisions, as well as formal/shared responsibility for the ethics decisions related to patient care. Medical doctors and registered nurses perception of involvement in decisions, possibility to influence and responsibility decreased when they were not present during the ethics discussion or when no ethics discussion was conducted at all. Healthcare professionals had a generally good understanding of the ethical issues and the ethics decisions. The whole group considered medical doctors to be the most important participants in the ethics discussions, followed by patients/family. Healthcare professionals wanted more teamwork and viewed ethics discussions as very helpful for teamwork when dealing with ethical issues in paediatric oncology., Conclusions: Ethics discussions in paediatric oncology practice increases the involvement within and the understanding of the decision-making process about ethical decisions. The understanding is not always dependent on participation, indicating a great trust in team members. Based on these findings the implementation of a structure for ethics support in paediatric oncology where patients/families are integrated is recommended., (Copyright © 2021. Published by Elsevier Ltd.)

The dramatic increases of opioid use and misuse in the past 15 years have resulted in a focus on the responsible and judicious use of opioids. In this Ethics Rounds, the commentators analyze the case of a 16-year-old girl with lymphoma and opioid misuse whose caregiver may have diverted her opioids. She is now at the end of life and prefers to die at home. The commentators, oncologists, palliative care providers, ethicists, and a medical student agree that supporting the patient's goals and practicing good opioid stewardship are not incompatible. They identify additional information that would be required to analyze the case more fully such as the nature of the evidence for misuse and diversion and whether bias inadvertently contributed to these concerns. They agree that multimodal analgesia, including but not limited to opioids, is important. Safeguards could include a contract, directly observed therapy, and/or urine drug screens. Supervision or removal of a caregiver diverting medication or admission of the patient misusing medications would be alternatives if the initial plan was unsuccessful. Such patient-centered care requires well-developed substance misuse treatment, pain management, and home hospice that are adequately reimbursed., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Competing Interests: Competing interests: None declared.

The emergence of corona virus disease 2019 (COVID-19) has caused a global public health emergency and the pandemic has forced the healthcare givers to organise their work differently to provide the same level of care to their patients. Meticulous planning and implementation of robust infection control, proper triage of patients, patient education and awareness and establishment of good command structure has become the norm. In this article we illustrate how the COVID-19 pandemic has affected the oncology department in a tertiary centre in the Caribbean country of Antigua & Barbuda. We describe the changes in treatment decisions for outpatient and inpatient services along with a look at the ethical considerations and the well-being of the oncology team., Competing Interests: The authors declare no competing interests., (©Nandan Maruti Shanbhag et al.)

Palliative medicine is specialized medical care for people with serious illness. Serious illness is one with high risk of mortality that negatively affects quality of life or function or is burdensome in symptoms, treatments, or caregiver stress. Palliative care improves symptom management and addresses the needs of patients and families, resulting in improved patient and caregiver quality of life and reduced symptom burden and health care utilization. Hospice is palliative care for patients with a prognosis of 6 months or less and is appropriate when goals are to avoid hospitalization and maximize time at home for patients who are dying., Competing Interests: Disclosure Dr P.E. Tatum is a director at large of the board of the American Academy of Hospice and Palliative Medicine, and he is a member of the Geriatrics and Palliative Care Standing Committee of the National Quality Forum., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Due to the high costs of providing long-term care to older adults with cognitive impairment, artificial companions are increasingly considered as a cost-efficient way to provide support. Artificial companions can comfort, entertain, and inform, and even induce a sense of being in a close relationship. Sensors and algorithms are increasingly leading to applications that exude a life-like feel. We focus on a case study of an artificial companion for people with cognitive impairment. This companion is an avatar on an electronic tablet that is displayed as a dog or a cat. Whereas artificial intelligence guides most artificial companions, this application also relies on technicians "behind" the on-screen avatar, who via surveillance, interact with users. This case is notable because it particularly illustrates the tension between the endless opportunities offered by technology and the ethical issues stemming from limited regulations. Reviewing the case through the lens of biomedical ethics, concerns of deception, monitoring and tracking, as well as informed consent and social isolation are raised by the introduction of this technology to users with cognitive impairment. We provide a detailed description of the case, review the main ethical issues and present two theoretical frameworks, the "human-driven technology" platform and the emancipatory gerontology framework, to inform the design of future applications.

Background: As collaborative team-based healthcare expands, there is a need for effective interprofessional education (IPE). Although the desired outcomes of IPE are defined by the Interprofessional Education Collaborative (IPEC), resources often limit IPE implementation. The purpose of this study is to assess the effectiveness of a novel interprofessional activity in improving health professions students' interprofessional competencies using team-based learning (TBL)., Interprofessional Education Activity: Teams of second year pharmacy and medical students participated in a novel IPE session targeting roles and responsibilities. This activity was designed and implemented by a small number of faculty and used TBL to educate a large number of students using limited resources. Class averages for individual and team readiness assurance test (iRAT/tRAT) scores were collected, and students were invited to complete the Interprofessional Collaborative Competencies Attainment Survey (ICCAS) to evaluate the effectiveness of the activity., Discussion: On average, tRAT scores were 20% higher than iRAT scores. While there was significant improvement for all items on the ICCAS, questions within the roles and responsibilities domain of the ICCAS were most affected., Implications: This novel IPE activity was successful in teaching a large group of professional students in the targeted domain of roles and responsibilities in a single session. This activity was a rich experience in which students learned together using limited resources which can be easily replicated at other institutions to help professional students gain proficiency in interprofessional competencies., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Health and social care professionals are required to work together to deliver person-centered care. Professionals therefore find themselves making decisions within multidisciplinary teams. For educators, there has been a call to bring students from differing professions together to learn to enable more effective teamwork, interprofessional communication, and collaborative practice. This multidisciplinary working is complicated by the increasingly complex nature of ethical dilemmas that health and social care professionals face. It is therefore widely recognized that the teaching and learning of ethics within health and social care courses is valuable. In this paper, we briefly make the case in support of teaching and learning health and social care ethics through the medium of interprofessional education (IPE). The purpose of this paper is to provide guidance to educators intending to design ethics-orientated IPE for health and social care students. The guidance is based on the ongoing experiences of designing and implementing ethics-orientated IPE across five departments within two universities located in the North of England over a five-year period. Descriptions of the ethics-orientated IPE activities are included in the guide, along with key resources recommended.

Background and Purpose: Interprofessional education can be used to prepare healthcare graduates for teamwork. Simulations, when used with interprofessional education, create realistic clinical situations that promote teamwork. Faculty assessed changes in pharmacy and nursing students' competence in treating adult cardiac arrest and perceived readiness for interprofessional learning and teamwork., Educational Activity and Setting: Eighty-three pharmacy students and 57 nursing students participated in a high fidelity simulation focused on adult cardiac arrest as an expectation of their respective courses. This study took place at a single campus College of Health Professions located at a public land grant institution., Findings: The Readiness for Health Care Students for Interprofessional Learning Scale (RIPLS) and Team Skills Scale (TSS) were used to develop a survey administered prepost simulation. A paired t-test indicated statistically significant increases of mean values prepost (p < 0.001) for: teamwork and collaboration, professional identity, team skills, and competence. An independent sample t-test found no differences by gender or degree., Discussion: This research supports using simulation in interprofessional education to increase competence and promote changes in attitudes toward interprofessional learning and teamwork., Summary: An interprofessional simulation increased student's perceived competence and positively increased perceptions of learning and working with other health profession students., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Little is documented about the experiences of pregnancy for transgender and gender-diverse individuals. There is scant clinical guidance for providing prepregnancy, prenatal, intrapartum, and postpartum care to transgender and gender-diverse people who desire pregnancy., Case: Our team provided perinatal care to a 20-year-old transgender man, which prompted collaborative advocacy for health care systems change to create gender-affirming patient experiences in the perinatal health care setting., Conclusion: Systems-level and interpersonal-level interventions were adopted to create gender-affirming and inclusive care in and around pregnancy. Basic practices to mitigate stigma and promote gender-affirming care include staff trainings and query and use of appropriate name and pronouns in patient interactions and medical documentation. Various factors are important to consider regarding testosterone therapy for transgender individuals desiring pregnancy.

Objectives: Reimbursement in skilled nursing facilities (SNFs) is driven by the number of minutes a patient receives rehabilitation. Physical therapists' (PTs) clinical decisions in evaluation and appropriate treatment of patients drive the dosing of rehabilitation services. Many times these 2 dynamics clash. The purpose of this study was to determine how PTs in SNFs viewed their ethical work environment, what primary issues drove their views, and what potential solutions were identified for the issues., Design: This was a mixed-methods, cross-sectional survey study., Setting and Participants: An organizational ethics survey along with 2 open-ended questions were sent to a random sample of 1200 PTs in the state of Georgia; 340 surveys were returned, and the respondents were categorized into 9 typical PT work settings. Twenty eight participants (8.2%) reported they worked in SNFs., Measures: The Ethics Environment Questionnaire was the quantitative measurement tool used for the study. In addition, 2 open-ended questions were asked regarding ethical concerns and possible solutions to those concerns., Results: Of the 9 workplace settings, therapists working in SNFs had the lowest perceptions of ethical work environment. They were also the only group that scored below the survey cut-off point for positive ethical work environment. Their primary concerns were overutilization issues, productivity standards, and billing and coding issues. The 2 primary themes regarding solutions were allowing PTs to be autonomous in their decision making and decreasing productivity standards., Conclusions/implications: The current Medicare reimbursement system rewards quantity of rehabilitation over quality. PTs are trained to deliver quality care that is dosed appropriately, and this may conflict with organizational objectives. The primary implication in this study is that clinicians and administrators should engage more in open, honest dialogue on how to share responsibility and balance organizational goals with clinical ethics., (Copyright © 2019 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

The question, what makes a clinician a healer? may evoke the image of a devoted physician paying a critically important home visit at the end of a long day or the image of an astute nurse-steadfast, empathic, anticipating the patient's needs before they become apparent to others. But health care is no longer provided by lone doctors or nurses. In the modern health care system, multiple professionals must work together to provide safe and effective care. The moral nature of healing has not changed. But what is required of clinicians to facilitate healing has. To be a healer today, a clinician must be a good team player. Medical students have opened our eyes to this new reality. Building on their observations, we articulate a view that, over and above the role of teamwork in providing technically appropriate care and preventing errors, health care requires teamwork to promote healing. Being a good team player is now a moral imperative because it makes an essential contribution to healing., (© 2019 The Hastings Center.)

In clinical settings, exploitation of patients who live in poverty can be exacerbated when health professions students' educational goals are overemphasized relative to patients' and communities' needs. Continuity of care relies on health system infrastructure and its capacity to keep patients engaged. Achieving just health care delivery in domestic and international settings requires balancing students', patients', and communities' interests. This article examines how students' interests in learning should be considered relative to patients' and communities' interests in receiving quality care., (© 2019 American Medical Association. All Rights Reserved.)

Aim: Professional supervision (PS), a collaborative relationship that promotes reflection on contextualised work-related issues for the benefit of ongoing learning and development and improved professional practice, is not well understood in the medical context. This study aimed to explore the attitudes and experiences of PS among doctors working in palliative care in New Zealand., Method: Eighty members of the Australia New Zealand Society of Palliative Medicine (ANZSPM) participated in a cross-sectional quantitative survey., Results: Overall, PS was felt to be important, particularly by those currently participating in PS, for enhancing clinical functioning and supporting doctors' wellbeing. Barriers to undertaking PS included finding a supervisor, lack of funding and time, with the most significant factor being whether the workplace supported PS. Supervisees' responses showed PS to be a safe experience, addressing a wide range of issues, with a positive effect on personal coping., Conclusion: Despite identified barriers, New Zealand-based palliative care doctors reported PS to be important and beneficial both personally and professionally. Further consideration should include the impact of professional and organisational culture on uptake of PS, future research and acknowledgment that palliative medicine may be in a position to highlight the benefits of PS for the wider medical community., Competing Interests: Nil.

Caring for patients who lack decision-making capacity is common in health care and presents numerous practical and ethical challenges. Unrepresented patients are vulnerable in part because they do not have anyone to help articulate their values and preferences, and they cannot do so themselves. This commentary suggests a deliberative approach to responding to these patients' needs., (© 2019 American Medical Association. All Rights Reserved.)

Neonatal professionals encounter many ethical challenges especially when it comes to interventions at the limit of viability (weeks 22-25 of gestation). At times, these challenges make the moral dilemmas in neonatology tragic and they require a particular set of intellectual and moral virtues. Intellectual virtues of episteme and phronesis, together with moral virtues of courage, compassion, keeping fidelity to trust, and integrity were highlighted as key virtues of the neonatal professional. Recognition of the role of ethics requires a recognition that answering the obvious question (what shall we do?) does not always suffice. Acknowledging the tragic question (is any of the alternatives open to us free from serious moral wrongdoing) and recognizing the ethical dilemmas, where the lines between right and wrong are blurred, leads to actions taken towards establishing ethics frameworks to support decision-making. In neonatology units, such organizational support can help in allowing the team members to recognize the ethical dilemmas, avoid moral distress, and improve team cohesion and the quality of care provided. Only when the organizational structure allows ethical dilemmas to be recognized, adequate decisions can be made.

Context:: Patients in medical intensive care units (MICUs) are medically complex. This complexity can lead to uncertainty about patient goals and prognosis. Ethical dilemmas arise when there is uncertainty about the clinically and ethically appropriate actions for managing seriously ill patients. Ethics and palliative care involvement may promote improved quality of care and reduced staff moral distress., Project Description:: In this clinical project, a physician with ethics, palliative care, and geriatrics expertise attended morning rounds with the MICU team weekly. Data on the logistics and impact from the first 2 years of the project were collected., Project Logistics and Preliminary Impact:: Rounds lasted approximately 1.75 hours per week. The rounder was present for discussion of approximately 200 patients per year and made comments on nearly half of the patients. The comments were categorized as 25% ethics, 40% palliative care, 10% geriatrics, and 25% a combination or other topic. Attending physicians rated the project as helpful. The number of ethics and palliative care consults from the MICU increased in the first 2 years. Downstream impact has included a dietician reviewing Physician Orders for Life Sustaining Treatment forms with teams throughout the hospital and routine review of advance directives of newly admitted patients., Discussion:: Weekly MICU rounding provides an opportunity to briefly teach staff and trainees about relevant ethics, palliative care, and geriatrics issues. It also provides a forum for discussion of ethically challenging cases. Considerations when starting a similar program are discussed.

The significance of technical skills and manual dexterity for surgeons is an indisputable fact. However, the systematic study of medical errors has revealed that a significant percentage of these errors are caused by factors related to non-technical skills. The review presented in this article intends to describe and explore the relevance of these non-technical skills, including: situational awareness, decision-making, leadership and communication. In conclusion, the authors propose that adequate importance needs to be given to these aptitudes to provide safe clinical care., (Copyright © 2019 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

In order to understand the lived experiences of physicians in clinical practice, we interviewed eleven expert, respected clinicians using a phenomenological interpretative methodology. We identified the essence of clinical practice as engagement. Engagement accounts for the daily routine of clinical work, as well as the necessity for the clinician to sometimes trespass common boundaries or limits. Personally engaged in the clinical situation, the clinician is able to create a space/time bubble within which the clinical encounter can unfold. Engagement provides an account of clinical practice as a unitary lived experience. This stands in stark contrast to the prevailing notion, referred to as a dual discourse, that describes medicine as the addition of humanism to science. Drawing on Aristotle's notion of phronesis and Sartre's definition of the situation, we illustrate how this novel perspective entwines clinical practice, the person of the clinician, and the clinician's situation.

The biopsychosocial model is characterized by the systematic consideration of biological, psychological, and social factors and their complex interactions in understanding health, illness, and health care delivery. This model opposes the biomedical model, which is the foundation of most current clinical practice. In the biomedical model, quest for evidence based medicine, the patient is reduced to molecules, genes, organelles, systems, diseases, etc. This reduction has brought great advances in medicine, but it lacks a holistic view of the person. To solve the problem, we propose an early team based approach where the primary care physician leads a group of people that can help her/him address the psychosocial issues while she/he attends to the biomedical issues. This article addresses one case where the clinical ethicist facilitating a team based biopsychosocial model for the care of a patient worked as a bridge between the primary team, the critical care team, and the psychosocial team to advance the argument that good communication among the groups can lead to a true biopsychosocial model where the collaboration of the social worker, psychologist, chaplain, ethicist and the different medical teams can improve the overall patient experience.

Aim: We herein describe the establishment of the Helsinki Vascularized Composite Allotransplantation (VCA) program and its execution in the first two face transplant cases., Methods & Patients: The Helsinki VCA program initially required the fulfillment of legal, hospital, financial, and ethical requirements. Thereafter, the assembling of a multidisciplinary team commenced. A team of Plastic, maxillofacial and ENT surgeons comprise the facial VCA team. The protocol involves collaboration with the Solid Organ Transplant (SOT) team, transplant immunology, immunosuppression, microbiology, psychiatric evaluation, well-defined VCA indications and informed consent. Between 2011 and 2017 two patients were selected for transplantation. Both patients had a severe composite facial deformity involving the maxilla and mandible following earlier ballistic injury., Results: Patient 1 was a 35 year-old male who underwent successful near total face transplantation in February 2016 and at 30 months he has a good aesthetic outcome with symmetrical restoration of the central face and good sensory and symmetrical motor functional outcomes. Patient 2 was a 58 year-old male who underwent full face transplantation in March 2018 and at 5 months he has recovered without major problems., Conclusion: A successful facial VCA program requires a well-prepared research protocol, experts from multiple specialties and careful patient selection. The establishment of the Helsinki VCA program required long and thorough planning and resulted in the first two Nordic face transplantation cases. This protocol now forms the platform (as a proof of concept) for other types of vascularized composite allotransplantations., (Copyright © 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

We present the case of a 19-month-old boy with complex congenital heart disease. His single father is skeptical of traditional medicine and does not offer the social support needed to make heart transplantation successful for his son. After the father demonstrates commitment to transplant success and provides enhanced social support, doctors place the child on a Berlin Heart (a biventricular assist device) as a bridge to transplantation and list him for transplant. When the child is matched to a donor heart, the father refuses transplantation, despite that it is the child's only chance for survival. His doctors report the case to child protective services, but they decline to take protective custody. The father then changes his mind and asks that the child be put back on the waiting list for transplant. By this time, the social supports the father implemented are no longer in place. This case raises a number of issues. First, should courts order heart transplantation when doctors believe that it is in the child's best interest and parents do not consent? Second, once parents refuse a transplant, can they change their minds? Third, if there are uncertainties regarding whether the child has the social support to make transplantation successful, should the child be relisted? Finally, should a child who is not currently a transplant candidate but who may become one in the future be supported with ventricular assist devices?, Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Perinatology is a dynamically developing field of medicine. The progress of technology in recent decades has made it possible to recognize birth defects very early, including those which are lethal or genetically determined. In many clinical situations, it is no longer possible to work alone to reach a definitive diagnosis, plan treatment or predict the clinical course of the affected fetus/newborn. There is a need for teamwork, which ensures the proper, early care starting in the fetal period, not only in the delivery room or NICU. This paper discusses the ethical foundations of creating interdisciplinary teams, taking as an example the Interdisciplinary Team for Fetal Malformation at the Institute of Mother and Child in Warsaw, which has been active for 25 years, and presents how it works in practice. On the basis of the clinical cases that are examined, practical guidelines were formulated for both the work of medical teams and the way parents are informed about the clinical situation of their child and about sharing the care after the birth of the child. A document was also proposed with information on prenatal diagnosis, decisions made by the interdisciplinary team regarding the mother and child, as well as the conclusions resulting from discussions with parents.

Aim: The aim of this research is to measure the impact that planned changes to nurse staffing and skill-mix have on patient, nurse, and organizational outcomes., Background: It has been highlighted that there are several design limitations in studies that explore the relationship between nurse staffing and patient, nurse and organizational outcomes; not least that the vast majority of research in this area emanates from studies that are predominantly observational in design. There are limited studies that measure nurse, patient, organizational, and economic outcomes using a longitudinal design following a planned change in nurse staffing., Design: The research will employ a longitudinal, multimethod approach to evaluate the impact that planned changes in nurse staffing and skill-mix have on wards in three pilot hospitals., Methods: Administrative data collection will take place on a shift-by-shift basis prospectively over a three-year period including the measurement of nursing sensitive outcomes: cross-sectional patient experience data and nurse outcomes (nursing work, job satisfaction, burnout, missed care) will be collected at intervals prior to, during and after the implementation of planned changes in nurse staffing and skill-mix. Data will be analysed using interrupted time-series models, adjusted for key hospital, ward and patient-level factors. An economic costing of the changes will further investigate the resources required for the intervention that can then be aggregated to a national level for future roll-out plans., Discussion: The study aims to provide evidence on the impact of planned changes to nurse staffing and skill-mix based on a systematic approach using a longitudinal design and to determine the extent to which the approach can be implemented at a national level., (© 2018 John Wiley & Sons Ltd.)

The number of people with dementia in Switzerland is currently around 150,000. The prevalence of this condition rises steeply after the age of 65. As a result of demographic changes, the number of people affected in Switzerland is thus expected to increase markedly over the coming decades. The course of dementia – which frequently occurs in combination with chronic somatic and/or mental disorders (multimorbidity) – is often protracted and is difficult to predict. Cognitive impairments mean that self-determination and alleviation of symptoms are more difficult to achieve in everyday practice. People with severe dementia generally lack capacity, and decisions then have to be made by representatives on the basis of the patient’s previously expressed or presumed wishes. The management and care of patients may be complicated by disease-related behavioural disturbances. The public, as well as the individuals affected, are fearful of the loss of independence and possible changes in personality associated with progressive dementia; in addition, people are often afraid of becoming a burden on their relatives or society. Against this background, difficult decisions and significant ethical conflicts are not unusual – all the more so since life with dementia runs counter to guiding values, such as independence, productivity and rationality, which are central to our society. The aim of these guidelines is to offer practical guidance for dealing with ethical conflict situations relating to the care and treatment of people with dementia. Specific issues are addressed which may ultimately arise for all those involved in dementia care, irrespective of the setting (domestic, hospital, residential) and professional group. Which of these ethical issues is the most salient will depend largely on the stage of the condition. Once the condition has been diagnosed, management should be based on the principles that are also applicable, for example, in palliative care: a focus on quality of life, equality of care, interprofessional collaboration and continuity, open and appropriate communication, support for decision-making processes, anticipation, a multidimensional approach, and involvement of those close to the patient. These guidelines were prepared in cooperation with the Swiss Society of Gerontology (SGG SSG) as part of the National Dementia Strategy 2014–2019 (subproject 5.1: “Establishment of ethical guidelines”).

An infant with complex congenital heart disease suffers a prolonged cardiac arrest with minutes of anoxia. He is left with severe brain damage and profound neurologic impairment. He no longer responds to caregivers. Much of the time, he cries and grimaces as if in pain. He has required increasing sedation to control these symptoms. His parents live hours from the hospital and seldom visit. When their infant's situation is explained to them over the telephone, they request that doctors "do everything to keep him alive." His bedside caregivers report high levels of moral and psychological distress and frequently discuss J.S.'s "suffering." An ethics consultation is requested, asking whether it is permissible to withdraw life support despite the parents' request that therapy continue., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Experienced on a personal and psychological level, work related stress nevertheless has social causes. New forms of management demand from staff an ever greater personal investment, but the growing intensification of the work often makes the missions they are given impossible to fulfil. This results in a feeling of having failed and of not being up to the job, which are in turn sources of suffering and stress., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

There is little research on the dynamics of the sexual assault response team (SART) members' interprofessional collaboration (IPC) practice. The study purposes were to (1) explore the perceptions of IPC among SART members; (2) evaluate the use of Perception of Interprofessional Collaboration Model Questionnaire with the SART; and (3) discuss the implications of the Interprofessional Core Competencies for emergency department nurses and sexual assault nurse examiners. This cross-sectional mixed-methods study (n = 49) was implemented using 4 SART teams in a mid-Atlantic state. There were no statistically significant differences in the subscales within the group level using analysis of variance but offered some valuable insight and content analysis. Emergency department nurses collaborate with different agencies and discipline within their working environment. Understanding the basics of IPC and the perception of IPC within the SART may open doors to further appreciate the dynamics of this team.