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Healthcare professionals often face ethical conflicts and challenges related to decision-making that have necessitated consideration of the use of conscientious objection (CO). No current guidelines exist within Spain's healthcare system regarding acceptable rationales for CO, the appropriate application of CO, or practical means to support healthcare professionals who wish to become conscientious objectors. As such, a procedural framework is needed that not only assures the appropriate use of CO by healthcare professionals but also demonstrates its ethical validity, legislative compliance through protection of moral freedoms and patients' rights to receive health care. Our proposal consists of prerequisites of eligibility for CO (individual reference, specific clinical context, ethical justification, assurance of non-discrimination, professional consistency, attitude of mutual respect, assurance of patient rights and safety) and a procedural process (notification and preparation, documentation and confidentiality, evaluation of prerequisites, non-abandonment, transparency, allowance for unforeseen objection, compensatory responsibilities, access to guidance and/or consultative advice, and organizational guarantee of professional substitution). We illustrate the real-world utility of the proposed framework through a case discussion in which our guidelines are applied., (© 2024. The Author(s).)

Objective: To assess the incidence and determinants of ICU-acquired muscle weakness (ICUAW) in adult patients with enteral nutrition (EN) during the first 7 days in the ICU and mechanical ventilation for at least 48 hours., Methods: A prospective, nationwide, multicentre cohort study in a national ICU network of 80 ICUs. ICU patients receiving invasive mechanical ventilation for at least 48 hours and EN the first 7 days of their ICU stay were included. The primary outcome was incidence of ICUAW. The secondary outcome was analysed, during days 3-7 of ICU stay, the relationship between demographic and clinical data to contribute to the onset of ICUAW, identify whether energy and protein intake can contribute independently to the onset of ICUAW and degree of compliance guidelines for EN., Results: 319 patients were studied from 69 ICUs in our country. The incidence of ICUAW was 153/222 (68.9%; 95% CI [62.5%-74.7%]). Patients without ICUAW showed higher levels of active mobility (p = 0.018). The logistic regression analysis showed no effect on energy or protein intake on the onset of ICUAW. Overfeeding was observed on a significant proportion of patient-days, while more overfeeding (as per US guidelines) was found among patients with obesity than those without (42.9% vs 12.5%; p<0.001). Protein intake was deficient (as per US/European guidelines) during ICU days 3-7., Conclusions: The incidence of ICUAW was high in this patient cohort. Early mobility was associated with a lower incidence of ICUAW. Significant overfeeding and deficient protein intake were observed. However, energy and protein intake alone were insufficient to explain ICUAW onset., Relevance to Clinical Practice: Low mobility, high incidence of ICUAW and low protein intake suggest the need to train, update and involve ICU professionals in nutritional care and the need for early mobilization of ICU patients., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Zaragoza-García et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Safeguarding the right to die according to the principles of autonomy and freedom of each person has become more important in the last decade, therefore increasing regulation of Euthanasia and Medically Assisted Suicide (MAS)., Aims: To learn the opinions that the nurses of the autonomous region of Madrid have regarding Euthanasia and Medically Assisted Suicide., Research Design: Cross-sectional descriptive study., Participants and Research Context: All registered nurses in Madrid. The study was done by means of a self-completed anonymous questionnaire. The variables studied were social-demographic, giving opinions about Euthanasia and MAS., Ethical Considerations: Each participant was assured maximum confidentiality and anonymity, ensuring the ethical principles set out in the Declaration of Helsinki, as well as in the Organic Law 3/2018, on Personal Data Protection and guarantee of digital rights., Findings: A total of 489 nurses answered the questionnaire. In total, 75.7% of the nurses confirmed that Euthanasia should be regulated in Spain. 66.3% indicated that information on Euthanasia should be provided jointly by doctors and nurses, and 42.3% considered that it could be applied by both medical and nursing professionals. A total of 87.2% advocated the participation of nurses in health policy, influencing the drafting of the law. In the face of possible regulation, 35% would request Conscientious Objection, being closely related to their religious beliefs., Discussion: Different authors point out that nurses' perceptions and attitudes towards Euthanasia are conditioned by different factors, such as religion, gender, poor palliative care, legality and the patient's right to die., Conclusion: Nurses are positioned in favour of the regulation and practice of Euthanasia and MAS, depending on their age, years of experience, training, model of care and especially religious beliefs.

Background: The ABCDE bundle is a set of evidence-based practices to systematically reduce the risks of sedation, delirium, and immobility in intensive care patients. Implementing the bundle improves clinical outcome., Aims and Objectives: To investigate the association between patient outcomes and compliance with bundle components ABC (analgosedation algorithms), D (delirium protocol), and E (early mobilization protocol)., Design: A Spanish multicentre cohort study of adult patients receiving invasive mechanical ventilation (IMV) for ≥48 h until extubation., Methods: The primary outcome was pain level, cooperation to permit Medical Research Council Scale administration, patient days of delirium, and mobility. The secondary outcome was cumulative drug dosing by IMV days. Tertiary outcomes (ICU days, IMV days, bed rest days, ICU mortality, ICUAW) and independent variables (analgosedation, delirium, early mobilization protocols) were also studied., Results: Data were collected from 605 patients in 80 ICUs and 5214 patient days with IMV. Two-thirds of the ICUs studied applied no protocols. Pain was not assessed on 83.6% of patient days. Patient cooperation made scale administration feasible on 20.7% of days. Delirium and immobility were found on 4.2% and 69.9% of days, respectively. Patients had shorter stays in ICUs with bundle protocols and fewer days of IMV in ICUs with delirium and mobilization bundle components (P = 0.006 and P = 0.03, respectively). Analgosedation protocols were associated with more opioid dosing (P = 0.02), and delirium and early mobilization protocols with more propofol (P = 0.001), dexmedetomidine (P = 0.001), and lower benzodiazepine dosing (P = 0.008)., Conclusions: The implementation rate of ABCDE bundle components was very low in our Spanish setting, but when implemented, patients had a shorter ICU stay, more analgesia dosing, and lighter sedation., Relevance to Clinical Practice: Applying some but not all the bundle components, there is increased analgesia and light sedation drug use, decreased benzodiazepines, and increased patient cooperation and mobility, resulting in a shorter ICU stay and fewer days of IMV., (© 2022 The Authors. Nursing in Critical Care published by John Wiley & Sons Ltd on behalf of British Association of Critical Care Nurses.)

Background: Early mobilization in the intensive care unit (ICU) helps improve patients' functional status at discharge. However, many barriers hinder this practice., Aim and Objectives: To identify mobility levels acquired by critically ill patients and their variables., Design: A multi-centre cohort study was conducted in adult patients receiving invasive mechanical ventilation for at least 48 hours., Methods: The primary outcome was level of mobility according to the ICU mobility scale. The secondary outcome was human resource availability and existence of ABCDEF bundle guidelines. A logistic regression was performed, based on days 3 to 5 of the ICU stay and significant association with active mobility., Results: Six hundred and forty-two patients were included from 80 ICUs. Active moving in and out of bed was found on 9.9% of patient-days from day 8 of the ICU stay. Bed exercises, or passive transfers, and immobility were observed on 45.6% and 42.2% of patient-days, respectively. Patients achieving active mobility (189/642, 29.4%) were in ICUs with more physiotherapist hours. Active mobility was more likely with a 1:4 nurse-patient ratio (odds ratio [OR] 3.7 95% confidence interval [CI] [1.2-11.2]), high MRC sum-score (OR 1.05 95% CI [1.04-1.06]) and presence of delirium (OR 1.01 95% CI [1.00-1.02]). By contrast, active mobility was hindered by higher BMI (OR 0.92 95% CI [0.88-0.97]), a 1:3 nurse-patient ratio (OR 0.54 95% CI [0.32-0.93]), or a shift-dependent nurse-patient ratio (OR 0.27 95% CI [0.12-0.62])., Conclusions: Immobility and passive mobilization were prevalent. A high MRC sum-score and presence of delirium are protective factors of mobilization. A 1:4 nurse-patient ratio shows a stronger association with active mobility than a 1:3 ratio., Relevance to Clinical Practice: Severity-criteria-based nurse-patient ratios hinder mobilization. Active mobilization may be enhanced by using nursing-intervention-based ratios, increasing physiotherapist hours, and achieving wider application of the ABCDEF bundle, resulting in more awake, cooperative patients., (© 2021 The Authors. Nursing in Critical Care published by John Wiley & Sons Ltd on behalf of British Association of Critical Care Nurses.)

Background: From the beginning, the COVID-19 pandemic increased ICU workloads and created exceptionally difficult ethical dilemmas. ICU staff around the world have been subject to high levels of moral stress, potentially leading to mental health problems. There is only limited evidence on moral distress levels and coping styles among Spanish ICU staff, and how they influenced health professionals' mental health during the pandemic., Objectives: To assess moral distress, related mental health problems (anxiety and depression), and coping styles among ICU staff during the first wave of the COVID-19 pandemic in Spain., Design: Cross-sectional., Settings and Participants: The study setting consisted of intensive care unit and areas converted into intensive care units in public and private hospitals. A total of 434 permanent and temporary intensive care staff (reassigned due to the pandemic from other departments to units) answered an online questionnaire between March and June 2020., Methods: Sociodemographic and job variables, moral distress, anxiety, depression, and coping mechanisms were anonymously evaluated through a self-reported questionnaire. Descriptive and correlation analyses were conducted and multivariate linear regression models were developed to explore the predictive ability of moral distress and coping on anxiety and depression., Results: Moral distress during the pandemic is determined by situations related to the patient and family, the intensive care unit, and resource management of the organisations themselves. intensive care unit staff already reached moderate levels of moral distress, anxiety, and depression during the first wave of the pandemic. Temporary staff (redeployed from other units) obtained higher scores in these variables (p = 0.04, p = 0.038, and p = 0.009, respectively) than permanent staff, as well as in greater intention to leave their current position (p = 0.03). This intention was also stronger in health staff working in areas converted into intensive care units (45.2%) than in normal intensive care units (40.2%) (p = 0.02). Moral distress, coupled with primarily avoidance-oriented coping styles, explains 37% (AdR 2 ) of the variance in anxiety and 38% (AdR 2 ) of the variance in depression., Conclusions: Our study reveals that the emotional well-being of intensive care unit staff was already at risk during the first wave of the pandemic. The moral distress they experienced was related to anxiety and depression issues, as well as the desire to leave the profession, and should be addressed, not only in permanent staff, but also in temporary staff, redeployed to these units as reinforcement workers., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Intensive care unit-acquired muscle weakness (ICUAW) has an incidence of 40-46%. Early mobilisation is known to be a protective factor., Objective: The aim of the study was to identify the incidence of ICUAW in Spain and to evaluate variables likely to contribute to the development of ICUAW., Methods: A 4-month, prospective observational multicentre cohort study was conducted on patients receiving invasive mechanical ventilation for at least 48 h. Data were collected from ICU day 3 until ICU discharge. The primary outcome was presence of ICUAW (diagnosed using the Medical Research Council [MRC] scale). The secondary outcome was nurse-patient ratio, physiotherapist availability, analgesia, sedation and delirium management, glycaemic control, and daily level of mobility during the ICU stay as per the ICU Mobility Scale. A logistic regression model was constructed based exclusively on days 3-5 of the ICU stay., Results: The data of 642 patients were analysed from 80 ICUs, accounting for 35% of all ICUs in Spain. The incidence of ICUAW was 58% (275 of 474 patients; 95% confidence interval [CI] [53-62]). The predictors for ICUAW were older age (odds ratio [OR] = 1.01; 95% CI [1.00-1.03]) and more days with renal replacement therapy (OR = 1.01; 95% CI [1.00-1.02]). The protective factors for ICUAW were male gender (OR = 0.58; 95% CI [0.38-0.89]), higher Barthel Index (showing prehospital functional independence) (OR = 0.97; 95% CI [0.95-0.99]), more days of being awake and cooperative (defined by a feasible MRC assessment) (OR = 0.98; 95% CI [0.97-0.99]), presence of delirium (OR = 0.98; 95% CI [0.97-0.99]), and more days with active mobilisation (ICU Mobility Scale ≥ 4) (OR = 0.98; 95% CI [0.97-0.99])., Conclusions: The risk factors for ICUAW were functional dependence before admission, female gender, older age, and more days on renal replacement therapy. The protective factors for ICUAW were feasibility of MRC assessment, the presence of delirium, and being actively mobilised during the first 5 days in the ICU., Competing Interests: Conflict of Interest The authors declare that there is no conflict of interest regarding the publication of this article., (Copyright © 2020 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

In March 2021, the Spanish Congress approved the law regulating euthanasia, that regulates both euthanasia and physician-assisted suicide (PAS). In this article, we analyse the Spanish law regulating euthanasia and PAS, comparing it with the rest of the European laws on euthanasia and PAS (Netherlands, Belgium and Luxembourg). Identified strengths of the Spanish law, with respect to other norms, are that it is a law with many safeguards, which broadly recognises professionals' right to conscientious objection and the specification that it makes on the prior comprehensive care of the patient, including the approach to care dependency. Regarding its shortcomings, the law does not differentiate well between euthanasia and PAS; it barely assigns a role to the healthcare team as a whole (similar to other regulations); it does not clarify the functions of the different professionals involved; it does not detail the specific composition and duration of theevaluation commission; it has not been accompanied by a prior or simultaneous regulation of palliative care; and, lastly, the period of time to implement the law is too short., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The study aim was to explore the experience of doctors and nursing assistants in the management of physical restraint (PR) in critical care units., Method: A multicentre phenomenological study that included 14 critical care units (CCU) in Madrid (Spain). The CCU were stratified according to their use of physical restraint: "frequently used" versus "seldom used". Three focus groups were formed: the first comprised nursing assistants from CCUs that frequently used physical restraint, the second comprised nursing assistants from CCUs that seldom used physical constraint, and the final group comprised doctors from both CCU subtypes. Sampling method: purposive., Data Analysis: thematic content analysis. Data saturation was achieved., Results: Four principle themes emerged: 1) concept of safety and risk (patient safety versus the safety of the professional), 2) types of restraint, 3) professional responsibilities (prescription, recording, and professional roles) and 4) "zero restraint" paradigm. The conceptualisation regarding the use of physical contentions shows differences in some of the principal themes, depending on the type of CCU, in terms of policies, use and management of physical constraint (frequently used versus seldom used)., Conclusions: The real reduction in the use of physical restraint in CCU must be based on one crucial point: acceptance of the complexity of the phenomenon. The use of physical restraint observed in the different CCU is influenced by individual, group and organisational factors. These factors will determine how doctors and nursing assistants interpret safety and risk, the centre of care (patient or professional-centred care), the concept of restraint, professional responsibilities and interventions, interactions of the team and the leadership., (Copyright © 2019 Sociedad Española de Enfermería Intensiva y Unidades Coronarias (SEEIUC). Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: In the last decades, there have been important developments in the scientific and technological areas of healthcare. On certain occasions this provokes conflict between the patients' rights and the values of healthcare professionals which brings about, within this clinical relationship, the problem of conscientious objection., Aims: To learn the opinions that the Nurses of the Madrid Autonomous Community have regarding conscientious objection., Research Design: Cross-cutting descriptive study., Participants and Research Context: The nurses of 9 hospitals and 12 Health Centers in the Madrid Autonomous Community. The study was done by means of an auto completed anonymous questionnaire. The variables studied were social-demographical and their opinions about conscientious objections., Ethical Considerations: The study was approved by the Ethical Community of Clinical Research of the University Hospital Príncipe de Asturias. Participants were assured of maximum confidentiality and anonymity., Findings: A total of 421 nurses answered the questionnaire. In total, 55.6% of the nurses confirmed they were religious believers, and 64.3% declared having poor knowledge regarding conscientious objection. The matters that caused the greatest objections were voluntary abortions, genetic embryo selection, refusal of blood transfusions, and therapy refusal., Discussion: Different authors state that the most significant cases of conscientious objections for health professionals are those regarding carrying out or assisting in abortions, euthanasia, the practice of assisted reproduction and, finally, the prescription and dispensing of the morning-after pill. In our study, the most significant cases in which the nurses would declare conscientious objections would be the refusal to accept treatment, the selection of embryos after genetic diagnosis preimplantation, the patient's refusal to receive blood transfusions due to religious reasons and pregnant women's request for voluntary abortions within the first 14 weeks., Conclusion: Nurses' religious beliefs influence their opinions regarding conscientious objection. The nurses who declare themselves as religious believers object in a higher percentage than those without religious beliefs.

Aim: To evaluate the degree of implementation of protocols associated with the prevention of intensive-care-unit (ICU) acquired muscle weakness, and the presence of the physiotherapist in various ICU in Spain., Method: A descriptive, cross-sectional study performed in 86 adult ICU in Spain between March and June 2017. Neurosurgical and major burns ICU were excluded. A multiple-choice survey was used that included questions on protocols for glycaemia control, sedation, pain assessment, delirium prevention, delirium management and early mobilisation. The survey was completed using a user-protected application and password. The Student's t-test or Mann-Whitney U test and Pearson's correlation or Spearman's Rho test were used for the inferential analysis., Results: Eighty-nine point five percent of the ICU had a glycaemia control protocol, with a predominating range of 110-140mg/dl. Seventy-four point four percent evaluated sedation levels, although only 36% had sedation protocols. Pain assessment was carried out on communicative patients in 73.7%, and on uncommunicative patients in only 47.5%. Only 37.2% performed daily screening to detect delirium and 31.4% of the ICU had delirium prevention protocols, 26.7% had delirium management protocols and 14% had protocols for early mobilisation. Thirty-four point nine percent requested cross consultation with the rehabilitation department., Conclusions: The implementation of the different protocols associated with the prevention of ICU-acquired muscle weakness was high in relation to glycaemia control protocols, sedation level and pain assessment in communicative patients, and was low for early mobilisation and delirium screening and prevention. Similarly, the physiotherapist was seldom present in the ICU., (Copyright © 2018 Sociedad Española de Enfermería Intensiva y Unidades Coronarias (SEEIUC). Publicado por Elsevier España, S.L.U. All rights reserved.)

Aims: To identify nursing experience on physical restraint management in Critical Care Units. To analyse similarities and differences in nursing experience on physical restraint management according to the clinical context that they are involved in., Method: A multicentre phenomenological study was carried out including 14 Critical Care Units in Madrid, classified according to physical restraint use: Common/systematic use, lacking/personalised use, and mixed use. Five focus groups (23 participants were selected following purposeful sampling) were convened, concluding in data saturation. Data analysis was focused on thematic content analysis following Colaizzi's method., Findings: Six main themes: Physical restraint meaning in Critical Care Units, safety (self-retreat vital devices), contribution factors, feelings, alternatives, and pending issues. Although some themes are common to the 3 Critical Care Unit types, discourse differences are found as regards to indication, feelings, systematic use of pain and sedation measurement tools., Conclusions: In order to achieve real physical restraint reduction in Critical Care Units, it is necessary to have a deep understanding of restraints use in the specific clinical context. As self-retreat vital devices emerge as central concept, some interventions proposed in other settings could not be effective, requiring alternatives for critical care patients. Discourse variations laid out in the different Critical Care Unit types could highlight key items that determine the use and different attitudes towards physical restraint., (Copyright © 2015 Elsevier España, S.L.U. y SEEIUC. All rights reserved.)

Objective: To identify knowledge, skills and attitudes among physicians and nurses of adults' intensive care units (ICUs), referred to advance directives or living wills., Design: A cross-sectional descriptive study was carried out., Setting: Nine hospitals in the Community of Madrid (Spain)., Participants: Physicians and nurses of adults' intensive care., Interventions: A qualitative Likert-type scale and multiple response survey were made., Variables: Knowledge, skills and attitudes about the advance directives. A descriptive statistical analysis based on percentages was made, with application of the chi-squared test for comparisons, accepting p < 0.05 as representing statistical significance., Results: A total of 331 surveys were collected (51%). It was seen that 90.3% did not know all the measures envisaged by the advance directives. In turn, 50.2% claimed that the living wills are not respected, and 82.8% believed advance directives to be a useful tool for health professionals in the decision making process. A total of 85.3% the physicians stated that they would respect a living will, in cases of emergencies, compared to 66.2% of the nursing staff (p = 0.007). Lastly, only 19.1% of the physicians and 2.3% of the nursing staff knew whether their patients had advance directives (p < 0.001)., Conclusions: Although health professionals displayed poor knowledge of advance directives, they had a favorable attitude toward their usefulness. However, most did not know whether their patients had a living will, and some professionals even failed to respect such instructions despite knowledge of the existence of advance directives. Improvements in health professional education in this field are needed., (Copyright © 2015 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.)

Objetive: To analyze proper control of endotracheal cuff pressure in an intensive care unit. The specific objective is to verify whether training of nursing professionals improves monitoring endotracheal cuff pressure., Basic Procedures: the study type is descriptive, observational and retrospective. All patients were admitted to the Critical Unit II of the Clínico San Carlos Hospital between May 2010-November 2011, requiring either a tracheal tube or tracheal cannula. Studied variables were: number of in range measures, number of intubated patients, or with tracheal cannula and register. Four cuts were made on all admitted patients admitted during the study period in order to measure endotracheal cuff pressure. Two cuts were performed before the professional nurses training and the other two cuts after a specific training with respect to endotracheal cuff pressure and Zero pneumonia., Results: There were 74 measurements. The first cut obtained 40.74% of measures in range. In the second cut 61.90% of measures were identified in range. In the third cut, it was found that 85.7% of measures were in range and in the fourth court, it was noted the 89.47% of measures were in range., Conclusions: Monitoring of the endotracheal cuff pressure was inadequate before specific training of professionals. Nursing professionals training facilitates the correct measurement of the endotracheal cuff pressure, which improves patient safety., (Copyright © 2013 Elsevier España, S.L.U. y SEEIUC. All rights reserved.)

Objective: To analyze the incidence of use of high-flow nasal cannula oxygen (HFNC) in intensive care and evaluate the procedure., Basic Procedures: descriptive prospective study., Inclusion Criteria: all participants were patients admitted to the intensive care units of the hospital Clínico San Carlos November 2012 - January 2013 that required HFNC., Variables: socio-demographic; indications, complications, objectives and flows of the therapy. Statistical analysis with average, standard deviation and percentages, with the statistical program SPSS ver18.0., Results: 12 cases of which 58.3% were men, with a mean age 68.66 (± 12) and with NEMS 33.25 (±7). The incidence of HFNC was 0.95%. The indication of HFNC was: 75% moderate respiratory failure or need for oxygen supply greater than 40%, 58.3% hypoxemia without hypercapnia, the 41.7% withdrawal and/or employment with non-invasive mechanical ventilation, the 25% support post-extubation, the 16.7% exacerbations of heart failure, the 16.7% improve respiratory work and the 8.3% acute lung edema. The main complications of the HFNC were: mouth-breathing (8.3%), nasal injury (8.3%) and abundant secretions (8.3%). In the fulfilment of the objectives of the HFNC, there was a 91.7% improvement of oxygen therapy, and in 50% of the cases orotracheal intubation was averted., Conclusions: There is a low incidence of HFNC in the unit. The main indication is the moderate respiratory failure or the high need for oxygen supply. Almost all patients have improved with oxygen therapy, although it has not been possible to avoid intubation., (Copyright © 2013 Elsevier España, S.L.U. y SEEIUC. All rights reserved.)

Objective: To analyze the impact of the use of mechanical restraint (MR) or physical restraints in a Critical Care unit and to evaluate the procedure., Basic Procedures: A descriptive, prospective study., Inclusion Criteria: patients who required MR from March to June 2010., Variables: demographic, clinical presentation, indications, techniques and devices. A statistical analysis with mean, standard deviation and percentages using the program SPSS 14.0., Results: A total of 85 cases were studied: 65.9% male, mean age 64.19 (±17.9), NEMS 29.3 (±8.2). Incidence of MR: 15.6%. Main indication for MR: Risk of serious disruption of treatment processes (80%). Decision nurse (94.1%). Urgent action: (85.9%). Registration procedure: 57.6%. Information to the family: 9.4%. Previous actions: verbal containment (100%), pharmacological (48.2%)., Conclusions: There is a relevant incidence of MR. The principal reason is that of avoiding interruption of the therapeutic process. The nurse makes the initial decision. Necessary information/training of professionals for legal and ethical repercussions is needed., (Copyright © 2011 Elsevier España, S.L. y SEEIUC. All rights reserved.)