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array:24 [ "pii" => "S2254887422000935" "issn" => "22548874" "doi" => "10.1016/j.rceng.2022.09.004" "estado" => "S300" "fechaPublicacion" => "2022-12-01" "aid" => "2058" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "copyrightAnyo" => "2022" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2022;222:593-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S001425652200131X" "issn" => "00142565" "doi" => "10.1016/j.rce.2022.09.004" "estado" => "S300" "fechaPublicacion" => "2022-12-01" "aid" => "2058" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2022;222:593-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original</span>" "titulo" => "Descripción de la experiencia de un servicio de consultoría en ética clínica en el período 2019-2021" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "593" "paginaFinal" => "598" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Description of the experience of a clinical ethics consultation service from 2019-2021" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 852 "Ancho" => 1670 "Tamanyo" => 75554 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Evolución del número de consultas al comité de ética para la asistencia sanitaria antes y después de la puesta en marcha del servicio de consultoría en ética clínica.</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Período previo a la institución del servicio de CEC entre 2014 y septiembre de 2019. Período tras la creación del servicio de CEC incluido en el análisis: septiembre de 2019 a septiembre de 2021.</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">En el año 2019, el CEAS recibió 4 consultas entre el 1 de enero y el 1 de septiembre (antes de que existiera el servicio de CEC) y 8 consultas en los meses posteriores a la creación del servicio de CEC.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E. López-Urrutia, A. Sancha, D. Useros, J.M. Galván-Román, Í. García-Sanz, F. Casals, J. Fernández-Bueno, D. Real de Asúa" "autores" => array:9 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "López-Urrutia" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Sancha" ] 2 => array:2 [ "nombre" => "D." "apellidos" => "Useros" ] 3 => array:2 [ "nombre" => "J.M." "apellidos" => "Galván-Román" ] 4 => array:2 [ "nombre" => "Í." "apellidos" => "García-Sanz" ] 5 => array:2 [ "nombre" => "F." "apellidos" => "Casals" ] 6 => array:2 [ "nombre" => "J." 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"apellidos" => "Real de Asúa" ] 8 => array:1 [ "colaborador" => "en representación del Comité de Ética para la Asistencia Sanitaria del Hospital Universitario de La Princesa" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2254887422000935" "doi" => "10.1016/j.rceng.2022.09.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887422000935?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S001425652200131X?idApp=WRCEE" "url" => "/00142565/0000022200000010/v1_202211290712/S001425652200131X/v1_202211290712/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2254887422000455" "issn" => "22548874" "doi" => "10.1016/j.rceng.2022.03.004" "estado" => "S300" "fechaPublicacion" => "2022-12-01" "aid" => "2038" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "edi" "cita" => "Rev Clin Esp. 2022;222:599-601" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Instruction on inhalation technique: What are we doing with our COPD patients?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "599" "paginaFinal" => "601" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Instrucción sobre la técnica de inhalación: ¿Qué estamos haciendo con nuestros pacientes EPOC?" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "N. Vázquez-González, P. Barnestein-Fonseca" "autores" => array:2 [ 0 => array:2 [ "nombre" => "N." "apellidos" => "Vázquez-González" ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Barnestein-Fonseca" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256522000650" "doi" => "10.1016/j.rce.2022.03.012" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256522000650?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887422000455?idApp=WRCEE" "url" => "/22548874/0000022200000010/v1_202212080727/S2254887422000455/v1_202212080727/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2254887422000741" "issn" => "22548874" "doi" => "10.1016/j.rceng.2022.05.006" "estado" => "S300" "fechaPublicacion" => "2022-12-01" "aid" => "2050" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2022;222:584-92" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "SOX2 como posible biomarcador pronóstico y diana molecular en el cáncer de pulmón: metaanálisis" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "584" "paginaFinal" => "592" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "SOX2 as a potential prognostic biomarker and molecular target in lung cancer: a meta-analysis" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 4341 "Ancho" => 1849 "Tamanyo" => 470153 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A) Forest plot of SOX2 and overall survival in lung cancer. B) Forest plot of subgroup analysis by tumor histology for SOX2 with overall survival in lung cancer. C) Forest plot of SOX2 and the other prognostic endpoints in lung cancer.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">NSCLC: non-small cell lung cancer; RFS: recurrence-free survival; SCLC: small-cell lung cancer; TTP: time-to-progression.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "K. Zang, Z.-H. Yu, M. Wang, Y. Huang, X.-X. Zhu, B. Yao" "autores" => array:6 [ 0 => array:2 [ "nombre" => "K." "apellidos" => "Zang" ] 1 => array:2 [ "nombre" => "Z.-H." "apellidos" => "Yu" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Wang" ] 3 => array:2 [ "nombre" => "Y." "apellidos" => "Huang" ] 4 => array:2 [ "nombre" => "X.-X." "apellidos" => "Zhu" ] 5 => array:2 [ "nombre" => "B." "apellidos" => "Yao" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256522000856" "doi" => "10.1016/j.rce.2022.05.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256522000856?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887422000741?idApp=WRCEE" "url" => "/22548874/0000022200000010/v1_202212080727/S2254887422000741/v1_202212080727/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Description of the experience of a clinical ethics consultation service from 2019 to 2021" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "593" "paginaFinal" => "598" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "E. López-Urrutia, A. Sancha, D. Useros, J.M. Galván-Román, Í. García-Sanz, F. Casals, J. Fernández-Bueno, D. Real de Asúa" "autores" => array:9 [ 0 => array:3 [ "nombre" => "E." "apellidos" => "López-Urrutia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Sancha" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "D." "apellidos" => "Useros" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "J.M." "apellidos" => "Galván-Román" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "Í." "apellidos" => "García-Sanz" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 5 => array:3 [ "nombre" => "F." "apellidos" => "Casals" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 6 => array:3 [ "nombre" => "J." "apellidos" => "Fernández-Bueno" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 7 => array:4 [ "nombre" => "D." "apellidos" => "Real de Asúa" "email" => array:1 [ 0 => "diego.realdeasua@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 8 => array:1 [ "colaborador" => "en representación del Comité de Ética para la Asistencia Sanitaria del Hospital Universitario de La Princesa" ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario de La Princesa, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Comité de Ética para la Asistencia Sanitaria, Hospital Universitario de La Princesa, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de La Princesa, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Unidad de Cuidados Paliativos Hospitalarios, Hospital Universitario de La Princesa, Madrid, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Descripción de la experiencia de un servicio de consultoría en ética clínica en el período 2019-2021" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 852 "Ancho" => 1670 "Tamanyo" => 75670 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evolution of the number of healthcare ethics committee (HEC) consultations before and after implementing the clinical ethics consultation (CEC) service.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Period prior to creation of the CEC service between 2014 and September 2019. Period following creation of the CEC service included in the analysis: September 2019 to September 2021.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In 2019, the HEC received 4 consultations between 1 January and 1 September (before the CEC service existed) and 8 consultations in the months following creation of the CEC service.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Healthcare ethics committees (HECs) are an essential part of healthcare institutions. Their functions include collaborating with professionals, patients, and family members to resolve ethical issues, and their presence provides an important reprieve for the uncertainty that these conflicts can produce. HECs additionally participate in ethics training and the creation of action protocols for diverse, complex hospital situations<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">However, HECs are often unable to respond quickly enough since these additional committee meetings require the presence of a minimum number of members. These members, in turn, must combine this responsibility with the performance of their regular healthcare role and tasks.</p><p id="par0015" class="elsevierStylePara elsevierViewall">While some cases that are referred to HECs do not require immediate response, the vast majority of daily ethical conflicts require swifter intervention. What’s more, the perception of these committees as entities that are distanced from “point-of-care” clinical practice often dissuades professionals from consulting them. This means that, in practice, committees receive a limited number of consultations, often leaving morally complex decisions to be made by the physician in charge, with the subsequent significant burden this represents<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>.</p><p id="par0020" class="elsevierStylePara elsevierViewall">To address these limitations, clinical ethics consultation (CEC) services have emerged as a model of ethics consulting that supplements HECs. Healthcare ethics consultants are appointed members of the HEC who can intervene in real time in everyday ethical conflicts, providing the urgent response that is often required. The consultants’ presence does not diminish the importance of the committee since the HEC maintains its role as the supervisory and advisory body.</p><p id="par0025" class="elsevierStylePara elsevierViewall">CEC services are the most widespread ethics consulting model in the English-speaking world and are currently being implemented in other European countries. Various studies have demonstrated their capacity to resolve most ethical issues that arise in daily clinical practice<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>, while also facilitating patient participation the decision-making process and promoting an attitude shift among the actors involved in the conflict<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6</span></a>. Despite these potential benefits, to date, CEC initiatives in Spain have been merely anecdotal<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In 2019, a CEC service was created at La Princesa University Hospital, which answers to the centre’s HEC. The objective of this paper is to describe the work method of the CEC service and categorize the consultations received over the course of its first two years, with the aim of sharing an experience that could serve as a point of reference or comparison for the work undertaken in other hospital centres.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Organisational setting and study design</span><p id="par0035" class="elsevierStylePara elsevierViewall">A retrospective, observational study was conducted on all the interventions of the La Princesa University Hospital CEC service between the period spanning 1 September 2019 and 31 August 2021.</p><p id="par0040" class="elsevierStylePara elsevierViewall">La Princesa University Hospital is a tertiary healthcare centre in the metropolitan area of Madrid that serves an estimated target population of 350,000 people. Its HEC, established in 1992, came to the agreement over the course of 2019 to supplement the committee’s ethics consulting work with a team of ethics consultants.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The CEC service, officially established on 1 September 2019, is comprised of five members of the HEC with specific training in clinical ethics who provide consultancy activities, either individually or in teams of 2–3 people, according to their availability which is dependent on their daily clinical workload. Initially, the CEC offered its services from 8 AM to 3 PM, Monday to Friday. However, starting in March 2020, the service became available on a continuous, 24/7 basis, and remains so today.</p><p id="par0050" class="elsevierStylePara elsevierViewall">This service is available for all parties involved in a clinical case (patients, family members, or health professionals, both the medical teams responsible for the case as well as other consulting services), through the following channels: internal telephone (pager), cross-consultation form integrated into the hospital computer system, or by directly contacting any of the members.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Each consultation is labelled with a priority level: standard (resolution can wait until the next HEC meeting), preferential (the case requires response within 24–72 h), or urgent (for cases requiring response in under 24 h).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Case selection</span><p id="par0060" class="elsevierStylePara elsevierViewall">All consecutive cases sent to the CEC service for consultation during its first two years were analysed. No exclusion criteria were applied.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Measurements and variables</span><p id="par0065" class="elsevierStylePara elsevierViewall">The following variables were collected for each case: response time (days), person requesting the consult (relationship with the case [medical professional, nurse, other health professionals, social worker, etc.], consulting service, and professional category), urgency of the consultation, contact channel used, patient demographic data (age and sex), presence of a designated representative or advance directives, and the need for HEC participation (full involvement) in the case.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The reason for consultation or ethical issue were also collected for each case (additional information on nomenclature and classification of the ethical issues can be found in Appendix B Supplementary Table 1). Each case could present more than one ethical issue.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Lastly, the perception of resolution of the issue was recorded, both from the patient or family member’s perspective and from the requesting professional’s perspective.</p><p id="par0080" class="elsevierStylePara elsevierViewall">As additional data, the total number of annual consultations received by the institution’s HEC since 2014 was reviewed.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical aspects</span><p id="par0085" class="elsevierStylePara elsevierViewall">The study was conducted according to good clinical practice guidelines<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and the Declaration of Helsinki<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>. All the data collected from the cases were anonymized according to the legislation in force<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The study was approved by the hospital’s Research Ethics Committee and, given its retrospective nature, was exempt from obtaining informed consent.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0095" class="elsevierStylePara elsevierViewall">Qualitative variables were expressed in frequency and percentage tables and quantitative variables as mean and standard deviation. The analysis was performed with Microsoft Excel® 2016 (Microsoft Corporation, Redmond, Washington, USA).</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Description of the consulting activity</span><p id="par0100" class="elsevierStylePara elsevierViewall">A total of 63 cases were recorded during the study period. Prior to the creation of the CEC service, between 2014 and September 2019, the average annual number of cases sent to the centre’s HEC for consultation was 3.6 ± 2.4. In 2019, the HEC received 4 consultations between 1 January and 1 September, while from implementation of the CEC service to 31 December, 8 consultations were received, as were 28 in 2020, and 27 up to the cut-off date in 2021, representing 2.1 ± 1.5 cases per month in 2020 and 2021 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">At least one report (either preliminary or final) was collected from the HEC for 60 of the 63 cases. In 79% of the cases (50), the response time was less than 24 h, with the anecdote that this time was greater than 3 calendar days from the consultation (5 cases, of which 4 consultations were received at weekend and one which was a standard HEC consultation whose priority level was confirmed via telephone by the enquiring professional within 24 h of their consultation).</p><p id="par0110" class="elsevierStylePara elsevierViewall">Pager was the preferred means for contacting the CEC service (36 cases; 57%), followed by cross-consultation via the computer system (13 cases; 21%), and curbside consultations (7 cases; 11%). Eight out of every ten consultations sent to the CEC requested assistance of an exceptional nature: 26 of them (41%) were urgent and 24 (38%) preferential.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The professionals who most frequently requested consultation were attending physicians, responsible for 54 cases (86%). Other health professionals who requested consults less often were resident physicians (5; 8%), nursing staff (3; 5%), and social work (1 consult). The medical services that most often requested consultation were Intensive Care (9 cases; 14%) and Internal Medicine (8 cases; 13%). The diversity of the services requesting consultations can be seen in Appendix B Supplementary Table 2.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Reasons for consulting</span><p id="par0120" class="elsevierStylePara elsevierViewall">From a total of 63 cases sent to the CEC service for consultation, 124 reasons for consultation were identified (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). In particular, the most common ethical issue referred to withholding/withdrawing treatment measures (24 cases; 19%), followed by issues resulting from communication with family members (21 cases; 17%) and patients (8 cases; 7%), and those related to treatment refusal decisions (19 cases; 15%) and conflicts regarding patient competence (13 cases; 11%).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">The “Other” section includes ethical issues that did not fit within any of the previously established consultation categories (Appendix B Supplementary). This group included consultations regarding how to conduct oneself when faced with inappropriate behaviour from patients (2 cases) or other professionals involved in a case (1 case), the limits of confidentiality (4 cases), or the limits of autonomy for admitted patients with regard to managing their own medication (2 cases). Two consultations referred to the use of mechanical restraints and two more involved requests for aid in dying prior to approval of Law 03/2021 which regulates euthanasia. Lastly, two issues were specifically related to the restrictions imposed as a result of the COVID-19 pandemic, mostly due to the limited schedule for hospital visits and potential exceptions.</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">This paper details the experience of a clinical ethics consultation service during its first two years of service. The CEC service received over 30 consultations per year during the study period, which represents a ten-fold increase over the number of cases consulted with the HEC in previous years. Eight out of every ten consultations requested urgent or preferential attention. Almost two thirds of the ethical conflicts were related to withholding/withdrawing treatment measures, communication issues between professionals, patients and family members, or treatment refusal requests.</p><p id="par0135" class="elsevierStylePara elsevierViewall">This increase in ethics healthcare activity following implementation of a CEC service has been reported in previous experiences<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a>. While improved ease of access for clinicians was expected to translate into a higher number of consultations, the observed increase was quite substantial.</p><p id="par0140" class="elsevierStylePara elsevierViewall">To put this into perspective, a national survey in the United States on CEC services with participation from 450 centres observed that the annual number of consultations received in institutions with more than 400 beds was 26–32<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>. In other words, the volume of consultations that our CEC service received is comparable to other U.S. hospitals of the same size as early as the first year after implementation. In fact, CEC services were also the predominant ethical advisory model in these centres, compared to the formal consulting provided by HECs (90% vs. 10% of consultations received, respectively)<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>.</p><p id="par0145" class="elsevierStylePara elsevierViewall">This exponential growth in the number of consultations as of the first year of this project reflects the magnitude of how important it is to have a CEC service that is integrated into the regular operation of the hospital.</p><p id="par0150" class="elsevierStylePara elsevierViewall">What’s more, it is worth highlighting that the majority of consultations (79%) requested priority attention. This volume of requests could not have been addressed if each case had required an additional <span class="elsevierStyleItalic">ad hoc</span> meeting of the HEC for their resolution. This urgency is also reflected in the characteristics of the individuals requesting said consultations.</p><p id="par0155" class="elsevierStylePara elsevierViewall">Unlike regular hospital practice, in which the youngest doctors are typically responsible for managing everyday procedures, such as consultations with other services, in our case the majority of cross-consultations (80%) originated from the associate specialists in charge. This percent is substantially greater than that published in U.S. series<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>. This result could be interpreted, though only indirectly, as a marker of the level of anxiety that moral conflicts cause among care teams.</p><p id="par0160" class="elsevierStylePara elsevierViewall">Another additional advantage of the CEC compared to the traditional HEC model is its enhanced transparency. The typical working procedure of HECs is to deliberate and then draft a report that is privately given to the requesting professional. However, the reports and assessments made by CEC services are included in the medical history as additional progress notes. This allows all professionals involved in a case to participate in the reflections and recommendations proposed by the CEC service, thereby increasing their clinical and educational impact. This benefit is not only limited to the “problem” episode but can also impact future patient consultations within other hospital contexts or settings.</p><p id="par0165" class="elsevierStylePara elsevierViewall">For example, if patient values, preferences, and aims that may help facilitate shared decision-making are assessed and described in the medical history, thanks to the intervention of the CEC service, this information could be highly useful in future emergency situations or for on-call doctors<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>.</p><p id="par0170" class="elsevierStylePara elsevierViewall">The primary reason for requesting a consult from the CEC were ethical issues regarding end-of-life decisions. Decisions surrounding whether to withhold or to withdraw certain treatments, conflicts regarding patient competence and the subsequent decisions of their representatives, or requests to refuse treatment are all part of everyday clinical practice.</p><p id="par0175" class="elsevierStylePara elsevierViewall">A recent survey by the Spanish Society for Internal Medicine among a group of 261 internists showed how these issues are the same problems that are most often encountered in daily clinical practice<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>. These same reasons for consultation where also the most prevalent in an observational study conducted on ethical issues experienced by teams of U.S. Internal Medicine hospitalists<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>.</p><p id="par0180" class="elsevierStylePara elsevierViewall">CEC services could be considered an import from the U.S. healthcare culture. However, the consistency between our results and previous series reflects the cross-sectionality of overarching topics of ethical issues across different socio-cultural settings. It also confirms how implementing a CEC model can be useful in a setting like Spain, regardless of the differences between the healthcare systems.</p><p id="par0185" class="elsevierStylePara elsevierViewall">This paper presents significant limitations. It is a retrospective, single-centre series in a tertiary university hospital in an urban setting. Therefore, the results are limited by the characteristics of the study environment. While one could think that this would make it difficult to generalize our experience, it is precisely in smaller hospitals and areas with a more scattered population, with fewer means and more difficulty to establish an HEC, that this CEC model can be most useful, as was observed in the U.S. setting<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>. Therefore, while there may be differences with regard to the volume of consultations, and the intrinsic difficulties of each hospital, it should not be assumed that it is impossible to implement such a program.</p><p id="par0190" class="elsevierStylePara elsevierViewall">It was not possible to include in this analysis any information regarding the resources used in the consultations as these parameters—type of activity carried out (ethical evaluation, mediation, ethical-legal clarification, etc.), parties involved (meetings with the medical team, family members, etc.), and the time invested—only started to be collected systemically after the study end date. Undoubtedly, this information would also be valuable for better measuring the investment that a service of this nature entails. Nevertheless, the economic feasibility of an ethical consultation service has been demonstrated in other settings<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19,20</span></a>.</p><p id="par0195" class="elsevierStylePara elsevierViewall">Lastly, the objective of this paper was to demonstrate the utility of this consultancy model, which is novel to our environment, and to share its characteristics as a point of reference or comparison for other hospitals. We understand that the particular traits or differences inherent to each centre or healthcare system may lead to modifications to the model, but this should not diminish the validity of these results or the general conclusions of the study.</p><p id="par0200" class="elsevierStylePara elsevierViewall">In conclusion, this paper details the experience of a CEC service during its first two years of operation. The ten-fold increase in consultations received and the need for priority assistance in the majority of said cases are a reflection of this previously unattended need. Similar to the most common ethical concerns of internists, almost two thirds of the ethical conflicts were related to decisions regarding withholding/withdrawing measures, communication issues, or treatment refusal requests.</p><p id="par0205" class="elsevierStylePara elsevierViewall">These results show that implementing a CEC service is possible in our setting and that these services can facilitate the fast and efficient resolution of ethical issues affecting health professionals in their everyday clinical practice.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Funding</span><p id="par0210" class="elsevierStylePara elsevierViewall">The authors received no public or private funding for the drafting of this paper.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of interest</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors declare that they do not have any conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1816582" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1585936" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1816581" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1585937" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Organisational setting and study design" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Case selection" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Measurements and variables" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Ethical aspects" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0040" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Description of the consulting activity" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Reasons for consulting" ] ] ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflicts of interest" ] 10 => array:2 [ "identificador" => "xack640821" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-08-28" "fechaAceptado" => "2022-09-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1585936" "palabras" => array:2 [ 0 => "Bioethics" 1 => "Ethics consultation" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1585937" "palabras" => array:2 [ 0 => "Bioética" 1 => "Consultoría ética" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Clinical ethics consultation services (CEC) are useful model for ethical counselling, albeit with scarce implementation in European countries. This article shares the experience of one of the first ethics consultation services in Spain.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">This work is a retrospective, observational study of all consultations received by the CEC service at La Princesa University Hospital (Madrid, Spain) from September 1, 2019 to August 31, 2021. The demographic, logistic, and ethical variables of the cases were analyzed.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 63 cases were analyzed in which a total of 124 ethical conflicts were identified. Forty-one percent of the cases (n = 26) were emergency consultations and 38% (n = 24) were preferential inquiries. An initial evaluation was performed with 24 h in 50 cases (79%). The department that consulted most often was the Intensive Care Unit (9; 14%). The preferred contact methods were via pager (36; 57%), the electronic medical record system (13; 21%), or direct conversations with consulting team (7; 11%). The most common ethical conflicts were those related to the adequacy of treatment measures (24; 19%), refusal of treatment (19; 15%), communication with the patient or his/her family (29; 23%), or the patient's capacity (13; 11%).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">CEC services provide quick, efficient assistance for resolving ethical problems in daily practice. Their implementation in Spain is feasible.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La consultoría en ética clínica (CEC) es un modelo útil de asesoría ética, pero con escasa implantación en Europa. En el presente artículo se comparte la experiencia de uno de los primeros servicios de consultoría ética en España.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional retrospectivo de todas las consultas recibidas por el servicio de CEC del Hospital Universitario de La Princesa (Madrid, España) entre el 1 de septiembre de 2019 y el 31 de agosto de 2021. Se analizaron variables demográficas, logísticas y éticas de los casos.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Se analizaron 63 casos, en los que se identificaron un total de 124 conflictos éticos. El 41% (n = 26) de las consultas eran de carácter urgente y el 38% (n = 24), preferentes. La evaluación inicial se realizó en menos de 24 horas en 50 casos (79%). El servicio que consultó con mayor frecuencia fue Medicina Intensiva (9; 14%). Los medios de contacto preferidos fueron el busca (36; 57%), el sistema electrónico de historia clínica (13; 21%) o la conversación directa con el equipo consultor (7; 11%). Los problemas éticos más comunes estaban relacionados con la adecuación de medidas terapéuticas (24; 19%), el rechazo del tratamiento (19; 15%), la comunicación con el paciente o su familia (29; 23%) o la competencia del paciente (13; 11%).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Los servicios de CEC proporcionan una asistencia rápida y eficiente para la resolución de problemas éticos en la práctica habitual. Su implementación en España es factible.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0230" class="elsevierStylePara elsevierViewall">The following is Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0075" ] ] ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 852 "Ancho" => 1670 "Tamanyo" => 75670 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evolution of the number of healthcare ethics committee (HEC) consultations before and after implementing the clinical ethics consultation (CEC) service.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Period prior to creation of the CEC service between 2014 and September 2019. Period following creation of the CEC service included in the analysis: September 2019 to September 2021.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In 2019, the HEC received 4 consultations between 1 January and 1 September (before the CEC service existed) and 8 consultations in the months following creation of the CEC service.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Reasons for consultation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n (%)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Withholding/withdrawing treatment measures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 (19.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Communication with family members \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 (16.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Treatment refusal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 (15.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 (15.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Competence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (10.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient communication \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (6.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Advance directives \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (4.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (4.0%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Communication between professionals \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (3.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Distributive justice \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (1.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Genetic counselling \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transplant \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Donation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">The percentages were established according to the total number of reasons for consultation (n = 124) and not the total number of cases (n = 63).</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Description of the ethical conflicts addressed by the clinical ethics consultation service.</p>" ] ] 2 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.docx" "ficheroTamanyo" => 19393 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Boletín Oficial de la Comunidad de Madrid. 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