Bioethics cardioteam useful for bedside crisis management.

Crisis is a point of progression of an illness at which either a tendency to improvement or to worsening is evident. Crises that happen later have a better prognosis.

Hippocrates (460-370 BC)

The physician, in good faith, assumes a civil and criminal liability when making ethical judgments for which he is sometimes ill equipped to make

Karen Williams Teel

Pediatrician who suggested boards to share responsibilities in the 70s

Preamble

Bedside crisis (BSC) is a high-stress incident in Medicine. Predicting the outcomes is difficult and short-term worsening probability is high[1-4].

Whether connected or not to malpractice, it usually represents frustrated hopes. It involves the health professional, patient, family, institution and the health system, in varying combinations.

In Cardiology, the symbolism of the heart, the social assumption of heart disease, the worrying levels of morbidity and mortality and the frequency of urgency and emergency exercise an "etiopathogenic" influence. Beliefs of inattention to the person, of technical limitation as denial of attention and malpractice in new unwanted beginnings point out to scenarios made up by fragmented case management and miscommunication[5,6].

The Need

Trust in the figure of the cardiologist of generations avoided expressions of criticism. However, profound social, cultural, economic and technological changes expose the current cardiologist to the lay judgment that he cannot control. The assessment of his commitment to the outcomes - intended, but not ensured - suffers the modeling effect of the cultures - not exclusively that culture in which we live - on experience of the disease. The biocultural model makes those with heart diseases, at a point in their lives and at a given level of diagnostic, therapeutic and prognostic expectation, to be represented in a multiple dimension that goes beyond the biomedical model underpinned by cellular processes[7] and covers physical and occupational functions, psychological state, social interaction and somatic sensation[8].

The observation of "logics" between the patient, the family, the payer, the institution and the health care system reinforces that integrity of character and the Hippocratic Oath are not enough for the cardiologist to be immune to "colonization of standoffs" at the bedside. That is why good communication, respect for preferences and values and interest in the well being of others are drivers of "human harmony" while the case is managed across updated charts of technical and scientific conduct.

It is a panorama where Bioethics presents itself as an instrument of safeguarding BSC "antigens". The intention is to help alerting to the (un)predictability of human nature and infrastructure, to help in the practical sense of prompt response and in the critical sense of conformity with legal ethics, morale and legality.

The stethoscope, the symbol of being a cardiologist, thus gains a partner for auscultation of any noise. The stethoscope at the traditional focuses of the chest and Bioethics at the focuses of grips and reversals of flows through the "circulation of warm blood" in the bedside environment.

The Proposal

In the USA, 81% of hospitals and 100% of those with at least 400 beds have Ethics Consultancies[5]. Many of them adopt the second edition (2011) of the Core Competencies for Health Care Ethics Consultation prepared by the American Society for Bioethics and Humanities.

The cardiologists need to spread this use of Bioethics in Brazil. Brazilian hospitals with Cardiology services and particularly those with training programs for young cardiologists have a moral commitment to give resolving and educational importance to BSC management underpinned by Bioethics, either due to the mishaps of dissatisfaction itself or due to the risks of a poorly structured response.

The human resource should not be restricted to a single consultant, since it would be insufficient because of the plurality of Cardiology performance. A committee is bureaucratic; a behavior that is averse to the resourcefulness required from cardiologists in general.

A Team has many advantages[3]. It embodies agility and stimulates enthusiasm and creativity. Each member is aware of their responsibilities and recognizes those of the others[9].

A Team works proactively or reactively, with more or less formality, even in a mere pre-appointment, but always dissociated from the technical and scientific conduct involved and sharing responsibilities[10].

The identity of the Time lies in the combination of leadership, assistance to the situation, mutual support and communication. Strength is generated in standards of concepts and methods based on Bioethics. Strong identity associates independence, pro-activity, reactivity, solidarity, neutrality, rather than authoritarianism, immediacy and troubleshooting ability.

It is encouraging for a cardiologist to have a Bioethics Cardioteam (BCT) to help identify-process-decide on conflicts and dilemmas when you feel turmoil in the complexity of the health care system-attention to a particular patient. As an example, a situation that combines heart failure, old age, and (no) free consent gathers the three most popular themes appreciated by an Ethics Consulting Team, namely: life terminality, (in)ability to make decisions and respect for autonomy[11].

Members should see themselves and be seen as part of the attention to the conflict. It is an assumption of the three-phase construction of reputation towards excellence[9]: a) portraying the existing culture, the history of crises and resources; b) planning strategies and supervised training; c) taking care of the mix of individual skills, organizational improvement and feedback to resolving and preventive aspects with an impact on the transformations of local culture.

Development of Bioethics Cardioteam

Interdisciplinarity

Diverse professional backgrounds are welcome: physician, nurse, psychologist, social worker, ombudsperson, physiotherapist, pharmacist, lawyer, philosopher, among others. They share or complement themselves to deliver three skills:

1. Evaluative skills: includes crisis identification and analysis skills and search for references in articles, guidelines and standards.

2. Procedural skills: covers the management of organizational facilities involving respect to documentation and use of procedural routines, scheduling meetings, assuming new directions and commissioning ad hoc consultants.

3. Interpersonal skills: employs empathic communication, nonviolent communication, promotes flow of communication among the stakeholders, compares moral views and gives acceptability to ethical and legal values.

The domain of anti-BSC expertise has been under international discussion[12,13]. Certification by a specialty Society or by a Graduate degree is attractive and should be aspired among us. However, it is a field that admits an informal case-by-case style under supervision in the good old classroom about bedside obligations and duties.

Through interdisciplinary exchange, the members develop a format of objectives, roles and methods that is different from what each one is used to in routine professional practice.

Availability of Time and Easy Commissioning

The BCT needs to be available. In addition to being an important factor of compliance, the promptness of the "here!" avoids hasty actions and reactions, essentially emotional ones, which impair resolution, lead to worsening of the crisis, encourage extremism and, moreover, jeopardize professional and institutional names either transiently or permanently.

The opportunity of commissioning, besides the classical in-person nature, offers ease of contact through information technology and telecommunication.

The subsequent follow-up is driven by the timing of usefulness. Some situations require a more immediate resolution (Jehovah's Witness patient in a surgical emergency of aortic dissection) and some situations require a slower process of analysis and negotiation (where the crux of the issue is difficult differential diagnosis due to atypical conditions).

Personal Attributes

The power and influence of the members must remain self-regulated. Their values ​​must not be authoritative and their steps need to be clearly recognized as guided by a combination of tolerance (understood as something that could be prevented in the field of opinion), patience (meaning tranquility and perseverance), compassion, humbleness and integrity[14].

Institutional Support

The institutional counterpart to the voluntary commitment of the BCT members is the commitment to supporting basic needs, including:

Independence of pressures derogatory of integrity;

Compensation of hours of work;

Fluid interaction with the Coordinator;

Easy access to literature;

Assistance to continuing education.

Education

The interaction of the BCT with those involved in a BSC, either directly or indirectly, the record of events and the outcomes and the profiles of those involved include educational corollaries and motivation to research:

Recognition of the appropriate time for commissioning;

Prudence before consulting;

Assimilation of procedural rationale;

Getting used to the usual steps;

Mastery of avoidance techniques;

Mastery of anticipation techniques;

Studies on ethical consultations[15] and the Brazilian experience in the Medical Councils indicate that the main pedagogical objective relating to items e) and f) is the good practice of oral and written communication.

Making the Request the Most Understandable One

The pre-mobilization stage means the BCT making sure that the issue falls under the BSC concept[16].

Not infrequently, the cases involve a difficult differential diagnosis of the critical level of the standoff and raise an enlightening preliminary discussion from different perspectives by which failures in diagnosis, treatment, prevention and communication are analyzable.

Setting the Relevance

Good practices in Cardiology give proportionate responses to the severity of the clinical picture. Likewise, the BCT is mostly focused on conflicts where there is a clear threat to the patient's life.

Expanding Information and Filling Gaps

The movement is like the one of a boomerang. The problem stems from the bedside and it returns as a solution, ideally. The efficiency of the round-trip route cannot dispense with an independent confirmation or acquisition of sequences of relevant information.

Conciliating Systematization and Brevity

Short recommendations tend to be applied by the cardiology care staff upon urgency/emergency care to the patient with heart disease. However, when BCT members cannot fail to meet validated anti-BSC systematizations, not always resulting in immediacy, although they seek to speed up the solution as much as possible.

Integrating Ethics, Morale and Legality to the Consulting Process

The BCT must believe that it is acting impartially by strictly abiding by the provisions of laws, codes and standards. It is a neutral stance that admits neither moralizing judgments nor conflicts of interest, or hesitation to reshape the course of orientation, much less that there will always be an appropriate response.

Conclusion

Cardiology in Brazil expanded into primary and secondary prevention. Greater knowledge of events allowed greater control of risks in our multi-ethnic and multi-cultural population. Adjustments of habits lead preventive recommendations. It is not different vis-à-vis the potential dissatisfactions and conflicts.

The BCT reinforces the importance of the habit of combining empathy, reflection, professionalism and trust[17], the so-called Narrative Skill that raises the level of cognitive, symbolic and affective understanding of verbal and nonverbal communication. Supervision and individuality of cases include conceptual propositions and contributes to the improvement of "know thyself and the other," which gives meaning and value to the cardiologist's style in the bedside environment. In other words, it helps building the memory on the steps experienced by the cardiologist, which is effective for the good quality of the bedside "ecology" that reduces the risk of BSC[17,18].