Recenti progressi in medicina最新文献

Coping with the end of life decision making process in ICU, its complexity adds a challenge for the healthcare team: how to report in the medical record the events and reasoning that led to withholding or withdrawing treatments shifting from intensive to palliative care. Each healthcare team must select the best approach for managing the decision-making process and the necessary rules to ensure a correct clinical history narrative, indicating who must write and what has to be written. Taking into account the team organization, the report may be written not necessarily by the ICU director, but also by a staff physician as a spokesperson in the individual case. Regardless of the variability of each case, four points must be necessarily recorded recalling them with the first four letters of the alphabet (A, B, C, D) for an easier memorization: A= Anamnesis (clinical summary); B= Balancing (remodulation of care); C= Collegiality (sharing of decisions); D= Dialogue (conversation with the patient and/or family members).

A 28-year-old woman was diagnosed with high-risk triple-expressor diffuse large B-cell lymphoma (DLBCL) (stage IV, IPI 4, CNS-IPI 5), with lymph node and extranodal involvement. The patient underwent first-line R-CHOP treatment, achieving a partial response with residual mediastinal uptake. A second-line platinum-based therapy with a transplant plan followed, resulting in stable disease; thus, she was considered refractory and started third-line therapy with CAR-T cells, receiving additional chemotherapy as bridging therapy. CAR-T treatment was well tolerated but complicated by late, persistent grade 4 cytopenia for over 2 years post-treatment, with complete and lasting lymphoma remission. Repeated chemotherapy exposure may predispose to acute and chronic toxicities, including cytopenia after CAR-T. If evaluated in 2024, the patient would have been considered for early access to CAR-T therapy, potentially reducing toxicity risks and improving event-free survival compared to conventional therapy.

The commentary focuses on the requirements for access to medical assistance in dying in countries where this practice is legal. It shows that the different solutions adopted reflect a different balance between the principles of protection of life, reduction of suffering and respect for autonomy. The article also analyses the potential ethical problems associated with the decision-making capacity of psychiatric patients. It emphasizes the need to assess the capacity on a case-by-case basis, without a priori excluding those suffering from mental disorders. It then examines the nature of existential suffering as a potential single condition for access to medical assistance in dying, highlighting its relevant ethical and social implications.

Deciding what type of health professional to be: the postural profile that is assumed in the care relationship is born from this challenge. These postures have a profound impact on the way in which care for the patient and end-of-life decisions will be developed. Broadly speaking, we can distinguish five macro postural profiles: the scientistic posture (the natural sciences are the only guide for the professional); the vitalist posture (the goal of saving the patient's life at all costs); the specialist posture (fragmentation of care managed by multiple specialists); the philanthropic posture (in which empathetic closeness to the patient prevails); the conversational posture (care "with" the patient, not "on" him). In light of this, it is essential to become aware of how you want to treat yourself and how you want to be treated, choosing, as far as possible, the appropriate travel companions.