Suchergebnisse

En el año 2012 en Colombia, aproximadamente 104 personas fallecieron cada día por enfermedad oncológica y 196 personas enfermaron de cáncer (1). Para el año 2015 se desarrolló el protocolo para la aplicación de procedimiento de eutanasia, donde se generan resoluciones y decretos juntos con la despenalización de la eutanasia a partir de la sentencia T-970 de la Corte Constitucional (2). Es de nuestro interés caracterizar los grupos poblacionales con diagnóstico de enfermedad oncológica en fase terminal que solicitan y reiteran eutanasia, con el objetivo de determinar las características del tipo de personalidad, y el entorno psicosocial del cual hace parte este individuo que permitiría como unidad de cuidados paliativos mejorar la prestación de servicios frente a los pacientes en el final de la vida: Métodos: Estudio observacional descriptivo. Resultados: Los pacientes oncológicos evaluados presentaron una mediana de edad de 60 años, donde el 75% de los pacientes fueron hombres con estadios terminal de la enfermedad. Las causas de negación de eutanasia fueron en el 100% por trastornos afectivos. La causa reiterada de solicitud de eutanasia por los pacientes fue por dolor y disnea. El 50% presentaron personalidad tipo A y el 50% restante personalidad tipo B. Conclusiones: La causa reiterada de solicitud de eutanasia en pacientes oncológicos con estadio terminal de la enfermedad, con mediana de edad de 60 años, generalmente es por dolor y disnea refractarios al tratamiento paliativo ofrecido por el equipo multidisciplinario. ; Introduction: in 2012 in Colombia, approximately 104 people died every day from oncological disease and 196 people became ill from cancer (1). For the year 2015, the protocol for the application of the euthanasia procedure was developed, where resolutions and decrees are generated together with the decriminalization of euthanasia based on the ruling T-970 of the Constitutional Court (2). It is in our interest to characterize the population groups with a diagnosis of terminal oncological disease that request and repeat euthanasia, to determine the characteristics of the personality type, and the psychosocial environment of which this individual is a part, which would allow as a care unit Palliative improve service delivery to patients at the end of life. Methods: cross sectional study. Results: The oncology patients evaluated had a median age of 60 years, where 75% of the patients were men with terminal stages of the disease. The reasons for denial of euthanasia were 100% due to affective disorders. The repeated cause of request for euthanasia by patients was pain and dyspnea. 50% had to type A personality and the remaining 50% had type B personality. Conclusions: The repeated cause of request for euthanasia in cancer patients with the terminal stage of the disease, with a median age of 60 years, is generally due to refractory pain and dyspnea to palliative treatment offered by the multidisciplinary team. ; Grupo de investigación Méderi, Dolor y cuidados Paliativos

Euthanasia has been leading the debate about the end of life, lately. The "right to a dignified death" is proposed; however, "dying" does not constitute a right in itself and dignity is an attribute of all human life. For its part, Psychiatry has been concerned during the last century with preparing documents, such as, the Hawaii Declaration (1977) and the Madrid Declaration (1996) to ethically regulate the practice of the profession. Surprisingly, countries like the Netherlands and, recently, Spain approve euthanasia in their legislation, at the risk of falling into the "slippery slope" phenomenon and losing control. As a solution, palliative care seeks the dignified treatment of the person who is about to die. ; Últimamente, la eutanasia ha encabezado el debate del final de la vida. Se plantea el "derecho a una muerte digna"; sin embargo, "morir" no constituye un derecho en sí mismo y la dignidad es un atributo de toda vida humana. Por su parte, la Psiquiatría se ha ocupado durante el último siglo de elaborar documentos, como la Declaración de Hawái (1977) y la Declaración de Madrid (1996) para regular éticamente el ejercicio de la profesión. Sorprendentemente, países como Holanda y, recientemente, España aprueban la eutanasia en su legislación, con el riesgo de caer en el fenómeno "pendiente resbaladiza" y llegar a perder el control. Como solución, los cuidados paliativos procuran el trato digno de la persona próxima a morir.

• A partir del análisis etnográfico del proceso de implementación de un proyecto que proponía la conformación de un coro de ensambles vocales de personas en situación de calle, indago en este artículo la ruptura que este proyecto propuso respecto del clásico esquema de asistencia paliativa que caracteriza al circuito asistencial en el que se ubican las políticas sociales dirigidas a la atención de la situación de calle en la Ciudad de Buenos Aires. Este proyecto, lejos de apuntar a la ayuda material en la supervivencia, otorgó una opción cultural que a partir del placer (no de la necesidad) motivó la participación. Sin embargo, diferentes aspectos oscurecieron este logro imprevisto: desde la mirada de los agentes gubernamentales que lo implementaron, el Resumen proyecto no logró su objetivo de ser un nexo entre la calle marginal y el mercado laboral formal. Los técnicos asociaban a las personas en situación de calle con una identidad y una localización específica, como si estuvieran desvinculadas de la sociedad. Sin embargo los modos en que las personas vivieron, sintieron y percibieron esta política, nos permiten cuestionar la existencia de aquella desvinculación. Las diversas expectativas en torno al proyecto desnaturalizan miradas y representaciones asociadas a las personas en situación de calle, quienes en esta experiencia se apropiaron de un proyecto del que participaron activamente y defendieron en forma colectiva. • In this paper, taking as my starting point the ethnographic analysis of the process of implementing a project proposing the formation of a choir of vocal ensembles for the homeless, I investigate the break this project brought about with the classic set-up of palliative treatment commonly used by the caring network, embracing the social policies addressing care issues for the homeless in the City of Buenos Aires. Far from addressing material aid with regard to survival, instead this project offered a cultural option, which encouraged people to take part out of pleasure (rather than out of need). Nevertheless, various aspects contrived to obscure this unexpected outcome: In the eyes of the government agents who brought it into being, the project did not achieve its aim of serving as a bridge between the city's down and outs and the formal labour market. The technicians associated the homeless with a specific location and identity, as if they were cut off from society. However, the ways in which these people lived, felt and perceived this policy enables us to question whether these ties were in fact really severed. The various expectations revolving around the project distort the views and representations associated with the homeless, who, in this experiment, embraced a project in which they played an active part and which they defended as a group.

Objectives Determining the cost-effectiveness of enzyme replacement therapy (ERT) for the classical infantile form of Pompe disease (complete acid α-glucosidase defi ciency-related) in two different settings: England and Colombia. Pompe disease is very rare (1:40,000 births incidence). Methods A literature review was made and historic databases searched for National Health Service (NHS) reimbursed costs in England and by health insurers in Colombia; expert opinion was elicited. Two Markov models were constructed for comparing both countries; alive with symptoms and dead were the transition states used. Patients aged ≤ 6 months receiving ERT were assumed to have 75 % survival rate and better health-related quality of life (HR-QoL) compared to those without treatment (0.700 HR- QoL using the EQ-5D scale). Results The incremental cost-effectiveness ratio (ICER) per quality-adjusted life year (QALY) gained was £234,307.7 for England and £109,991 for Colombia. Uncertainty about fi nal HR-QoL with ERT, disease progression and cost from palliative care had the biggest impact on the ICER in both models. If ERT costs were reduced to 10,000 times per dose and HR-QoL was 0.750-0.820 ICER, then £165,000 could be attainable for England and £65,000 for Colombia. Transaction costs per case in Colombia were high. Conclusions ERT was more effective than no ERT in treating infantile Pompe disease, but high levels of uncertainty still remain about survival and progression rates and QoL in the long-run. ICERs were high compared to CE thresholds. Manufacturers' ERT costs and monopoly had a major impact on fi nal CEA results.

Altres ajuts: This project was funded by a grant from the Catalan Government Health Service (SLT/682/2012). ; Altres ajuts: MSCBS/EC11-313 ; Objective: To assess the monetary savings resulting from a pharmacist intervention on the appropriateness of prescribed drugs in community-dwelling polymedicated (≥8 drugs) elderly people (≥70 years). Method: An evaluation of pharmaceutical expenditure reduction was performed within a randomised, multicentre clinical trial. The study intervention consisted of a pharmacist evaluation of all drugs prescribed to each patient using the "Good Palliative-Geriatric Practice" algorithm and the "Screening Tool of Older Persons Prescriptions/Screening Tool to Alert doctors to Right Treatment" criteria (STOPP/START). The control group followed the routine standard of care. A time horizon of one year was considered and cost elements included human resources and drug expenditure. Results: 490 patients (245 in each group) were analysed. Both groups experienced a decrease in drug expenditure 12 months after the study started, but this decrease was significantly higher in the intervention group than in the control group (−14.3% vs. − 7.7%; p = 0.041). Total annual drug expenditure decreased 233.75 €/patient (95% confidence interval [95%CI]: 169.83-297.67) in the intervention group and 169.40 €/patient (95%CI: 103.37-235.43) in the control group over a one-year period, indicating that 64.30 € would be the drug expenditure savings per patient a year attributable to the study intervention. The estimated return per Euro invested in the programme would be 2.38 € per patient a year on average. Conclusions: The study intervention is a cost-effective alternative to standard care that could generate a positive return of investment.

L'articolo analizza la sentenza n. 242/2019 della Corte costituzionale, che ha riscritto l'art. 580 c.p., con una sentenza manipolativa e additiva molto dettagliata. L'aiuto al suicidio resta reato, ma non è più punibile colui che agevola l'esecuzione del proposito suicida nei casi in cui l'aspirante suicida si trova in alcune condizioni, verificate da strutture pubbliche del sistema sanitario nazionale e dai comitati etici territorialmente competenti. La sentenza, di carattere normativo derogatorio, viene criticata dall'Autrice in quanto apre una fessura nelle garanzie poste a tutela della vita, nonostante la stessa Corte lo definisca primo dei diritti inviolabili e presupposto per l'esercizio di tutti gli altri diritti; la sentenza si basa poi sul discutibile presupposto che rifiutare trattamenti sanitari equivalga al procurare intenzionalmente la morte, oltre che sull'idea che l'aiuto al suicidio possa qualificarsi trattamento sanitario, in disaccordo con l'opinione delle società mediche scientifiche. Tuttavia l'A. considera apprezzabile che la Corte abbia chiarito che dal diritto alla vita discende il dovere dello Stato di tutelare la vita e non quello di riconoscere un aiuto a morire; e che, di conseguenza, non sussiste alcun dovere dei medici di esaudire tali richieste. Altrettanto apprezzabili sono ritenute le affermazioni sulla priorità delle cure palliative, un pre-requisito di altre scelte, un aspetto del diritto fondamentale alla salute e un diritto umano riconosciuto universalmente, ben diverso da percorsi di "non punibilità". Positiva viene ritenuta anche la mancata accentuazione del concetto di dignità intesa in senso soggettivo, che aveva caratterizzato invece la precedente ordinanza della Corte cost. n. 207/2018. L'A. si interroga infine sui rischi legati ad una legge in materia, ritenuta non strettamente obbligatoria, per il fatto stesso che la Corte, dopo aver lasciato un anno al Parlamento per disciplinare il suicidio medicalmente assistito, abbia ritenuto di pronunciare questa sentenza per rimuovere il vulnus costituzionale. Infine, l'A. osserva come il dramma causato dal Coronavirus, qualche mese dopo, abbia messo in luce che il fondamento della medicina, in realtà, non è l'autonomia del paziente, la sua volontà e lo stesso consenso informato. Si è evidenziata in modo chiaro l'asimmetria tra il paziente e il medico. Lo stesso mito dell'autodeterminazione, come prospettiva in grado di interpretare l'intera realtà delle relazioni, è andato in crisi. Inoltre molti medici hanno dato la vita per continuare a curare i malati, certamente non per l'ideale rappresentato dal principio del consenso informato o dell'autonomia, ma per il motivo che il dovere del medico è «la protezione della vita, della salute fisica e mentale dell'uomo e il sollievo dalla sofferenza», in accordo con le previsioni di molti codici di deontologia medica nel mondo. L'ideologia della vita indegna di essere vissuta è apparsa meschina e distante dalla realtà. In effetti, il senso di umanità dell'opinione pubblica si è trasformato con apprensione per le vite in pericolo, anche quelle considerate "un po' indegne", e l'impegno eroico dei medici nei loro confronti è sembrato ammirevole e "giusto", a causa della comune dignità umana. ; The paper analyzes judgment no. 242/2019 of the Constitutional Court, which rewrote art. 580 of the Italian Criminal Code, by a very detailed manipulative and additive ruling, after the previous order n. 207/2018, by which the same Court gave Italian Parliament one year to amend the current legislation in the sense indicated (without the Parliament obeying). According to the judgment, aid to suicide remains a crime, but the person who facilitates the execution of the suicidal purpose is no longer punishable in cases where the suicidal aspirant is in certain conditions, verified by public structures of the national health system and by the territorially competent ethical committees. One of the conditions is that the person is kept alive by life-support treatments and suffering from an irreversible pathology, source of physical or psychological suffering which he or she considers intolerable. The sentence, which is a "legislative" and derogating rule, is criticized by the Author as it opens a gap in the guarantees placed to protect right to life, despite the fact that the Court defines it the most inviolable right and premise for the exercise of all other rights; the judgment is then based on the questionable assumption that refusing health treatments is the same as intentionally procuring death, as well as on the idea that suicide aid could be qualified as health treatment, in disagreement with the opinion of scientific medical societies. However, the Author considers appreciable that the Court has clarified that from the right to life derives the State's duty to protect life and not to recognize aid to die; and that, consequently, there is no duty of the doctors to grant these requests. Equally appreciable are the statements on the priority of palliative care, a pre-requisite for other choices, an aspect of the fundamental right to health, as well as a universally recognized human right, very different from "non-punishable" paths. The failure to accentuate the concept of dignity understood in a subjective sense, which had instead characterized the previous order n. 207/2018 of the Constitutional Court, is also considered positive. The Author wonders about the risks associated with a law on the matter, considered not strictly mandatory, for the very fact that the Court, after leaving a year to the Parliament to adopt a law on assisted medical suicide, decided to pronounce this judgment to remove the constitutional weak point (vulnus). Finally the Author notes how the drama caused by Coronavirus, a few months lather, has brought to light that the foundation of medicine, in reality, is not the patient's autonomy, his will and the same informed consent. The asymmetry between the patient and the doctor also became clear. The same myth of self-determination, as a perspective capable of interpreting the whole reality of relationships, has gone into crisis. Moreover many doctors gave their lives to assist the sick, certainly not for the ideal represented by the principle of informed consent or autonomy, but for the reason that doctor's duty is «the protection of life, physical and mental health of Man and relief from suffering», as stated by many Medical Code of Ethics in the world. The ideology of life unworthy of being lived appeared petty and distant from reality. In fact, the sense of humanity of public opinion turned with apprehension towards lives in danger, even those considered "a little unworthy", and the heroic commitment of the physicians to them seemed admirable and "just", because of the common human dignity.

The violence that women had been undergoing during centuries has been named as «domestic violence», «bad treatments/mistreatments» or «familiar violence». This way of naming joined to the concept that until now we have had about what is or is not violence, took us to a constraint and an out of focus vision of the problem; it has limited the violence to the physical violence, without taking into account other ways of materialization of the violence that women are suffering: economical, emotional, sexual, etc. that, without any doubt, have devastating consequences in their lives. Therefore, the actions taken until some years ago have been palliative and for their welfare without making an allowance for the complexity and implications of the violence that women are bearing. The effort made by feminist women supposed a grater knowledge and a new conceptualization of the violence: from a private problem it has turn into a public problem that requires an integral intervention, that not only should consider welfare aspects but also prevention, non tolerance, public awareness, legislative changes, etc., that needs the implication of the Estate and qualified professionals, the creation of resources in order to safeguard the integrity of the women and their daughters and sons —in case of be necessary—, and to make possible her later integration in a full citizenship. The Local Administration due to its proximity to the citizenship appears as the suitable space to create measures, develop strategies and mobilize necessary resources that will permit a more effective and coordinated intervention in aspects as prevention, security and welfare to the victims. ; La violencia que a lo largo de los siglos han venido padeciendo las mujeres ha sido nombrada como violencia doméstica, malos tratos o violencia familiar Esta forma de nombrar, junto con el concepto que hasta hace poco se ha tenido sobre qué es o no es violencia, ha llevado a una limitación y a una visión desenfocada del problema; ha acotado el término a la violencia física, obviando las otras manifestaciones de violencia que también sufren las mujeres y que tienen que ver con los aspectos económicos, emocionales o sexuales, con consecuencias devastadoras sobre sus vidas. De este modo, las intervenciones que se han venido realizando hasta hace unos años, han sido paliativas y asistenciales, sin un enfoque que contemplara la complejidad e implicaciones de la violencia que padecen las mujeres. El esfuerzo realizado por las mujeres feministas ha llevado a un mayor conocimiento de la violencia y a una nueva conceptualización; ha pasado de ser un problema privado para convertirse en un problema público que requiere de una intervención integral que contemple, además de los aspectos asistenciales, la prevención, la no tolerancia, la sensibilización, los cambios legislativos, etc., y que precisa de la implicación del estado y de profesionales cualificados, de la creación de los recursos necesarios para salvaguardar la integridad de las mujeres y de sus hijas e hijos, en los casos que sean necesario, y que contemple su posterior integración a una plena ciudadanía. La Administración Local, por su cercanía a la ciudadanía, se configura como el espacio idóneo en el que se pueden concretar medidas, desarrollar estrategias y movilizar los recursos necesarios que permitan una intervención más eficaz y coordinada en aspectos como la prevención, la seguridad y la asistencia a las víctimas.

La presente tesis doctoral, se lleva a cabo en Clínicas seleccionadas de la ciudad de Barranquilla, Colombia tales como: la Clínica La Asunción, Clínica Bonadona, Clínica San Martin, Clínica Murillo, consultorios de profesionales especialistas en cuidado paliativo y diez parroquias de la Arquidiócesis de Barranquilla, estas brindan atención a pacientes oncológicos en fase terminal. Es fundamental afirmar que también se trabajó en hogares de pacientes con los mismos criterios de inclusión para el cumplimiento de los objetivos de la investigación, cuarenta y cinco participantes participaron en el proyecto clasificados de la siguiente manera once pacientes, once familiares – cuidadores, once sacerdotes de la Arquidiócesis y doce profesionales de la salud, lo anterior se ejecutó en un período de diez meses. La revisión sistematizada de artículos científicos y libros, nos muestra la poca existencia de investigación sobre fase final de la enfermedad y también la escasez del mismo estudio desde un enfoque bioético y teológico, por lo tanto, se planteará la pregunta. ¿Cuáles son los factores asociados a la tensión entre beneficencia y autonomía que emerge en la práctica pastoral para enfrentar el sufrimiento del paciente oncológico en fase terminal? Reconociendo la autonomía, actitudes, conceptos de muerte, impacto de la enfermedad, entre otras razones, propone reflexionar sobre el enfermo oncológico, tratamientos clínicos, prácticas de profesionales de la salud, las prácticas pastorales y el gran impacto de la enfermedad en la familia y los puntos de vistas de la Eutanasia. El propósito es, identificar los factores que emergen en la tensión entre beneficencia y autonomía en práctica pastoral frente al sufrimiento, examinando prácticas discursivas y no discursivas de la población que participa en la investigación y que manifiestan algunos textos bíblicos y discursos bioéticos sobre el sufrimiento y eutanasia, considerando aportes críticos a las ciencias humanas, los discursos que se transmiten de generación en generación lo que Michael Foucault llama arqueología del saber. Reconociendo la noción de autonomía quebrada manejada por la bioética de Pelluchon, que definen la capacidad de los sujetos morales y políticos, se tendrá en cuenta para escoger su estilo de vida, comportamiento y valores, como también la definición de autonomía de Hanns kuns desde los textos: vida eterna y morir con dignidad. A nivel metodológico, se empleará desde un paradigma cualitativo, los datos son tomados de técnicas etnográficas, observación y entrevista a profundidad con pacientes, familiares o cuidadores, sacerdotes Capellanes y profesionales de la salud en el servicio al enfermo en fase terminal. Los datos descriptivos serán analizados e interpretados desde las principales categorías de la presente investigación, sin dejar de lado que la persona con un diagnostico oncológico y en fase terminal, al suponer la cercanía y el enfrentamiento con la muerte, atraviesan períodos en aspectos emocionales y existenciales, altamente críticos y desconcertantes para los que no se encuentran preparados. Finalmente, se pretende develar las tensiones entre los principios de beneficencia y autonomía al desmitificar la noción del sufrimiento manejada actualmente, permitiendo al paciente una perspectiva bioética, más adecuada del sufrimiento, siendo autónomo en sus decisiones finales. Lo que se espera en este trabajo desde la bioética con un tema teológico es acercarse más al paciente y reconocer su libertad para tomar decisiones. ; Doctor en Bioética ; Doctorado ; This doctoral thesis is carried out in selected clinics in the city of Barranquilla, Colombia such as: La Asunción Clinic, Bonadona Clinic, San Martin Clinic, Clínica Murillo, offices of professionals specialized in palliative care and ten parishes of the Archdiocese of Barranquilla, these provide care to oncological patients in terminal phase. It is essential to affirm that we also worked in patients' homes with the same inclusion criteria for the fulfillment of the research objectives, forty-five participants participated in the project classified as follows eleven patients, eleven relatives - caregivers, eleven priests of the Archdiocese and twelve health professionals, the above was executed in a period of This doctoral thesis is carried out in selected clinics in the city of Barranquilla, Colombia such as: La Asunción Clinic, Bonadona Clinic, San Martin Clinic, Clínica Murillo, offices of professionals specialized in palliative care and ten parishes of the Archdiocese of Barranquilla, these provide care to oncological patients in terminal phase. It is essential to affirm that we also worked in patients' homes with the same inclusion criteria for the fulfillment of the research objectives, forty-five participants participated in the project classified as follows eleven patients, eleven relatives - caregivers, eleven priests of the Archdiocese and twelve health professionals, the above was executed in a period of ten months. The systematic review of scientific articles and books shows us the scarcity of research on the final phase of the disease and also the scarcity of the same study from a bioethical and theological approach, therefore, the question will be raised. What are the factors associated with the tension between beneficence and autonomy that emerges in pastoral practice to face the suffering of terminal cancer patients? Recognizing autonomy, attitudes, concepts of death, impact of the disease, among other reasons, it proposes to reflect on the cancer patient, clinical treatments, practices of health professionals, pastoral practices and the great impact of the disease on the family and the views of Euthanasia. The purpose is to identify the factors that emerge in the tension between beneficence and autonomy in pastoral practice in the face of suffering, examining discursive and non-discursive practices of the population that participates in the research and that manifests some biblical texts and bioethical discourses on suffering and euthanasia, considering critical contributions to the human sciences, the discourses that are transmitted from generation to generation what Michael Foucault calls the archeology of knowledge. Recognizing the notion of broken autonomy managed by Pelluchon's bioethics, which define the capacity of moral and political subjects, it will be taken into account to choose their lifestyle, behavior and values, as well as the definition of autonomy of Hanns kuns from the texts: eternal life and dying with dignity. At a methodological level, it will be used from a qualitative paradigm, the data are taken from ethnographic techniques, observation and in-depth interviews with patients, relatives or caregivers, Chaplain priests and health professionals in the service of the terminally ill. The descriptive data will be analyzed and interpreted from the main categories of this research, without neglecting that the person with an oncological diagnosis and in terminal phase, by assuming the proximity and the confrontation with death, go through periods in emotional and existential aspects , highly critical and puzzling for those who are unprepared. Finally, the aim is to unveil the tensions between the principles of charity and autonomy by demystifying the notion of suffering currently managed, allowing the patient a bioethical perspective, more appropriate of suffering, being autonomous in their final decisions. What is expected in this work from bioethics with a theological theme is to get closer to the patient and recognize his freedom to make decisions.

Advanced Practice Nursing (APN) emerged as a response to the need for professionals capable of giving care to patients, thereby improving the quality of healthcare; the results obtained by implementing APNs in healthcare teams confirm that APNs can be implemented in the healthcare of patients of all ages and with varied health situations (1). Levels of development in APN are very diverse in distinct countries, in the legal aspect as well as in the roles that a nurse with this level of training can fulfill. The International Council of Nurses (ICN) counts around seventy countries as being preoccupied with introducing clear function for APNs (20); nonetheless, literature describes the main progress in this sense occurring in Canada, Australia, Ireland, Finland, the United Kingdom, and the United States, although in the last ten years significant advances have been identifies in Belgium, Germany, Switzerland, Thailand, Singapore, Korea, and Africa (3, 4). In Latin-American, progress in this initiative is embryonic: the role that a APN can fulfill has not been sufficiently disseminated and the implementation of this strategy has been limited by healthcare policies in many countries or by the opposition to APNs by professionals in other areas who are reacting to misinformation or to fear of usurpation of certain functions by APNs. However, in primary care, APNs have been incorporated into healthcare teams, and research shows positive results for the expansion of coverage and reduction of healthcare costs, in both rural areas and urban centers (1, 5). Thanks to these advances, in 2000 the ICN supported the creation of the International Nurse Practitioner/Advanced Practice Nursing Network (INP/APNN) with the objective of favoring dialogue, advancing the installation of APNs in the countries, facilitating the interchange of knowledge, determining the limits in the expansion of the role of nurses, and defining the guidelines for the formation of human resources at this level. Likewise, the World Health Organization and the Pan-American Health Organization (PAHO) have worked with universities and nursing associations in Latin America and the Caribbean to, through context analyses, propose implementation of APNs (5). During August 2018, the 10th Conference of the International Nursing Council convened in Rotterdam with the goal of exploring the role of APNs in the transformation of healthcare (6). With the participation of more than fifty countries, the council established a global panorama of the situation and of the challenges nursing faces as an active participant and agent for achieving universal health coverage. An important conclusion drawn from the event is the recognition given by all participating countries to APNs for allowing significant advancement of strategies for primary healthcare and the achievement of goals related with universal health coverage and sustainable development: the guarantee of a healthy life and the promotion of wellness for everyone at every age (4, 5). These propositions imply a process and the need for countries to work towards the expansion of nursing roles, which requires the promotion of a collective project that unites different sectors involved in the formation of human talent, on one hand, that the offering of health services on the other. Likewise, administrators of education and health policy along with associations involved in the nursing discipline need to contribute to the analyses of strategies for implementing a sustainable and efficient health system that allows universal access to health (1, 4, 7). In this context, APNs are understood to have undergone master or doctorate level training that develops scientific knowledge, clinical expertise, leadership, political formation, communicational capacity, and education for the patient, family, and community groups. Therefore, the professional is enabled to take ethical decisions, work autonomously, interact in intra- and interdisciplinary groups, and understand that ANP's work will be determined by the unique environment, healthcare structure, and legislation of different countries. In accord with Morán-Peña (8), the International Nursing Council states that APNs are characterized by an autonomous practice that allows the implementation of tools like: valuation, diagnostic reasoning, decision making for the handling of cases, plan development, implementation and evaluation of programs as part of consultation services, and being the first point of contact in the healthcare system. This implies that an ANP will have competencies to participate in the elaboration of public policy as well as on teams dedicated to care for individuals, families, groups, and communities in disease prevention, health promotion, treatment, recuperation, and palliative care (7, 9, 10). Consequently, working on the implementation of the EPA can possibly lead to transformation of healthcare systems in the clinical area, improvement in the access to primary healthcare, and in the design and development of investigation projects whose results can be applied in practice; in short, it would affect the quality and effectiveness of healthcare at different levels and allow the urgent and much needed evolution of healthcare systems (11). With this perspective, the fundamental question is whether sufficient political interest exist for the development of APN's roles, the definition of APN's limits, the adaption of the existing structure, the establishment of guidelines for educational programs, and the application of expert knowledge, among other aspects, in benefit of health coverage, healthcare quality, and the establishment of a sustainable healthcare system. ; Advanced Practice Nursing (APN) emerged as a response to the need for professionals capable of giving care to patients, thereby improving the quality of healthcare; the results obtained by implementing APNs in healthcare teams confirm that APNs can be implemented in the healthcare of patients of all ages and with varied health situations (1). Levels of development in APN are very diverse in distinct countries, in the legal aspect as well as in the roles that a nurse with this level of training can fulfill. The International Council of Nurses (ICN) counts around seventy countries as being preoccupied with introducing clear function for APNs (20); nonetheless, literature describes the main progress in this sense occurring in Canada, Australia, Ireland, Finland, the United Kingdom, and the United States, although in the last ten years significant advances have been identifies in Belgium, Germany, Switzerland, Thailand, Singapore, Korea, and Africa (3, 4). In Latin-American, progress in this initiative is embryonic: the role that a APN can fulfill has not been sufficiently disseminated and the implementation of this strategy has been limited by healthcare policies in many countries or by the opposition to APNs by professionals in other areas who are reacting to misinformation or to fear of usurpation of certain functions by APNs. However, in primary care, APNs have been incorporated into healthcare teams, and research shows positive results for the expansion of coverage and reduction of healthcare costs, in both rural areas and urban centers (1, 5). Thanks to these advances, in 2000 the ICN supported the creation of the International Nurse Practitioner/Advanced Practice Nursing Network (INP/APNN) with the objective of favoring dialogue, advancing the installation of APNs in the countries, facilitating the interchange of knowledge, determining the limits in the expansion of the role of nurses, and defining the guidelines for the formation of human resources at this level. Likewise, the World Health Organization and the Pan-American Health Organization (PAHO) have worked with universities and nursing associations in Latin America and the Caribbean to, through context analyses, propose implementation of APNs (5). During August 2018, the 10th Conference of the International Nursing Council convened in Rotterdam with the goal of exploring the role of APNs in the transformation of healthcare (6). With the participation of more than fifty countries, the council established a global panorama of the situation and of the challenges nursing faces as an active participant and agent for achieving universal health coverage. An important conclusion drawn from the event is the recognition given by all participating countries to APNs for allowing significant advancement of strategies for primary healthcare and the achievement of goals related with universal health coverage and sustainable development: the guarantee of a healthy life and the promotion of wellness for everyone at every age (4, 5). These propositions imply a process and the need for countries to work towards the expansion of nursing roles, which requires the promotion of a collective project that unites different sectors involved in the formation of human talent, on one hand, that the offering of health services on the other. Likewise, administrators of education and health policy along with associations involved in the nursing discipline need to contribute to the analyses of strategies for implementing a sustainable and efficient health system that allows universal access to health (1, 4, 7). In this context, APNs are understood to have undergone master or doctorate level training that develops scientific knowledge, clinical expertise, leadership, political formation, communicational capacity, and education for the patient, family, and community groups. Therefore, the professional is enabled to take ethical decisions, work autonomously, interact in intra- and interdisciplinary groups, and understand that ANP's work will be determined by the unique environment, healthcare structure, and legislation of different countries. In accord with Morán-Peña (8), the International Nursing Council states that APNs are characterized by an autonomous practice that allows the implementation of tools like: valuation, diagnostic reasoning, decision making for the handling of cases, plan development, implementation and evaluation of programs as part of consultation services, and being the first point of contact in the healthcare system. This implies that an ANP will have competencies to participate in the elaboration of public policy as well as on teams dedicated to care for individuals, families, groups, and communities in disease prevention, health promotion, treatment, recuperation, and palliative care (7, 9, 10). Consequently, working on the implementation of the EPA can possibly lead to transformation of healthcare systems in the clinical area, improvement in the access to primary healthcare, and in the design and development of investigation projects whose results can be applied in practice; in short, it would affect the quality and effectiveness of healthcare at different levels and allow the urgent and much needed evolution of healthcare systems (11). With this perspective, the fundamental question is whether sufficient political interest exist for the development of APN's roles, the definition of APN's limits, the adaption of the existing structure, the establishment of guidelines for educational programs, and the application of expert knowledge, among other aspects, in benefit of health coverage, healthcare quality, and the establishment of a sustainable healthcare system. ; Advanced Practice Nursing (APN) emerged as a response to the need for professionals capable of giving care to patients, thereby improving the quality of healthcare; the results obtained by implementing APNs in healthcare teams confirm that APNs can be implemented in the healthcare of patients of all ages and with varied health situations (1). Levels of development in APN are very diverse in distinct countries, in the legal aspect as well as in the roles that a nurse with this level of training can fulfill. The International Council of Nurses (ICN) counts around seventy countries as being preoccupied with introducing clear function for APNs (20); nonetheless, literature describes the main progress in this sense occurring in Canada, Australia, Ireland, Finland, the United Kingdom, and the United States, although in the last ten years significant advances have been identifies in Belgium, Germany, Switzerland, Thailand, Singapore, Korea, and Africa (3, 4). In Latin-American, progress in this initiative is embryonic: the role that a APN can fulfill has not been sufficiently disseminated and the implementation of this strategy has been limited by healthcare policies in many countries or by the opposition to APNs by professionals in other areas who are reacting to misinformation or to fear of usurpation of certain functions by APNs. However, in primary care, APNs have been incorporated into healthcare teams, and research shows positive results for the expansion of coverage and reduction of healthcare costs, in both rural areas and urban centers (1, 5). Thanks to these advances, in 2000 the ICN supported the creation of the International Nurse Practitioner/Advanced Practice Nursing Network (INP/APNN) with the objective of favoring dialogue, advancing the installation of APNs in the countries, facilitating the interchange of knowledge, determining the limits in the expansion of the role of nurses, and defining the guidelines for the formation of human resources at this level. Likewise, the World Health Organization and the Pan-American Health Organization (PAHO) have worked with universities and nursing associations in Latin America and the Caribbean to, through context analyses, propose implementation of APNs (5). During August 2018, the 10th Conference of the International Nursing Council convened in Rotterdam with the goal of exploring the role of APNs in the transformation of healthcare (6). With the participation of more than fifty countries, the council established a global panorama of the situation and of the challenges nursing faces as an active participant and agent for achieving universal health coverage. An important conclusion drawn from the event is the recognition given by all participating countries to APNs for allowing significant advancement of strategies for primary healthcare and the achievement of goals related with universal health coverage and sustainable development: the guarantee of a healthy life and the promotion of wellness for everyone at every age (4, 5). These propositions imply a process and the need for countries to work towards the expansion of nursing roles, which requires the promotion of a collective project that unites different sectors involved in the formation of human talent, on one hand, that the offering of health services on the other. Likewise, administrators of education and health policy along with associations involved in the nursing discipline need to contribute to the analyses of strategies for implementing a sustainable and efficient health system that allows universal access to health (1, 4, 7). In this context, APNs are understood to have undergone master or doctorate level training that develops scientific knowledge, clinical expertise, leadership, political formation, communicational capacity, and education for the patient, family, and community groups. Therefore, the professional is enabled to take ethical decisions, work autonomously, interact in intra- and interdisciplinary groups, and understand that ANP's work will be determined by the unique environment, healthcare structure, and legislation of different countries. In accord with Morán-Peña (8), the International Nursing Council states that APNs are characterized by an autonomous practice that allows the implementation of tools like: valuation, diagnostic reasoning, decision making for the handling of cases, plan development, implementation and evaluation of programs as part of consultation services, and being the first point of contact in the healthcare system. This implies that an ANP will have competencies to participate in the elaboration of public policy as well as on teams dedicated to care for individuals, families, groups, and communities in disease prevention, health promotion, treatment, recuperation, and palliative care (7, 9, 10). Consequently, working on the implementation of the EPA can possibly lead to transformation of healthcare systems in the clinical area, improvement in the access to primary healthcare, and in the design and development of investigation projects whose results can be applied in practice; in short, it would affect the quality and effectiveness of healthcare at different levels and allow the urgent and much needed evolution of healthcare systems (11). With this perspective, the fundamental question is whether sufficient political interest exist for the development of APN's roles, the definition of APN's limits, the adaption of the existing structure, the establishment of guidelines for educational programs, and the application of expert knowledge, among other aspects, in benefit of health coverage, healthcare quality, and the establishment of a sustainable healthcare system.

Advanced Practice Nursing (APN) emerged as a response to the need for professionals capable of giving care to patients, thereby improving the quality of healthcare; the results obtained by implementing APNs in healthcare teams confirm that APNs can be implemented in the healthcare of patients of all ages and with varied health situations (1). Levels of development in APN are very diverse in distinct countries, in the legal aspect as well as in the roles that a nurse with this level of training can fulfill. The International Council of Nurses (ICN) counts around seventy countries as being preoccupied with introducing clear function for APNs (20); nonetheless, literature describes the main progress in this sense occurring in Canada, Australia, Ireland, Finland, the United Kingdom, and the United States, although in the last ten years significant advances have been identifies in Belgium, Germany, Switzerland, Thailand, Singapore, Korea, and Africa (3, 4). In Latin-American, progress in this initiative is embryonic: the role that a APN can fulfill has not been sufficiently disseminated and the implementation of this strategy has been limited by healthcare policies in many countries or by the opposition to APNs by professionals in other areas who are reacting to misinformation or to fear of usurpation of certain functions by APNs. However, in primary care, APNs have been incorporated into healthcare teams, and research shows positive results for the expansion of coverage and reduction of healthcare costs, in both rural areas and urban centers (1, 5). Thanks to these advances, in 2000 the ICN supported the creation of the International Nurse Practitioner/Advanced Practice Nursing Network (INP/APNN) with the objective of favoring dialogue, advancing the installation of APNs in the countries, facilitating the interchange of knowledge, determining the limits in the expansion of the role of nurses, and defining the guidelines for the formation of human resources at this level. Likewise, the World Health Organization and the Pan-American Health Organization (PAHO) have worked with universities and nursing associations in Latin America and the Caribbean to, through context analyses, propose implementation of APNs (5). During August 2018, the 10th Conference of the International Nursing Council convened in Rotterdam with the goal of exploring the role of APNs in the transformation of healthcare (6). With the participation of more than fifty countries, the council established a global panorama of the situation and of the challenges nursing faces as an active participant and agent for achieving universal health coverage. An important conclusion drawn from the event is the recognition given by all participating countries to APNs for allowing significant advancement of strategies for primary healthcare and the achievement of goals related with universal health coverage and sustainable development: the guarantee of a healthy life and the promotion of wellness for everyone at every age (4, 5). These propositions imply a process and the need for countries to work towards the expansion of nursing roles, which requires the promotion of a collective project that unites different sectors involved in the formation of human talent, on one hand, that the offering of health services on the other. Likewise, administrators of education and health policy along with associations involved in the nursing discipline need to contribute to the analyses of strategies for implementing a sustainable and efficient health system that allows universal access to health (1, 4, 7). In this context, APNs are understood to have undergone master or doctorate level training that develops scientific knowledge, clinical expertise, leadership, political formation, communicational capacity, and education for the patient, family, and community groups. Therefore, the professional is enabled to take ethical decisions, work autonomously, interact in intra- and interdisciplinary groups, and understand that ANP's work will be determined by the unique environment, healthcare structure, and legislation of different countries. In accord with Morán-Peña (8), the International Nursing Council states that APNs are characterized by an autonomous practice that allows the implementation of tools like: valuation, diagnostic reasoning, decision making for the handling of cases, plan development, implementation and evaluation of programs as part of consultation services, and being the first point of contact in the healthcare system. This implies that an ANP will have competencies to participate in the elaboration of public policy as well as on teams dedicated to care for individuals, families, groups, and communities in disease prevention, health promotion, treatment, recuperation, and palliative care (7, 9, 10). Consequently, working on the implementation of the EPA can possibly lead to transformation of healthcare systems in the clinical area, improvement in the access to primary healthcare, and in the design and development of investigation projects whose results can be applied in practice; in short, it would affect the quality and effectiveness of healthcare at different levels and allow the urgent and much needed evolution of healthcare systems (11). With this perspective, the fundamental question is whether sufficient political interest exist for the development of APN's roles, the definition of APN's limits, the adaption of the existing structure, the establishment of guidelines for educational programs, and the application of expert knowledge, among other aspects, in benefit of health coverage, healthcare quality, and the establishment of a sustainable healthcare system.

La Bioética nos enseña que la medicina no solo debe comprometerse con la búsqueda del mayor beneficio para el paciente sino también a tener en cuenta sus intereses, respetando su identidad y su cultura, sin tratar de imponer opiniones de terceros, ya sean de carácter filosófico, moral, religioso o político. El considerable aumento en la expectativa de vida de nuestra población latinoamericana en los últimos 40 años y la creciente incidencia de enfermedades neurológicas que comprometen las funciones mentales como la enfermedad cerebrovascular y las demencias, han traído consigo la aparición de un nuevo e importante problema: ¿Cómo se deben tomar decisiones médicas en pacientes que han perdido la capacidad para tomar sus propias decisiones? El presente trabajo analiza los problemas bioéticos que surgen alrrededor de las decisiones médicas en sujetos con compromiso de sus funciones mentales o con deterioro cognitivo. Primero, en el MARCO DE ANTECEDENTES, se realiza una revisión de la literatura acerca de los problemas bioéticos encontrados en torno a las decisiones médicas en sujetos con compromiso de sus funciones mentales. Posteriormente, en el MARCO TEÓRICO CONCEPTUAL, se analizan los conceptos filosóficos relacionados (ser humano, persona, autonomía, dignidad humana y calidad de vida) con un enfoque al sujeto con compromiso de las funciones mentales, revisando las funciones mentales y su compromiso desde la medicina y la neurología, el proceso de toma de decisiones en medicina y su enfoque desde la neurociencia, así como también algunas propuestas de mejora actuales. Se revisa aquí también el abordaje bioético a la toma de decisiones en medicina, examinando este proceso desde varios aspectos bioéticos fundamentales y a través de los principales problemas que presentan estas decisiones en el sujeto con compromiso de sus funciones mentales al final de la vida, como la limitación del esfuerzo terapéutico, la eutanasia, el cuidado paliativo y la muerte digna, así como el abordaje actual que propone la medicina en estos casos, sus críticas y posibles alternativas desde una bioética integral. En tercer lugar, con el fin de intentar comprender mejor estos problemas, se realizó una investigación de tipo cualitativa interpretativa con enfoque de estudio de caso para explorar la percepción de los principales actores involucrados en el proceso, los médicos, mediante un trabajo de campo en un hospital general. En el MARCO METODOLÓGICO, se presenta en detalle el proceso metodológico empleado para el estudio, sus fundamentos, su diseño, la implementación del proceso y los aspectos éticos y bioéticos de la investigación. En el MARCO DE ANÁLISIS Y RESULTADOS se presenta el plan de análisis, el perfil de los médicos entrevistados y el análisis detallado de toda la información obtenida. Estos resultados se ilustran mediante un mapa conceptual que muestra una unidad hermenéutica con familias y categorías, las cuales se describen e interpretan a profundidad. La investigación realizada permitió establecer que existen factores relevantes que influyen en la toma de decisiones médicas en pacientes con compromiso de sus funciones mentales y que hay algunos problemas importantes en este contexto que fueron percibidos por los profesionales entrevistados. Algunos de estos factores se consideraron relevantes, ya que pueden influir marcadamente en la toma de decisiones médicas en estos pacientes. Entre ellos, fue notable la presencia del paternalismo médico. Finalmente, en CONCLUSIONES Y RECOMENDACIONES, se discuten los resultados a la luz de la investigación teórica efectuada y se comparan con hallazgos y conclusiones de estudios previos. Algunos de los factores encontrados en este estudio, que inciden en la toma de decisiones médicas en estos pacientes, se encontraron reportados en estudios previos, pero otros no. El proceso de toma de decisiones respecto al tratamiento médico en pacientes con compromiso de sus funciones mentales debe principalmente garantizar el respeto a la autonomía del paciente; este estudio demuestra que este es el núcleo fundamental del problema bioético en torno a las decisiones médicas en ellos. Se encontró que este problema bioético se origina tanto en factores dependientes de los profesionales de la salud y del sistema de salud, como en factores dependientes del propio paciente, de su familia y de la cultura. Se concluye que se deben promover medidas que permitan que las decisiones médicas se adhieran lo más posible a la voluntad del paciente, ya sea ésta obtenida por indagación a sus familiares o por conocimiento de las voluntades anticipadas. Es necesario crear espacios que permitan discutir las políticas existentes en el manejo de estos pacientes y buscar formas alternativas desde las cuales se puedan tomar decisiones en casos particulares, considerando una visión más holística del paciente. ; INTRODUCCIÓN _________________________________________________ 11 PLANTEAMIENTO DEL PROBLEMA, JUSTIFICACIÓN Y ALCANCES ______ 17 PROPÓSITO DEL ESTUDIO ________________________________________ 19 PRESUPUESTOS Y OBJETIVOS ____________________________________ 20 Objetivo General _____________________________________________________ 20 Objetivos Específicos _________________________________________________ 20 1. MARCO DE ANTECEDENTES ____________________________________ 21 1.1. ACERCA DE FACTORES NO MÉDICOS QUE INFLUYEN EN LA TOMA DE DECISIONES MÉDICAS _______________________________________________ 21 1.2. ACERCA DE LA TOMA DE DECISIONES MÉDICAS EN SUJETOS DE EDAD AVANZADA _________________________________________________________ 25 1.3. ACERCA DE LA TOMA DE DECISIONES MÉDICAS EN SUJETOS CON COMPROMISO DE SUS FUNCIONES MENTALES __________________________ 27 1.3.1. La Evaluación de la capacidad del paciente para tomar sus propias decisiones ___ 28 1.4. ACERCA DE LAS DECISIONES MÉDICAS CUANDO SE CONOCEN LAS PREFERENCIAS PREVIAS DEL PACIENTE _______________________________ 31 1.5. ACERCA DE LA INTERVENCIÓN DE LA FAMILIA EN LA TOMA DE DECISIONES MÉDICAS EN SUJETOS NO COMPETENTES __________________ 32 1.6. ACERCA DE LA PERCEPCIÓN DE LOS PROFESIONALES DE LA SALUD SOBRE LA TOMA DE DECISIONES MÉDICAS EN SUJETOS CON COMPROMISO DE SUS FUNCIONES MENTALES _______________________________________ 33 1.7. ACERCA DE LA ENSEÑANZA DE LA TOMA DE DECISIONES ÉTICAS EN MEDICINA __________________________________________________________ 34 1.8. ACERCA DE LA LEY EN LAS DECISIONES MÉDICAS EN PACIENTES CON COMPROMISO DE SUS FUNCIONES MENTALES __________________________ 38 1.8.1. La protección a la autonomía y a la discapacidad __________________________ 38 1.8.2. El Decálogo de los derechos de los pacientes de 1991 ______________________ 42 1.8.3. El consentimiento informado ___________________________________________ 43 1.8.4. Las voluntades anticipadas ____________________________________________ 45 2. MARCO TEÓRICO CONCEPTUAL _______________________________ 49 2.1. LOS CONCEPTOS DE SER HUMANO, PERSONA, AUTONOMÍA, DIGNIDAD HUMANA Y CALIDAD DE VIDA _________________________________________ 49 2.1.1. Los conceptos de ser humano y persona _________________________________ 49 2.1.2. El concepto de autonomía ____________________________________________ 52 2.1.3. Autonomía y Dignidad ________________________________________________ 53 2.1.4. La dignidad desde otras perspectivas ____________________________________ 55 2.1.5. El concepto de Calidad de vida _________________________________________ 57 2.2. LAS FUNCIONES MENTALES Y SU COMPROMISO ___________________ 59 2.2.1. El sujeto con compromiso de sus funciones mentales _______________________ 61 2.2.2. La vulnerabilidad ____________________________________________________ 61 2.2.3. La irreversibilidad ___________________________________________________ 62 2.3. EL ABORDAJE DEL PACIENTE EN MEDICINA _______________________ 63 2.3.1. El modelo médico tradicional __________________________________________ 63 2.3.2. La propuesta holística al abordaje del paciente ____________________________ 68 2.3.3. El abordaje holístico al paciente con compromiso de sus funciones mentales ____ 69 2.3.4. El abordaje al paciente neurológico desde la perspectiva de Oliver Sacks _______ 73 2.4. LA TOMA DE DECISIONES _______________________________________ 77 2.4.1. El proceso de Toma de decisiones desde la Neurociencia ___________________ 79 2.4.2. Las emociones y la toma de decisiones __________________________________ 79 2.4.3. Neurobiología de la toma de decisiones __________________________________ 81 2.4.4. Las decisiones morales _______________________________________________ 84 2.4.5. La toma de decisiones en medicina _____________________________________ 85 2.5. LA BIOÉTICA Y EL PROCESO DE TOMA DE DECISIONES MÉDICAS ____ 88 2.5.1. Ética, Bioética y Neuroética ___________________________________________ 88 2.5.2. Problema y Dilema Bioético ___________________________________________ 90 2.5.3. La ética hipocrática __________________________________________________ 90 2.5.4. Los principios bioéticos _______________________________________________ 91 2.5.5. El cambio de paradigma en bioética _____________________________________ 94 2.5.6. Los comités de bioética clínico-asistenciales ______________________________ 96 2.5.7. Problemas bioéticos más importantes asociados a la toma de decisiones médicas en sujetos no competentes _____________________________________________________ 96 3. MARCO METODOLÓGICO ____________________________________ 107 3.1. DISEÑO METODOLÓGICO DEL ESTUDIO DE CAMPO _______________ 109 3.2. LUGAR DEL ESTUDIO __________________________________________ 109 3.3. DESCRIPCION Y SELECCIÓN DE LOS SUJETOS PARTICIPANTES ____ 110 3.4. TÉCNICAS DE RECOLECCIÓN DE LA INFORMACIÓN _______________ 111 3.4.1. La observación ____________________________________________________ 111 3.4.2. Entrevista semiestructurada __________________________________________ 112 3.4.3. Recolección de la información ________________________________________ 117 3.5. CONSIDERACIONES ÉTICAS ____________________________________ 118 4. MARCO DE ANÁLISIS Y RESULTADOS _________________________ 119 4.1. PLAN DE ANÁLISIS ____________________________________________ 119 4.2. PERFIL DE LOS ENTREVISTADOS _______________________________ 119 4.3. PROCESAMIENTO DE LAS ENTREVISTAS ________________________ 121 4.4. ANÁLISIS DE LAS ENTREVISTAS ________________________________ 122 4.4.1. Mapa conceptual de la unidad hermenéutica _____________________________ 123 4.4.2. Primera familia: Relación e interacción entre actores involucrados ____________ 124 4.4.3. Segunda familia: Factores generadores de problemas _____________________ 133 4.4.4. Tercera familia: Factores relevantes en la toma de decisiones _______________ 146 5. DISCUSIÓN DE LOS RESULTADOS DE LA INVESTIGACIÓN DE CAMPO 162 6. CONCLUSIONES Y RECOMENDACIONES _______________________ 169 6.1. Acerca de los antecedentes revisados ____________________________ 169 6.2. Análisis conceptual ____________________________________________ 171 6.3. Análisis de los resultados de la investigación ______________________ 175 6.4. SIGNIFICACIÓN, APORTES Y LIMITACIONES ______________________ 177 7. ANEXOS ___________________________________________________ 178 7.1. ANEXO 1: CONSENTIMIENTO INFORMADO ________________________ 178 7.1.1. Explicación consentimiento informado __________________________________ 178 7.1.2. Hoja de Consentimiento informado para el profesional _____________________ 180 REFERENCIAS BIBLIOGRAFICAS _________________________________ 181 ; Bioethics teaches us that medicine must not only commit itself to the search for the greatest benefit for the patient but also to take into account their interests, respecting their identity and culture, without trying to impose the opinions of third parties, whether of a philosophical nature, moral, religious or political. The considerable increase in the life expectancy of our Latin American population in the last 40 years and the increasing incidence of neurological diseases that compromise mental functions such as cerebrovascular disease and dementias, have brought with it the appearance of a new and important problem: ¿¿ How should medical decisions be made in patients who have lost the ability to make their own decisions? The present work analyzes the bioethical problems that arise around medical decisions in subjects with compromised mental functions or cognitive impairment. First, in the BACKGROUND FRAMEWORK, a review of the literature is carried out on the bioethical problems found around medical decisions in subjects with compromised mental functions. Subsequently, in the CONCEPTUAL THEORETICAL FRAMEWORK, the related philosophical concepts (human being, person, autonomy, human dignity and quality of life) are analyzed with a focus on the subject with commitment to mental functions, reviewing mental functions and their commitment from the medicine and neurology, the decision-making process in medicine and its approach from neuroscience, as well as some current proposals for improvement. The bioethical approach to decision-making in medicine is also reviewed here, examining this process from several fundamental bioethical aspects and through the main problems that these decisions present in the subject with compromise of their mental functions at the end of life, such as limitation of the therapeutic effort, euthanasia, palliative care and dignified death, as well as the current approach proposed by medicine in these cases, its criticisms and possible alternatives from a comprehensive bioethics. Thirdly, in order to better understand these problems, a qualitative interpretive research was carried out with a case study approach to explore the perception of the main actors involved in the process, the doctors, through field work in a general hospital. In the METHODOLOGICAL FRAMEWORK, the methodological process used for the study, its foundations, its design, the implementation of the process and the ethical and bioethical aspects of the research are presented in detail. The ANALYSIS AND RESULTS FRAMEWORK presents the analysis plan, the profile of the doctors interviewed and the detailed analysis of all the information obtained. These results are illustrated by a conceptual map that shows a hermeneutical unit with families and categories, which are described and interpreted in depth. The research carried out allowed to establish that there are relevant factors that influence medical decision-making in patients with compromised mental functions and that there are some important problems in this context that were perceived by the professionals interviewed. Some of these factors were considered relevant, since they can strongly influence medical decision-making in these patients. Among them, the presence of medical paternalism was notable. Finally, in CONCLUSIONS AND RECOMMENDATIONS, the results are discussed in light of the theoretical research carried out and compared with the findings and conclusions of previous studies. Some of the factors found in this study, which influence medical decision-making in these patients, were reported in previous studies, but others were not. The decision-making process regarding medical treatment in patients with compromised mental functions must mainly guarantee respect for the patient's autonomy; This study shows that this is the fundamental nucleus of the bioethical problem around medical decisions in them. It was found that this bioethical problem originates both in factors dependent on health professionals and the health system, as well as in factors dependent on the patient herself, her family and culture. It is concluded that measures should be promoted that allow medical decisions to adhere as closely as possible to the will of the patient, whether it is obtained by inquiring their relatives or by knowledge of advance directives. It is necessary to create spaces that allow the discussion of existing policies in the management of these patients and seek alternative ways from which decisions can be made in particular cases, considering a more holistic view of the patient. ; Doctorado