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Background Prolonged support of organ functions without therapeutic benefit represents a serious problem of therapy in intensive care units (ICUs). This kind of treatment, called "futile therapy", prolongs the process of dying and should be avoided. In Poland, the guidelines and protocol defining the best clinical practice for the avoidance of futile therapy in ICUs was published in 2014. The aim of study was to analyse the protocols concerning futile therapy in the general ICU in the University Hospital in Wroclaw, Poland during the years 2015-2018. Methods The content of protocols was analysed. The protocols contained information on clinical problems, ethical and social aspects, data on communication with relatives, and therapeutic procedures regarded as futile and consequently withheld or withdrawn. Results During the study 1660 patients were treated in the ICU, of whom 557 patients died. Protocols regarding futile therapy were analysed in 146 patients. The diagnosis before starting the protocol was multiorgan failure (56%), permanent CNS injury (39%), respiratory failure (3%), and circulatory failure (2%). The withholding of therapeutic procedures was preferred, and the cases of withdrawal were rare. All patients with protocols died during hospital stay, 81.5% of them in the ICU. Conclusions The protocols concerning futile therapy were instituted in 1 in 10 patients treated in the ICU in Wroclaw, which comprised was nearly one-fifth of all ICU deaths. The withholding of futile therapeutic procedures was preferred in comparison to withdrawing. Communication with relatives was essential to the process of avoiding futile therapy.

ResumenLos cuidados intensivos pediátricos son una especialidad nueva, con importantes avances tecnológicos que pueden prolongar el proceso de morir. Uno de los problemas bioéticos frecuentes es la limitación del esfuerzo terapéutico, que es la adecuación y/o proporcionalidad del tratamiento tratando de evitar obstinación y futilidad.ObjetivoConocer la experiencia de médicos que trabajan en unidades de cuidado intensivo (UCIP) ante decisiones ético-clínicas.Sujetos y métodoEstudio observacional, descriptivo y transversal, aplicando una encuesta anónima a médicos de UCIP, solicitando datos sobre problemas éticos que se generan en la atención al niño crítico y su procedimiento de resolución. Aprobado por el Comité de Ética de la Investigación de la Facultad de Medicina de la Universidad del Desarrollo-Clínica Alemana.ResultadosRespondieron 126 médicos de 34 UCIP de Chile. El 98,41% ha tomado decisiones de limitación terapéutica. El tipo de limitación más frecuente mencionado fue la orden de no reanimar (n=119), seguido por la no instauración de medicamentos (n=113), limitación de ingreso a UCIP (n=81), siendo la menos mencionada la retirada de tratamientos (n=81). El 34,13% consideró que existían diferencias éticas entre no instaurar o retirar un determinado tratamiento.ConclusionesLos dilemas ético-clínicos son comunes en la UCIP, siendo frecuentes las decisiones de limitación terapéutica. Muchos médicos reconocen no poseer conocimientos en ética clínica y necesitar formación continua en bioética.AbstractPaediatric intensive care is a relatively new specialty, with significant technological advances that lead to the prolongation of the dying process. One of the most common bioethical problems is limitation of treatment, which is the adequacy and/or proportionality treatment, trying to avoid obstinacy and futility.ObjectiveTo determine the experience of physicians working in Paediatric Intensive Care Units (PICU) when faced with bioethical decisions.Subjects and methodAn observational, descriptive and cross-sectional study was conducted using an anonymous questionnaire sent to physicians working in PICU. The data requested was related to potential ethical problems generated in the care of the critical child, and the procedure for their resolution. The study was approved by the Ethics Research Committee of the Faculty of Medicine UDD CAS.ResultsA total of 126 completed questionnaires were received from physicians working in 34 PICU in Chile. Almost all (98.41%) of them acknowledged having taken therapeutic limitation decisions (TLD). The most common type of TLD mentioned was the Do Not Resuscitate order (n=119), followed by the establishment of no medications (n=113), limited admission to PICU (n=81), with the withdrawal of treatment being the least mentioned (n=81). Around one-third (34.13%) felt that there were no ethical difference between introducing or removing certain treatments.ConclusionsBioethical dilemmas are common in the PICU, with therapeutic limitation decisions being frequent. Many recognise not having expertise in clinical ethics, and they need continuing education in bioethics.

This study investigated how intensivists make decisions regarding withholding and withdrawing treatment for patients at the end of their lives. This involved completing in-depth interviews from two sites of the South of England, United Kingdom by twelve intensivists. The data collected by these intensivists were analysed using thematic analysis. This resulted in the identification of three themes: intensivists’ role, treatment effectiveness, and patients’ best interest. Transcending these were two overarching themes relating to the balance between quantity and quality of life, and the intensivists’ sense of responsibility versus burden. The results are considered in terms of making sense of death and the role of beliefs in the decision-making process.

A general rationale is presented for withholding and withdrawing medical treatment in end-of-life situations, and an argument is offered for the moral irrelevance of the distinction, both in the context of pharmaceutical treatments, such as chemotherapy in cancer, and in the context of life-sustaining treatments, such as the artificial ventilator in lateral amyotrophic sclerosis. It is argued that this practice is not equivalent to sanctioning voluntary active euthanasia and that it is not likely to favour it.

End-of-life decisions are made daily in intensive care units worldwide. There are numerous factors affecting these decisions, including geographical location as well as religion and attitudes of caregivers, patients, and families. There is a spectrum of end-of-life care options from full continued care, withholding treatment, withdrawing treatment, and active life-ending procedures.

Trabajo fin de grado. Defendido en febrero de 2014. Bibliografía: p. 102-105 (Según el contador de la aplicación) : Carpeta 1-4: CV Alumno ; Resumen indicativo ; Resumen informativo ; TFG El presente trabajo de fin de grado pretende analizar la nueva redacción del artículo 16 de la Ley del Impuesto sobre Sociedades (LIS) que introduce la Ley 36/2006, de Prevención del Fraude Fiscal, y su desarrollo reglamentario, y más concretamente, el apartado 8 del citado precepto, regulador del denominado ajuste secundario. Tras una introducción y unos comentarios sobre la metodología utilizada en la elaboración del presente trabajo, realizamos una exposición sobre la evolución normativa que ha sufrido el régimen de las operaciones vinculadas, desde los orígenes históricos de su normalización en el ámbito internacional hasta la regulación actual del art. 16 LIS en nuestro Derecho interno. Por supuesto, se analiza la primera regulación de las citadas operaciones vinculadas en el ámbito doméstico, ofrecida por la Ley del impuesto de 1978, pasando por la reforma del año 1995, hasta la redacción actual que introduce la nombrada Ley 36/2006, de Prevención del Fraude Fiscal. El desarrollo lo iniciamos con conceptos generales de la regulación: qué se entiende por valor normal de mercado, cuándo las entidades serán consideradas vinculadas, los distintos métodos de valoración regulados, la documentación obligatoria a mantener a disposición de la Administración tributaria y el régimen sancionador derivado del incumplimiento del mencionado precepto. Paralelamente analizamos el Derecho Mercantil, más concretamente el Derecho Contable, para conocer el tratamiento contable a dar a este tipo de operaciones en las que existe vinculación. Estudiamos el ámbito subjetivo y objetivo de la norma reguladora de las operaciones entre vinculadas, así como las diferencias, de existir, entre la valoración a valor razonable -valoración contable- y el valor normal de mercado -valoración fiscal-. Una vez analizada la regulación contable y tributaria de este tipo de operaciones nos centramos en el tema central objeto de estudio: el denominado ajuste secundario reconocido en el apartado octavo del precepto. Partimos del concepto de ajuste secundario y del objetivo que con el mismo se pretende alcanzar, que no es otro que calificar el desplazamiento patrimonial que la diferencia de valoración comporta bajo el supuesto de operaciones realizadas entre la entidad y sus socios (dividendos, liberalidades). [...] Llegados a este punto, antes de poder vertebrar las conclusiones sobre el estudio realizado sobre la normativa interna, consideramos que nos aportaría una visión más amplia el análisis de la regulación del régimen en el ámbito internacional tanto en el marco de la Unión Europea como en algunos países miembros de la OCDE. Por último, respecto a la metodología, hemos utilizado como fuentes teóricas, la propia normativa que regula este tipo de operaciones, artículos doctrinales, libros especializados, doctrina administrativa, así como la jurisprudencia emanada tanto de los tribunales nacionales como del Tribunal de Justicia de la Unión Europea. Ordenador con navegador de Internet ; Adobe Acrobat Reader 105 p. (Según el contador de la aplicación)

Introduction The objective of the present study was to evaluate the opinion of Portuguese intensive care physicians regarding 'do-not-resuscitate' (DNR) orders and decisions to withhold/withdraw treatment. Methods A questionnaire was sent to all physicians working on a full-time basis in all intensive care units (ICUs) registered with the Portuguese Intensive Care Society. Results A total of 266 questionnaires were sent and 175 (66%) were returned. Physicians from 79% of the ICUs participated. All participants stated that DNR orders are applied in their units, and 98.3% stated that decisions to withhold treatment and 95.4% stated that decisions to withdraw treatment are also applied. About three quarters indicated that only the medical group makes these decisions. Fewer than 15% of the responders stated that they involve nurses, 9% involve patients and fewer than 11% involve patients' relatives in end-of-life decisions. Physicians with more than 10 years of clinical experience more frequently indicated that they involve nurses in these decisions (P < 0.05), and agnostic/atheist doctors more frequently involve patients' relatives in decisions to withhold/withdraw treatment (P < 0.05). When asked about who they thought should be involved, more than 26% indicated nurses, more than 35% indicated the patient and more than 25% indicated patients' relatives. More experienced doctors more frequently felt that nurses should be involved (P < 0.05), and male doctors more frequently stated that patients' relatives should be involved in DNR orders (P < 0.05). When a decision to withdraw treatment is made, 76.8% of 151 respondents indicated that they would initiate palliative care; no respondent indicated that they would administer drugs to accelerate the expected outcome. Conclusion The probability of survival from the acute episode and patients' wishes were the most important criteria influencing end-of-life decisions. These decisions are made only by the medical group in most of the responding ICUs, with little input from nursing staff, patients, or patients' relatives, although many respondents expressed a wish to involve them more in this process. Sex, experience and religious beliefs of the respondents influences the way in which these decisions are made.

En este ensayo se analizan los efectos de la congestión de las líneas de transmisión de una red interconectada en la competencia en un mercado spot mayorista de generación, con producción hidro-térmica de electricidad, en un ambiente oligopólico. Se desarrolla un modelo de equilibrio dentro del enfoque Nash-Cournot., This essay analyzes the network-transmission lines congestion effects on the wholesale generation spot market competence, with a hydrothermal electricity production, and within an oligopolic environment. It develops a Nash-Cournot equilibrium model.

Background: Limitations of life-support interventions, by either withholding or withdrawing support, are integrated parts of intensive care unit (ICU) activities and are ethically acceptable. The end-of-life legal aspects and practices in United Arab Emirates ICUs are rarely mentioned in the medical literature. The objective of this study was to examine the current practice of limiting futile life-sustaining therapies in our ICU, modalities for implementing of these decisions, and documentations in dying critically ill patients. Materials and Methods: This was a retrospective observational study conducted at our ICU. We studied all ICU patients who died from September 2008 to February 2009. Patients’ baseline demo-graphics, past medical problems, diagnosis on admission to ICU, and decision to withhold, withdraw and their modalities were collected. Methods: This was a retrospective observational study conducted at our ICU. We studied all ICU patients who died from September 2008 to February 2009. Patients’ baseline demo-graphics, past medical problems, diagnosis on admission to ICU, and decision to withhold, withdraw and their modalities were collected. Results: The electronic medical records of 67 patients were reviewed. The commonest method of limiting therapy was no escalation 53.6%. Interventions were withheld in 41.5%. “Do not resuscitate” order was documented in only 16.3%. The commonest method of documenting limitation of therapy was discussion with the family and documenting the prognosis and futility of additional therapy (73.3%). Patients who died early (48 hrs) of ICU admission received terminal cardiopulmonary resuscitation more frequently (P < 0.007), had less frequent prognosis documentation (P < 0.009), and had more vasopressors administered (P < 0.006). Conclusion: Withholding therapy after discussion with the family was the preferred mode of limiting therapy in a dying patient.