Dr. Ferran Masanés: “We need to know how frail a patient is in order to correctly assess the level of therapeutic intensity to be applied in each case”

The Healthcare Ethics Committee is a consultative body that advises on possible ethical dilemmas in the healthcare setting during clinical practice.  It is a multidisciplinary committee made up of: doctors, nursing staff, social workers, philosophers and lawyers. It is an autonomous committee, separate from the hospital’s management.  

The Committee has a permanent committee that meets every 15 days, and we hold 3 plenary meeting each year.  We also hold extraordinary meetings when a specific issue needs to be assessed.  

Basically, our function is to advise on ethical dilemmas that arise during healthcare practice.  We also assess all donation procedures for living donor transplants.  In this regard, the committee acts as an advocate for the donor.  Above all, we focus on ensuring that the donor carries out this act altruistically and without any type of coercion.  

We often find ourselves in situations at both ends of life. In other words, on the one hand end-of-life processes:  and this mean making decisions about elderly patients or about very young patients at the start of their life: often, in relation to the application of assisted reproduction techniques - for example, embryo selection in specific cases. There are also other decisions about treatments that do not have sufficient scientific evidence or issues that are related to informed consent processes with patients who are to undergo surgery or have a diagnostic test.  We also carry out training activities for professionals inside and outside the hospital, and for residents in particular.

All committee members are required to have training or interest in ethical issues.  The Committee uses the deliberative method and applies the principles of bioethics.  I have been a member of the ethics committee for almost 20 years now, and we have never taken a vote to decide on a position.  We have always reached decisions by consensus.  The fact that the Committee is made up of different professional profiles makes it easier to reach decisions. For example, the philosophers’ viewpoint is very interesting, as they provide a very different perspective from the one we health professionals may have.  

No. It is true that in recent years some issues have led to more complex deliberations. However, when the final decision is made, we are convinced that what we have agreed on is best for both the patient and the institution.   I don’t remember there ever being any dissenting votes in the deliberative processes, for example.  

With regard to the application of the Euthanasia Law, since it was approved the Committee has been by the hospital management’s side to advise them on any necessary aspects and our role, above all, has been to carry out training activities. We also helped draw up the two internal protocols we have at the hospital to apply the Law with full guarantees.   My assessment of the implementation of the Euthanasia Law in the hospital is very positive.  There have been 10-12 patients who have asked to make use of the law.   

This issue is the one that has been most difficult for the Committee since I became a member. We spent several weeks assessing this project.  It is a very complex issue and its final approval was given jointly with the research ethics committee because what was approved was an application in the context of a research project.  Nevertheless, it is an issue that generates debate and, although we approved it by consensus, it was not an easy subject to assess.  The Healthcare Ethics Committee participated in this process in a more significant way, by evaluating the act of donating an organ from a living person.

The fact that the uterus transplant project had the approval of the Healthcare Ethics Committee and the Research Ethics Committee was one of the essential points that allowed it to go ahead. We assessed it and we approved it with conviction. If we had not approved it, it would not have been possible to carry it out.   

We shall continue to assess start- and end-of-life processes, for sure.  There are two issues that will give ethical committees more work in the future. These are issues related to gene therapies and to the application of artificial intelligence in healthcare.  

t is obviously a challenge.  However, despite the multidisciplinary nature of the Committee, we may find that members do not have a sufficiently good command of a subject to be able to give an advisory opinion.  In these cases, what we do is to invite experts in the given field to advise us and train us in certain aspects.  Once we have the tools required for making a decision, we deliberate on the Committee’s position. 

We must give the same excellence that we give in the care of illness to end-of-life care for our patients.  The Hospital decided to create the ‘End of life’ project as part of the Strategic Plan (NUCLI 2025), and the aim was to identify areas for improvement and to design specific measures to improve care in the end-of-life process. In the midst of the project’s development, the COVID-19 crisis broke out, and it led us to reflect on some of the aspects that might have been done better.   

Patient loneliness. In those patients whose death process is foreseeable, we must provide the best care possible. This involves improving the coordination between different levels of care, moving forward and coordinating ourselves better, trying to avoid these foreseeable deaths occurring in A&E and, if they do, ensuring that the patients’ family members have a private space—individual rooms— during this process.   

At the same time, we need to be able to correctly identify when a patient is in an end-of-life process. Among other things, that will allow the therapeutic effort to be adapted in line with the patient's situation.

It has changed radically. Thirty years ago, elderly people were treated in the internal medicine and geriatric wards. Now, geriatric patients are admitted to all wards. The population has aged a great deal and this group includes some very frail patients.  This means that the other professionals in the hospital—not just the geriatrics specialists—must be aware of the differential aspects of care for the elderly. It is an inescapable reality. This approach will allow us to have an understanding of these patients’ needs, which often go beyond the care of the patient and also include a social aspect.

Frailty is a health condition and not a specific illness. However, we must know how to detect it.  Age in itself should not limit our actions, but we must find a balance.  Therefore, we need to know how frail a patient is in order to correctly assess the level of diagnostic and therapeutic intensity to be applied in each case.   

At the start of my professional life, death affected me more. However, over the years I have come to understand that it is part of our healthcare work. Some cases affect you more than others, but we try to support the patient and their family as well as possible during this stage of life. 

The professionals starting out now are increasingly trained in this aspect. Before, we had no training on how to deal with the death of a patient.  In this respect, we are certainly better off than we were 30 years ago.