title: New frontiers in the future of palliative care: real-world bioethical dilemmas and axiology of clinical practice.
abstract: BACKGROUND
  In our time there is growing interest in developing a systematic approach to oncologic patients and end-of-life care. An important goal within this domain is to identify the values and ethical norms that guide physicians' decisions and their recourse to technological aids to preserve life. Though crucial, this objective is not easy to achieve. The purpose of this study is to evaluate empirically the real-life bioethical dilemmas with which palliative physicians are confronted when treating terminal cancer patients.
  
  
  METHODS
  A quasi-experimental, observational, comparative, prospective and mixed (qualitative and quantitative) study was conducted in order to analyse the correlation between the palliative doctor-patient relationship and ethical judgments regarding everyday bioethical dilemmas that arise in palliative clinical practice. The values at stake in decision-making on a daily basis were also explored. From February 2012 to march 2014, palliative healthcare personnel were invited to participate in a research project on axiology of clinical practice in palliative medicine. Each participant answered to a set of survey instruments focusing on ethical dilemmas, views, and representations of clinical practice. For this analysis we selected a convenience sample of 30 physicians specialized in pain medicine and palliative care (algologists and palliativists), with two or more years of experience with oncologic patients and end-of-life care.
  
  
  RESULTS
  113 dilemmas were obtained, the most frequent of which were those regarding sedation, home administration of opioids, and institutional regulations. We observed that the ethical nucleus of palliative medicine is truth-telling, implying bidirectional trust between patients and healthcare providers. The two most prominent virtues among the participants in our study were justice and professional humility. The outstanding roles of the physician in palliative medicine are as educator and as adviser, followed by that of provider of medical assistance.
  
  
  CONCLUSIONS
  This investigation opens up new horizons in a career path where professional wearing is rampant. The rediscovery of values and virtues in palliative clinical practice will renew and replenish the motivation of healthcare providers who carry out these duties, giving them a new professional and personal perspective of growth.
authors.affiliation: Facultad de Medicina y Cirugía de la Universidad Autónoma Benito Juárez de Oaxaca, Oaxaca, Mexico. uriaguevara271@gmail.com.|Centro Interdisciplinario para el Estudio y Tratamiento del Dolor y Cuidados Paliativos del UMAE "Dr. Victorio de la Fuente Narvaez", México, DF, Mexico. uriaguevara271@gmail.com.|Grupo Transfuncional en Ética Clínica, Centro Médico Nacional Siglo XXI, IMSS, México, DF, Mexico. uriaguevara271@gmail.com.
authors.forename: Uría
authors.initials: U
authors.lastname: Guevara-López
authors.affiliation: Grupo Transfuncional en Ética Clínica, Centro Médico Nacional Siglo XXI, IMSS, México, DF, Mexico. myriamab@unam.mx.|Unidad de Investigación de Enfermedades Metabólicas, Centro Médico Nacional Siglo XXI, IMSS, México, DF, Mexico. myriamab@unam.mx.
authors.forename: Myriam M
authors.initials: MM
authors.lastname: Altamirano-Bustamante
authors.affiliation: Facultad de Medicina, UNAM, México, DF, Mexico. carlosviesca@yahoo.com.
authors.forename: Carlos
authors.initials: C
authors.lastname: Viesca-Treviño
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D026688:Bioethical Issues; D001675:Bioethics; D003657:Decision Making / Q000941:ethics*; D030881:Disclosure; D004992:Ethics, Medical; D005260:Female; D006801:Humans; D008297:Male; D009369:Neoplasms / Q000628:therapy*; D059408:Pain Management; D010166:Palliative Care / Q000941:ethics* / Q000639:trends; D010353:Patient Education as Topic; D010817:Physician-Patient Relations; D012935:Social Justice; D011795:Surveys and Questionnaires; D013727:Terminal Care / Q000941:ethics*; D035502:Trust; D028722:Virtues