This study aims to carry out the cultural adaptation and the validation of the GOHAI scale for the Colombian population. Translation process, cultural adaptation, and content and face validity were carried out with a sample of 63 participants as a pretest. The validation counted with a sample of 7,200 subjects, divided into two groups: a work sample (WS) with 3,628 subjects and a confirmatory sample (CS) with 3,572 subjects. Construct, criterion validity and internal consistency were performed for both samples. Test-retest reliability was assessed with a sub-sample of 75 participantsp= 0.0001), while discriminant validity showed significant differences regarding groups according to age group, skin color, educational level, socio-economic level, healthcare affiliation and self-perception about need of dental prostheses. Gender groups did not show significant differences among groups within either sample. The CS showed similar results, differences existed among factorial structures of 2 and 3 factors, and for discriminant validity, the CS showed statistically significant differences for the Area variable not in the WS. Kendall’s test-retest analysis’s correlation is 0.85 (p= 0.0000).  The GOHAI showed an appropriate face and content validity, the pre-test revealed an understandable questionnaire, the scale showed a unidimensional factorial structure and a Cronbach’s Alpha of 0.8. Convergent validity with a self-perception on general health scale pointed to a significant correlation ( The GOHAI scale is valid and reliable enough to be used as a measure of Oral-Health-Related Quality of Life in the Colombian elderly population, also could be applied for other Latin-American populations. Quality of Life -QL has been defined as people’s individual perception of their position in life within the context of their culture and the systems of values they live with, and with regards to their goals, expectations and concerns. It is a broad concept which is impacted by a person’s physical health, psychological state, degree of independence, social relationships, personal beliefs and his/her relationship with the environment ,,The process of aging creates changes in the social scope, the sensorial perception, and the cognitive and motor functioning of some elderly people (EP) ,Based on demographic aging and the need of measuring self-perception on elderly people’s oral, multiple measuring scales have been developed through easy-to-approach questionnaires and appropriate predictors of some clinical conditions. These instruments or scales have been validated in several languages. Among the existing instruments, the scales of preference are the Oral Health Impact Proﬁle - OHIP, the Oral Impact on Daily Performances - OIDP, the Geriatric Oral Health Assessment Index - GOHAI, the Subjective Oral Health Status Indicators - SOHSI and the Dental Impact on Daily Living - DIDL ,The GOHAI scale has been employed in Colombia in elderly groups, and the validation process of this instrument has been done in elder population in several countries -The validation process was conceptually grounded in the framework exposed by Locker in 1988, which shows different effects on Quality of Life based on changes arising in the oral cavity. This model has been used to elaborate several instruments of oral Quality of Life, as well as previous validations of the GOHAI scale “Encuesta Salud, Bienestar y Envejecimiento”  - SABE Colombia 2015, a national survey which aims to gather information about the aging process among 60 years old and older Colombians. The survey had a field collection time of one year, between 2015-2016. The SABE survey, as well as the GOHAI scale validation study, were endorsed by the Universidad del Valle’s Ethics Committee (Cod. 083/014 and 093/015), and all participants signed an informed consent form. The survey respondents were 23,694 subjects, among them, 4,689 were excluded due to cognitive impairment identified by the Minimental Test. In total, 19,005 elderly people responded to the GOHAI scale. A pre-test of the GOHAI was tested among 63 participants The study was performed on the subjects participating in the The GOHAI scale is a self-reporting instrument made up by 3 dimensions that assess the physical function, the psychosocial function, pain and discomfort. The instrument consists of 12 questions replicated in a Likert scale that confers each answer a score ranging from 1 to 5; the options used by the scale being Always, Often, Sometimes, Seldom and Never. The total score corresponds to the whole sum of each question and deems the oral health as adequate when the score ranks between 57 and 60, moderate between 51 to 56 and low below or equal to 50. The questions corresponding to numerals 1, 2, 4, 6, 8, 9, 10, 11 and 12 exhibit Likert categories from 1 to 5, the others 3, 5 and 7 exhibit the Likert scale inversely The translation process was carried out by two translators external to the whole research process, who met the following criteria: competent in the study languages (English and Spanish), being acquainted or immersed in the culture where the validated scale would be applied and having basic training on health measuring; training understood as having some kind of prior experience on translating instruments or health-issued documents. The objective was to check for changes in the phrasing, semantic and idiomatic equivalency. Upon receiving the translation, an expert committee was formed by a professional on dentistry, doctor on public health, oral rehabilitator, epidemiologist, Master on Gerontology, Master on epidemiology. This committee performed some joint modifications to the initial version, and an adjusted version of the GOHAI instrument was obtained according to experts.The same translators provided a positive report in the face of the new version, which was the one tested at the pilot test and employed in the fullness of the SABE survey back translated the instrument again.It was carried out at three municipalities: Bogotá (Census code: 11001), Ubaté (Census code: 25843) and Soledad (Census code: 8758) to 63 elderly persons, these three were chosen because they are culturally diverse in the country and would help to understand the aspects to be dealt with in different regions. In addition, two are small towns and one the capital city, an important aspect when testing the instrument. 3-5 blocks were selected in each municipality and all the elderly who lived in the blocks were interviewed.The results showed that the questions were understood by interviewees and interviewers alike. Cronbach’s Alpha was 0.74, reflecting an acceptable internal consistency, on account of which the study was decided to be continued with that GOHAI version. It was decided to not perform factorial analysis at this stage due to an insufficient sample size. ,working sample (sample WS) and the confirmatory sample (sample CS).In studies validating a scale, the process that requires a larger sample is the factorial analysis. Some authors define their sample’s size based on the number of items in the scale to be validated; considering between 10 and 20 subjects per item as an appropriate alternative. Other authors recommend a sample size over 500 subjects as good and over 1,000 ones as excellent Both samples (WS and CS) were obtained randomly from the 18,863 subjects who responded the GOHAI scale, after eliminating duplicates, atypical data and GOHAI scores below 12 or above 60. Then, two samples (WS and CS), about 3,600 subjects each, were selected using proportional sampling fractions according to the gender, age-groups, and dwelling area  variables among the 18.863 subjects selected from the whole survey. All the analyses were performed in both samples, in this manner at the end of the study, it counted with a sample of 7,200 subjects, divided into two groups of approximately 3,600 subjects each one.The The following existing variables in the SABE Colombia Survey were used: age , gender , educational level (8 sub-groups), dwelling area , socioeconomic level , healthcare affiliation (5 sub-groups), self-perception about dental prostheses need (yes/no), overall oral health self-perception (three sub-groups) and skin color (three sub-groups), with the latter inquired using the pallet of colors from the PEARL in Latin-America project, which displays people’s face pigmentation as a proxy of ethnicity identification They were appraised through expert analysis by asking themselves if the GOHAI scale truly measures Quality of Life regarding Oral Health, and whether the contents integrate the constructs that would be affected upon the appearance of a favorable or unfavorable oral health condition.Kruskal-Wallis’ and Mann-Whitney’s tests were used to determine if significant differences existed between the samples in relation to the study variables.All analyses were carried out on working (WS) and confirmatory (CS) samples. After sampling based on frequency weights, according to the socio-demographic variables already described, work sample consisted of 3.628 registries and confirmatory sample of 3,572; response frequency for both samples and the GOHAI’s translated version are shown in the Internal consistency was assessed through Cronbach’s Alpha in order to measure homogeneity among items. Using the same interviewees, it was carried out another reliability aspect defined as stability measurement over time, by replicating the GOHAI scale on two different opportunities. 75 subjects were chosen to this part of the validation. The first application was done in the first visit to the elderly whit the application of the SABE survey, the second between 5 and 7 days after the first application. For the test re-test analysis Kendall’s correlation coefficient was used. The coefficient’s interpretation ranges between -1 and +1 pointing to negative or positive associations respectively, while zero (0) means no correlation. Bartlett's test for sphericity and the Kaiser-Meyer-Olkin’s measure of sampling adequacy ,With the purpose of determining the construct’s validity, and stablishing dimensions of variables to be identified, exploratory factorial analysis was used by means of oblique Promax rotation. Factor analysis assumptions were assessed by ,Upon being a self-reported scale on a personal construct, which has no gold standard, the GOHAI scale assesses its criteria validity through discriminant and convergence analysis. The discriminant aspect sheds lights on the scale’s ability to differentiate between groups where it must do so, and its inability to differentiate the groups where it must not; this was analyzed though the relationship between the GOHAI total score and socio-demographic variables such as area, age, skin color, educational level, socioeconomic level, healthcare affiliation, self-perception of oral prostheses need and gender. The relationship with the oral health self-perception assessment was used for convergent validity, which inquires how the target construct measured by the studied scale converges to or relates with other scales assessing similar constructs. Kruskal-Wallis’ or Mann-Whitney’s tests were utilized to stablish differences between medium-sized groups depending on the dichotomy or categorical nature of the variables; these tests have been widely used throughout GOHAI validation literature p >0.05) for all the variables age, gender, socioeconomic level, marital status, dwelling area, healthcare affiliation, educational level and skin color, that is, the characteristics among the two randomly selected samples were similar.Both WS and CS displayed similar characteristics; the Kruskal-Wallis’ and Mann-Whitney’s tests yielded no significant differences ; both indicating appropriate conditions in order to performing factorial analyses. The factorial structure suggested in both samples was two-factored, considering eigenvalues above 1.0. It is worth clarifying that for both WS and CF a third factor emerged very closely to an eigenvalue of 1.0: 0.96 for WS and 0.98 for CS. Thus, Promax-type rotations were performed for two- and three-factorial structures but the factorial loadings on the GOHAI items were different between both samples. In contrast, the one-factorial structure was consistent over both samples (WS and CS).Construct analysis for both WS and CS yielded a Kaiser-Meyer-Olkin’s measure above 0.85, which is considered as remarkable, and a significant Bartlett's test (p <0.05). Discriminant differences were not significant for gender (p >0.05); for dwelling area was not significant in WS (p >0.05), but it was significant in the CS (p <0.05). Discriminant validity for WS and CS yielded significant differences between the means of variables age, skin color, educational level, socioeconomic level, healthcare affiliation, and self-perception of prostheses need , construct validity and internal consistence on a quite representative Colombian population of 60 years old and more, aside from a reliability test-retest sub-sample sufficient enough to determine the test’s reliability.Likewise, two sub-samples were used in order to corroborate the validations analyses and results within the SABE Colombia study database.The construct’s validity based on eigenvalues suggested a two-factorial structure; however, Quality of Life in terms of oral health is shown as a single factor structure (i.e. a dimension). In the original version presenting the GOHAI scale Regarding the number of factors reported by other studies validating the GOHAI scale, the Spanish version In the current validation study, the structures displayed for scenarios of two and three factors are not consistent with the theoretical structure which underlies the GOHAI scale; verifying that participants do not discriminate between physical, pain-discomfort and psychosocial conceptual constructs, which could be explained by the interrelation of oral Quality of Life’s impact on each of these conceptual dimensions.The findings above would corroborate the lack of replicability of factorial structure’s of two and three factors between both samples (WS and CS), and supports the choice of a uni-factorial structure for the Colombian GOHAI, hence matching the original scale on a single dimension where Quality of Life within Oral Health is considered a single conceptual construct The Colombian GOHAI scale allows for discriminating among subjects of different characteristics in terms of age groups, skin color, educational level, socioeconomic level, healthcare affiliation and self-perception of oral prostheses need, which are variables conceptually related with the quality of oral health. In contrast, no discriminant results were found for gender (in both WS and CS samples) neither for dwelling areas in the WS sample.,,,The discriminant validity results of the Colombian GOHAI scale agree with previous findings in the literature. Differences in GOHAI scores according to age groups have been found in the validation of the French version ,,,Educational level differences were assessed by studies on the Mexican, American and French versions Furthermore, in the current study, the “colors pallet”, for the assessment of the skin color, was used in discriminant validity analyses. This variable has not been used in other validations. In Colombian settings, skin color is related with discrimination issues and the socioeconomic status ,,-The lack of discriminant validity of GOHAI for gender is in line with previous findings from Mexican, American, Spanish, Swiss, Chinese and French validation studies Dwelling area was previously evaluated only in the French version of the GOHAI In relation to the convergent validity, the correlation tests included overall health, oral health self-perception and the self-perception of treatment necessity, showing significant correlations among the constructs.It is worth clarifying that differences in the results, of the current validation study, are product of transcultural conditions among countries which make these issues incomparable, aside the population’s inherent characteristics and the validation study’s design.,,-,,,,,,-In terms of internal consistency, most Cronbach’s alpha values, from previous GOHAI validations, range between 0.8 and 0.9. The Colombian GOHAI attained an internal consistency equal to 0.80, which is consistent with the American, Chinese, Tamil, Persian and Malaysian validations When withdrawing the GOHAI item 4, the Cronbach’s alpha would come to be 0.81, meaning that internal consistency would change in a single digit, an aspect which does not imply conceptual changes in the internal consistency tests; therefore, the exclusion of item 4 was not accepted.-,,,The authors from the Greek validation ,,,The results as displayed by the GOHAI Colombian version validation, show the correlation measurement to be quite good by yielding a 0.85 Kendall’s coefficient, with a perfect relationship being 1.0, indicating that the Colombian GOHAI has equal or higher test-retest reliability in comparison with the validation of GOHAI versions in other countries; only the Greek, French, Tamil and Dutch versions The Colombian version of the GOHAI scale proved it has appropriate validity and reliability psychometric properties, which suggest this version should be used in longitudinal and cross-sectional research studies about the oral health of the elderly in Colombia. Taking into account the current and the previous validation studies of the GOHAI scale in several Spanish speaking countries (including Spain), it is possible to apply the Colombian version of the GOHAI scale in different Latin-American Spanish speaking countries, adjusting for minor changes in the Spanish wording according to the local vocabulary and other local cultural issues.The proposed Colombian GOHAI scale will serve, besides, as a public health tool in order to assessing the elderly people’s oral quality of life during the implementation of public health programs or clinical interventions focused on this population. As suggested future studies, it is necessary to perform the confirmatory factorial structure of the GOHAI, aside from assessing the test among different populations, and comparing improvements of the oral quality of life in elderly subjects before and after oral health interventions. La Calidad de Vida (CV) se ha definido como la percepción individual de las personas frente a su posición en la vida, en el contexto de su cultura y los sistemas de valores con los que viven, y con respecto a sus objetivos, expectativas e inquietudes. Es un concepto amplio que se ve afectado por la salud física de una persona, el estado psicológico, el grado de independencia, las relaciones sociales, las creencias personales y su relación con el medio ambiente ,,El proceso de envejecimiento genera cambios sociales, sobre la percepción sensorial y el funcionamiento cognitivo y motor de algunas personas mayores (PM) ,Sobre la base del envejecimiento demográfico y la necesidad de medir la autopercepción oral de las personas mayores, se han desarrollado múltiples escalas de medición a través de cuestionarios fáciles de abordar y predictores adecuados de algunas condiciones clínicas. Estos instrumentos o escalas han sido validados en varios idiomas. Entre los instrumentos existentes, las escalas de preferencia son el Perfil de Impacto de Salud Oral - OHIP, el Impacto Oral en el Desempeño Diario - OIDP, el Índice de Evaluación de Salud Oral Geriátrica - GOHAI, los Indicadores Subjetivos del Estado de Salud Oral - SOHSI y el Impacto Dental en el Diario Vivir - DIDL,La escala GOHAI se ha empleado en Colombia en grupos de ancianos, y el proceso de validación de este instrumento se ha realizado en la población de ancianos en varios países -El proceso de validación se basa conceptualmente en el marco expuesto por Locker en 1988, que muestra diferentes efectos sobre la calidad de vida basado en los cambios que surgen en la cavidad oral. Este modelo se ha utilizado para elaborar varios instrumentos de calidad de vida oral, así como validaciones previas de la escala GOHAI El estudio se realizó en los sujetos participantes de la "Encuesta de Salud, Bienestar y Envejecimiento - SABE Colombia 2015”, una encuesta nacional cuyo objetivo era recopilar información sobre el proceso de envejecimiento de colombianos de 60 años y más. La encuesta tuvo un tiempo de recolección de campo de un año, entre 2015-2016. La encuesta SABE, así como el estudio de validación de la escala GOHAI, fueron avalados por el Comité de Ética de la Universidad del Valle (Cod. 083/014 y 093/015), y todos los participantes firmaron el consentimiento informado. Los encuestados fueron 23,694 sujetos, entre ellos, 4,689 fueron excluidos debido al deterioro cognitivo identificado por el filtro establecido con la prueba Minimental AMMSE. En total, 19.005 personas mayores respondieron a la escala GOHAI. Se realizó un pre-test de la escala GOHAI con 63 participantes La escala GOHAI es un instrumento de autorreporte compuesto por 3 dimensiones que evalúan la función física, la función psicosocial, el dolor y la incomodidad. El instrumento consta de 12 preguntas en una escala Likert que confiere a cada respuesta una puntuación que va de 1 a 5; Las opciones de respuesta son: siempre, casi siempre, con frecuencia, casi nunca y Nunca. adecuada cuando el puntaje se ubica entre 57 y 60, moderado entre 51 a 56 y bajo por debajo o igual a 50 Las preguntas correspondientes a los números 1, 2, 4 , 6, 8, 9, 10, 11 y 12 exhiben categorías Likert del 1 al 5, las demas preguntas 3, 5 y 7 exhiben la escala Likert inversamente. El puntaje total corresponde a la suma total de cada pregunta y considera que la salud oral es El proceso de traducción fue realizado por dos traductores externos a todo el proceso de investigación, que cumplieron con los siguientes criterios: competentes en los idiomas de estudio (inglés y español), familiarizados o inmersos en la cultura donde se aplicaría la escala validada y teniendo entrenamiento básico en medición de salud; capacitación entendida como tener algún tipo de experiencia previa en la traducción de instrumentos o documentos emitidos en salud. El objetivo era verificar los cambios en la redacción, la equivalencia semántica e idiomática. Al recibir la traducción, un equipo de expertos compuesto por profesionales en odontología con formación de doctorado en salud pública, especialización en rehabilitación oral, epidemiólogo, magíster en gerontología y en epidemiología realizó algunas modificaciones conjuntas a la versión inicial, y se obtuvo una versión ajustada del instrumento GOHAI según los expertos. Los mismos traductores proporcionaron un informe positivo frente a la nueva versión, que fue la que se probó en la prueba piloto y empleado en la totalidad de la encuesta SABE, intrumento traducido nuevamente por ellos. Se llevó a cabo integrando 63 personas mayores en Bogotá (código de censo: 11001), Ubaté (código de censo: 25843) y Soledad (código de censo: 8758). Los tres sitios fueron elegidos por ser culturalmente diversos en el país y ayudaria a comprender los aspectos al tratar diferentes regiones. Además, dos son pueblos pequeños y uno la ciudad capital del pais, un aspecto importante al probar el instrumento. Se seleccionaron 3-5 bloques en cada municipio y se entrevistó a todos los adultos mayores que vivían en los mismos.Los resultados mostraron que los participantes y los entrevistadores entendieron las preguntas. El Alfa de Cronbach fue de 0.74, lo que refleja una consistencia interna aceptable, por lo que se decidió continuar el estudio con esa versión de GOHAI. No se realizó análisis factoriales en esta etapa debido a un tamaño de muestra insuficiente para ese proceso.,En los estudios de validación de escala, el proceso que requiere una muestra más grande es el análisis factorial. Algunos autores definen el tamaño de su muestra en función del número de preguntas en la escala a validar, considerando entre 10 y 20 sujetos por ítem como una alternativa apropiada. Otros autores recomiendan un tamaño de muestra de más de 500 sujetos como bueno y más de 1,000 como excelente Después de eliminar duplicados, datos atípicos y puntajes GOHAI por debajo de 12 o por encima de 60, se obtuvieron 18,863 sujetos que respondieron la escala GOHAI en el estudio SABE. Luego, dos muestras (WS y CS) fueron obtenidas al azar, alrededor de 3,600 sujetos cada una, se seleccionaron usando fracciones de muestreo proporcionales de acuerdo con las variables de género, grupos de edad y área de vivienda  entre los 18,863 sujetos seleccionados de toda la encuesta. Todos los análisis se realizaron en ambas muestras, de esta manera al final del estudio, se contó con una muestra de 7,200 sujetos, divididos en dos grupos de aproximadamente 3,600 sujetos cada uno. La Se utilizaron las siguientes variables existentes en la Encuesta SABE Colombia: edad , género (hombre-mujer), nivel educativo (8 subgrupos) , área de vivienda , estrato socioeconómico , afiliación a la atención médica (5 subgrupos), autopercepción sobre la necesidad de prótesis dentales (sí / no), autopercepción general de salud oral (tres subgrupos) y color de piel (tres subgrupos), esta ultima se preguntó utilizando la paleta de colores del proyecto PEARL en América Latina, que muestra la pigmentación de la cara de las personas como un proxy de identificación étnica Fueron evaluados a través del análisis de expertos acerca de la escala GOHAI y si ella realmente mide la calidad de vida con respecto a la salud bucal, y si los contenidos integran las construcciones que se verían afectadas ante la aparición de una condición de salud bucal favorable o desfavorableTodos los análisis se realizaron en las muestras de trabajo (WS) y confirmatorias (CS). Después del muestreo basado en los pesos de frecuencia, de acuerdo con las variables sociodemográficas ya descritas, la muestra de trabajo consistió en 3,628 registros y la muestra confirmatoria de 3,572; La frecuencia de respuesta para ambas muestras y la versión traducida del GOHAI se muestran en la La consistencia interna se evaluó mediante el Alfa de Cronbach para medir la homogeneidad entre los ítems. Utilizando los mismos entrevistados, se llevó a cabo otro aspecto de confiabilidad definido como medición de estabilidad a lo largo del tiempo, al replicar la escala GOHAI en dos oportunidades diferentes. Se eligieron 75 sujetos para esta parte de la validación. La primera aplicación se realizó en la primera visita a los adultos mayores participantes en la aplicación de la encuesta SABE, la segunda entre 5 y 7 días después de la primera aplicación. Para el análisis de la reevaluación de la prueba se utilizó el coeficiente de correlación de Kendall. La interpretación del coeficiente oscila entre -1 y +1 apuntando a asociaciones negativas o positivas respectivamente, mientras que cero (0) significa que no hay correlación.,Con el fin de determinar la validez del constructo y establecer las dimensiones de las variables a identificar, se utilizó un análisis factorial exploratorio mediante rotación oblicua de Promax. Los supuestos del análisis factorial se evaluaron mediante la prueba de esfericidad de Bartlett y la medida de adecuación muestral de Kaiser-Meyer-Olkin ,Al ser una escala autoinformada en una construcción personal, que no tiene un estándar de oro, la escala GOHAI evalúa la validez de sus criterios mediante análisis discriminante y de convergencia. El aspecto discriminante arroja la capacidad de la escala para diferenciar entre grupos donde debe hacerlo, y su incapacidad para diferenciar los grupos donde no debe hacerlo; esto se analizó a través de la relación entre el puntaje total de GOHAI y las variables sociodemográficas como área, edad, color de piel, nivel educativo, estrato socioeconómico, afiliación al regimen de salud, autopercepción de la necesidad de prótesis orales y género. La relación con la evaluación de autopercepción de salud oral se utilizó para la validez convergente, que indaga cómo el constructo objetivo medido por la escala estudiada converge o se relaciona con otras escalas que evalúan construcciones similares. Las pruebas de Kruskal-Wallis o Mann-Whitney se utilizaron para establecer diferencias entre los grupos de tamaño mediano según la dicotomía o la naturaleza categórica de las variables; Estas pruebas se han utilizado ampliamente en toda la literatura de validación de GOHAI p >0.05) para todas las variables edad, sexo, estrato socioeconómico, estado civil, área de vivienda, afiliación a la atención médica, nivel educativo y color de la piel, es decir, las características entre las dos muestras seleccionadas al azar fueron similares.Tanto WS como CS mostraron características similares; Las pruebas de Kruskal-Wallis y Mann-Whitney no arrojaron diferencias significativas ; ambos indican condiciones apropiadas para realizar análisis factoriales. La estructura factorial sugerida en ambas muestras fue de dos factores, considerando valores propios superiores a 1.0. Vale la pena aclarar que tanto para WS como para CF surgió un tercer factor muy cercano a un valor propio de 1.0: 0.96 para WS y 0.98 para CS. Por lo tanto, se realizaron rotaciones de tipo Promax para estructuras factoriales de dos y tres, pero las cargas factoriales en los ítems de GOHAI fueron diferentes entre ambas muestras. Por el contrario, la estructura unifactorial fue consistente en ambas muestras (WS y CS).El análisis de construcciones para WS y CS arrojó una medida de Kaiser-Meyer-Olkin superior a 0.85, que se considera notable, y una prueba de Bartlett significativa (p <0.05). Las diferencias discriminantes no fueron significativas para el género (p >0.05); para el área de vivienda no fue significativa en WS (p >0.05), pero fue significativa en el CS (p <0.05).La validez discriminante para WS y CS arrojó diferencias significativas entre las medias de las variables edad, color de la piel, nivel educativo, nivel socioeconómico, afiliación al regimen de salud y autopercepción de la necesidad de prótesis , validez de constructo y consistencia interna en una población colombiana bastante representativa de 60 años y más, aparte de una submuestra de aplicación-re aplicación suficiente para determinar la confiabilidad de la escala.Asimismo, se utilizaron dos submuestras para corroborar los análisis de validación y los resultados dentro de la base de datos del estudio SABE Colombia.La validez de constructo basada en valores propios sugirió una estructura de dos factores; sin embargo, la calidad de vida en términos de salud bucal se muestra como una estructura de factor único . En la versión original que presentaba la escala GOHAI Con respecto al número de factores informados por otros estudios que validan la escala GOHAI, la versión en español En el estudio de validación actual, las estructuras mostradas para escenarios de dos y tres factores no son consistentes con la estructura teórica que subyace en la escala GOHAI; corroborando que los participantes no discriminan entre construcciones conceptuales físicas, de incomodidad del dolor y psicosociales, lo que podría explicarse por la interrelación del impacto de la calidad de vida oral en cada una de estas dimensiones conceptuales.Los hallazgos anteriores corroborarían la falta de replicabilidad de la estructura factorial de dos y tres factores entre ambas muestras (WS y CS), y respaldan la elección de una estructura uni-factorial para el GOHAI colombiano, por lo tanto, coinciden con la escala original en una sola dimensión donde la calidad de vida dentro de la salud oral se considera una construcción conceptual única La escala GOHAI colombiana permite discriminar entre sujetos de diferentes características en términos de grupos de edad, color de piel, nivel educativo, estrato socioeconómico, regimen de salud y autopercepción de la necesidad de prótesis orales, que son variables conceptualmente relacionadas con la calidad de la salud bucal. Por el contrario, no se encontraron resultados discriminantes para el género (en las muestras WS y CS) ni para las áreas de vivienda en la muestra WS.,,,Los resultados de validez discriminante de la escala GOHAI versión Colombia concuerdan con hallazgos previos en la literatura. Se han encontrado diferencias en los puntajes de GOHAI según los grupos de edad en la validación de la versión francesa ,,,Las diferencias en el nivel educativo fueron evaluadas por estudios en las versiones mexicana, estadounidense y francesa Además, en el estudio actual, la "paleta de colores", para la evaluación del color de la piel, se utilizó en análisis de validez discriminante. Esta variable no se ha utilizado en otras validaciones. En entornos colombianos, el color de la piel está relacionado con problemas de discriminación y el estado socioeconómico ,,-La falta de validez discriminante de GOHAI para el género está en línea con los hallazgos anteriores de estudios de validación mexicanos, estadounidenses, españoles, suizos, chinos y franceses El área de vivienda se evaluó previamente solo en la versión francesa del GOHAI En relación con la validez convergente, las pruebas de correlación incluyeron la salud general, la autopercepción de la salud oral y la autopercepción de la necesidad de tratamiento, mostrando correlaciones significativas entre los constructos.Vale la pena aclarar que las diferencias en los resultados del estudio de validación actual son producto de condiciones transculturales entre países que hacen que estos problemas sean incomparables, aparte de las características inherentes de la población y el diseño del estudio de validación.,,-,,,,,,-En términos de consistencia interna, la mayoría de los valores alfa de Cronbach de validaciones anteriores de GOHAI, oscilan entre 0.8 y 0.9. El GOHAI versión Colombia alcanzó una consistencia interna igual a 0,80, que es consistente con las validaciones estadounidense, china, tamil, persa y malasia Al retirar el ítem 4 de GOHAI, el alfa de Cronbach llegaría a ser 0.81, lo que significa que la consistencia interna cambiaría en un solo dígito, un aspecto que no implica cambios conceptuales en las pruebas de consistencia interna; por lo tanto, no se aceptó la exclusión del ítem 4.-,,,Los autores de la validación griega ,,,Los resultados mostrados por la validación de la versión colombiana de GOHAI muestran que la medida de correlación es bastante buena al arrojar un coeficiente de Kendall de 0.85, con una relación perfecta de 1.0, lo que indica que el GOHAI versión Colombia tiene una confiabilidad test - retest igual o mayor en comparación con validación de versiones de GOHAI en otros países; solo las versiones griega, francesa, tamil y holandesa La versión colombiana de la escala GOHAI demostró que tiene propiedades psicométricas de validez y confiabilidad apropiadas, lo que sugiere que esta versión podría ser usada en estudios de investigación longitudinales y transversales sobre la salud oral de los adultos mayores en Colombia. Teniendo en cuenta los estudios de validación actuales y anteriores de la escala GOHAI en varios países de habla hispana (incluida España), es posible aplicar la versión colombiana de la escala GOHAI en diferentes países latinoamericanos de habla hispana, ajustando los cambios menores en la redacción española de acuerdo con el vocabulario y otros temas culturales locales.La escala GOHAI en su versión para Colombia servirá, además, como una herramienta de salud pública para evaluar la calidad de vida oral de las personas mayores durante la implementación de programas de salud pública o intervenciones clínicas enfocadas en esta población. Como se sugiere en futuros estudios, es necesario realizar la estructura factorial confirmatoria del GOHAI, además de evaluar la prueba entre diferentes poblaciones y comparar las mejoras de la calidad de vida oral en adultos mayores antes y después de las intervenciones de salud oral.


To define physician´s behavior in the face of a mentally capable elderly dysphagic patients at risk of pulmonary aspiration, who do not accept oral restriction.Observational, cross-sectional study, presenting a clinical case of an independent elderly with clinical complaints of dysphagia and laryngotracheal aspiration by flexible endoscopic evaluation of swallowing who rejected the proposal to restrict oral diet. A questionnaire about the patient's decision-making process was used to assess whether the physician was sympathetic and justify their answer, and if they are aware of hierarchy of ethical principles , in the decision-making process, and which was the main principle that guided their decision.One hundred participants were classified by time since graduation as Group I (less than 10 years) and Group II (more than 10 years). Of them, 60% agreed with the patient's decision, with no difference between the groups. The main reason was autonomy of patients, in both groups. Among those who were not sympathetic, the main argument was beneficence and nonmaleficence, considering the risk between benefit and harm. As to awareness about the hierarchy of principles, we did not find differences between the groups. Autonomy was the principle that guided those who were sympathetic with the patient's decision, and justice among those who didnot agree.Physicians were sympathetic with the patient's decision regarding autonomy, despite the balance between risks of beneficence and nonmaleficence, including death. We propose to formalize a non-compliance term. This condition may result in the interruption of the pleasure of eating, because of its repercussions in the safety and comfort of feeding, in nutrition and hydration, and even in the control of oral secretions, leading to changes in habits, and often, in oral feeding restrictions and resulting decline in quality of life.Dysphagia is any difficulty in the swallowing process, in the transport of food from the mouth to the stomach, Dysphagia has become an emergent concern among healthcare professionals, especially those who treat elderly patients, with an impact on quality of life, and tends to be a public health problem.(–)Due to the high risk of aspiration caused by dysphagia, it is difficult to distinguish the fine line that separates dysphagia from aspirative syndromes, which are frequently silent and increase the risk of aspiration pneumonia, as well as to structural and functional impairment of the lungs, deteriorating the fragile health of the elderly, and increasing morbidity and mortality.The prevalence of dysphagia varies according to the group studied: 13% of individuals aged 65 years, 16% in the age group 70-79 years, and 33% among individuals over 80 years of age who live independently. seeking to value human beings (integrity/dignity); to do good (maximize the benefit) − beneficence, and avoid evil  – nonmaleficence; respecting the patient's choices (autonomy); and seeking to be just in every action (justice).The physician-patient relationship is ruled by ethical bases and principles,Considering the impossibility of oral ingestion due to the risks exposed above, a proposal of oral route restriction, with indication of the nasogastric tube (NGT) or percutaneous endoscopic gastrostomy (PEG) is made for the patient. This management may be promptly accepted or not. In face of the refusal by the patient, we should clarify the inherent risks of maintenance of the oral route, and with additional information, the patient and their family members can accept such a proposal. The professional should make every effort to explain its importance, based on the principle of beneficence and not of autonomy.The current study is justified based on the following dilemma: a patient who is at risk of pulmonary aspiration when feeding, but insists on feeding him/herself orally, refusing the proposed procedure of an alternate route to guarantee water and calorie intake, considering that he/she is malnourished, and running the risk of aspiration.To analyze medical behavior in case of refusal of proposal of oral intake restriction in the dysphagic patient with risk of pulmonary aspiration, in the light of bioethics.Hospital São Paulo and was registered at Plataforma Brasil, with certificate of presentation for ethical appreciation, CAAE: 78089717.8.00005505 and opinion no. 2.423.709.This is an observational study carried out from September to November 2017. During the recruitment process, we presented the study design to attending physicians from different organizations in the city of São Paulo. Those interested in participating voluntarily were included and invited to sign the Informed Consent Form (ICF). The study was approved by the Ethics Committee of We present a true case of a lucid mentally capable elderly 86-year-old patient, who lived independently, with an active social life, who had had difficulty swallowing every food consistency over the previous two years, with non-intentional weight loss of 12kg , choking on his own saliva, symptoms that worsened with the offer of food, throat clearing and cough. He denied pneumonia but had past history of ischemic stroke one year before, without sequelae. He did not accept changes in diet or speech therapy.A flexible endoscopic evaluation of swallowing (FEES) was performed, which showed saliva stasis in valleculae, pyriform sinuses, and retrocricoid region, with laryngotracheal penetration and aspiration, and insufficient throat clearing and cough to clear glottis . The offWe presented a written self-explanatory questionnaire to 100 physicians who could treat the dysphagic patient , as to the patient's decision in light of bioethics. In this questionnaire, we evaluated: (1) whether the physician agreed or not with the patient's decision, and then, justification was requested of the answer, which was classified within the principles and foundations that rule the decision-making process , and (2) whether the participant had knowledge of the ethical principles in face of a decision-making process, and which was the primary principle that directed their decision. The proposed questionnaire was designed by the investigators.2 test or the exact test (Fisher's exact test) was used in the analysis of hierarchy of principles.Sample calculation was made using the G-Power 3.1 program, with a 90% confidence level, composed of 100 patients. The characteristics evaluated were described according to the groups of time since graduation, and the existence of an association with the likelihood ratio test (LRT) was verified when we used the primary argument and the main principle. The χFor each group, the associations between agreement and the primary argument used in the decision were assessed, and we also considered the response of awareness of hierarchy, with classification of the main principle (excluding the remaining principles) utilized individually and voluntarily chosen, which rules the decision-making process in the management proposed with the use of the LRT. Moreover, the primary principle in hierarchy (not excluding the others) was assessed by the chi-squared test or Fisher's exact test in the analysis of hierarchy of principles. The tests were performed with a 5% significance level.The 100 participants were divided into two groups: Group I (GI), with physicians with up to 10 years since graduation (58%), in which 34 were residents exclusively at public services , and other classified individuals, such as fellows, collaborators, and lecturers ; and Group II (GII), composed of professionals with more than 10 years since graduation (42%), in which 19 were ENT professionals, and 23 were from other specialties. The remaining 66 participants worked both in the private and public areas. As to sex, 52% were female.Nevertheless, the main argument to be sympathetic with the patient's decision was isolatedly autonomy, followed by the balance among the three principles . Among the non- sympathetic, the argument used was the balance between the two principles: do good and avoid doing evil (p<0.001).There was no statistically significant association between the groups as to awareness of hierarchy of principles that rule the decision (p=0.764), but in GII, justice as the main principle used was statistically more frequent when compared to GI (p=0.001).In GII, autonomy as the main principle in the decision was statistically greater in sympathetic individuals (p=0.003), while justice as the main principle in the decision was statistically more frequent in the not sympathetic (p=0.004).There was no statistically significant association between awareness of hierarchy and the main principle chosen in the decision between the two groups (p>0.05).We separately analyzed the group of ENTs, composed of 57 participants and divided into two groups: Group ENT I, for those graduated up to 10 years before (63%), and Group ENT II, for those who graduated over 10 years before (37%). The ENTs were residents, fellows, collaborators, and lecturers. The main argument used (autonomy) showed a statistically significant association with sympathy in both groups . The main argument to be sympathetic with the patient's decision was isolatedly autonomy, followed by a balance among the three principles: autonomy, beneficence, and nonmaleficence. Among the not sympathetic, the argument used was the balance between the two principles: do good and avoid doing evil (p<0.001).We evaluated the main principle of decision voluntarily chosen in the decision to be or not sympathetic between the two groups of ENTs, and whether they were aware of the hierarchy of principles. There was no statistically significant association between the groups as to awareness of hierarchy of principles that rule the decision (p=0.707), nor as to the main principle used in the individual's decision to be or not be sympathetic.Among the ENT specialists, there was no statistically significant association between them as to awareness of hierarchy of principles that rule the decision (p=0.707) and the time since graduation, but in the ENT II Group, justice as the primary principle used was statistically more frequent compared to the ENT I Group (p=0.022). Applying Fisher's exact test to the hierarchization of principles, as primary principle in the decision, autonomy proved to be statistically higher in sympathetic individuals (p=0.003), and justice among the not sympathetic (p=0.004), ENT II Group.nil per os and propose feeding by an alternative route, via NGT or PEG. This is to guarantee fluid and nutrition support and minimize the risk of pulmonary aspiration until reestablishing safe swallowing, which must have the consent from the patient. When this management is not accepted by the patient, a dilemma appears, and the main objective of the study was that of defining the physician's behavior, in light of bioethics, in face of the refusal of a proposal of nil per os in the dysphagic patient with risk of pulmonary aspiration.Among the greatest challenges in the management of dysphagia are the legal, ethical, and moral needs of the requirement to  and there is a proposal that malnutrition be included among the giants of the geriatric syndrome, since the relation between oropharyngeal dysphagia and increased morbidity and mortality in hospitalized patients is well established. The European Society for Swallowing Disorders (ESSD) defines guidelines for the evaluation and safety of swallowing, and determined the nutritional support be assured, until recovery of the nutritional status and rehabilitation of swallowing. If malnutrition is present, an individualized program should be developed, considering different aspects of the aged, such as beliefs, attitudes, preferences, expectations, and aspirations.Nutrition is a basic human right that simply cannot be denied, and a duty for the protection of frail elderly individuals with dementia. To others, it is a lack of respect of the right to chose (autonomy) when refusing the therapeutic response at issue, even among the aged and frail, but with cognition intact. Our study showed that the analysis among physicians sympathetic with the dysphagic patient's decision in refusing feeding by an alternative route, despite the risk of pulmonary aspiration, was respect for the autonomy of decision, followed by the balance among the three principles: autonomy, beneficence, and nonmaleficence. The same was found among the ENT specialists.To obligate the patient, however, to receive feeding through an alternative route against his/her desire is an object of discussion. Some consider it the means to preserve life, morally required to guarantee human dignity and integrity; The best way to improve patients’ autonomy is by providing information and sharing decision making.Information should be clear and sufficient in order to guarantee that the patients understand the medical decision, considering the duty to care and the interests of the patient. We suggest a broad discussion of the risks and benefits of the proposal, the risk of not accepting the medical management, and the search for consent, in face of an individual who is mentally capable. There should also be the right to change opinions at any time, both in favor of and contrary to the management proposed. The autonomy of the capable patient should be respected, even if the refusal might result in death. This was well established by Law 10.241 and was discussed in patient rights and legislations.Among the non-sympathetic, the primary argument used was the balance between the two principles: do good and avoid evil. We chose to include the foundation of integrity and dignity in our questionnaire. Whenever the professional proposes any therapeutic intervention, first of all, we should recognize the dignity of the patient and consider them in their totality , seeking to offer them the best treatment, both as to technique and as to acknowledgement of the physical, psychological, or social needs.Bioethical principles are applied to swallowing disorders and decision-making in clinical practice. Beneficence means to “do good,” and nonmaleficence means “avoid evil,” guaranteeing respect for the patient's autonomy and justice.A professional should, above all, desire the best for the patient (beneficence), in order to reestablish health, prevent worsening, or promote health. In the case at issue, this would result in proposing effective treatment for dysphagia, aiming at nutritional recovery, guaranteeing nutritional and water intake, and restricting the oral route until swallowing is rehabilitated by means of speech therapy.We perceive that there is difficulty in considering these two principles separately , because we always evaluate the bionomial as a balance between risk and benefit (do good and avoid evil) of any proposal in medical care. On the other hand, when the results are uncertain and it is improbable that damage be done , abstention from treatment is justifiable for reasons that are both moral and ethical. In the aged, the application of the principle of beneficence should override all other considerations, as per Eibling et al.Intuitively, physicians know how to argue about their position in being sympathetic or not with the patient's decision to refuse the medical management. Generally, their answers are based on the principles, but not all patients are aware of hierarchy of principles, and even those who do know of its existence, do not necessarily base themselves on the primary hierarchical principle as being the main principle, nor do they show a relation between awareness of hierarchy with time since graduation. Considering the hierarchization of the principles, as the first principle in the decision, autonomy was shown to be more frequent among sympathetic physicians (according to the hierarchization of principles: the first/primary and main principle), and justice among those who are not sympathetic  in GII. The same was found among the ENT specialists.Patients should be treated justly, with no discrimination based on social status, race, ethnicity, or religious beliefs. In practice, healthcare professionals need to develop sensitivity towards diversity of opinion. The principle of justice overlapped among the physicians with more time since graduation; justified by the idea that a decision would not be ethical if one of the players involved  were to be harmed. This idea is also reinforced among those who were not sympathetic, within this context of giving the person what he/she needs.Oral ingestion is a complex process vital for life. It is not only essential for existence, but also plays an important role in happiness and socialization, and restriction of the oral route reflects on pleasure/happiness and consequently, on quality of life, leading us to ethical considerations. For some patients, there is loss of quality of life, damaging the main principle, which is integrity/dignity.Conscious of the unique capacity of human being to reflect on their own existence and on their environment; perceive injustice; avoid danger; take responsibility; seek cooperation, and demonstrate the moral meaning that provides the expression of ethical principles, so that we should always seek their consent.nil per os, that is, nothing by oral route. In this way, the management of the oral offer by caregivers and/or family members, under some conditions, a diet may be offered with modified texture, or have restrictions of one or more food consistencies, according to the medical and speech therapy evaluations.Patients who presented with unsafe swallowing, but have mental capacity, should be encouraged to follow the recommendations of the physician and initiate speech therapy in order to maintain the oral route, rehabilitating it as quickly as possible, not those who remain in The risk of autonomy should be clarified. The patient is not always in a condition to evaluate which is the best treatment for them . The professional should make every possible effort to explain to the patient the importance of the management plan. After all, it is the principle of always seeking consent, making clear the possibility of patients to change their mind. The patient described herein, for example, returned to the physician who had cared for him convinced of the proposed management, and he was given feeding by NGT and speech therapy. He recovered his nutritional status and safe oral feeding.One of the limitations of this study is our sample, with a 90% confidence power. Since it is an observational study, it allows the establishment of associations, but does not define the relation of causality and risk. We highlight its clinical importance in the need to initiate a wider discussion among all medical specialties as to the decision of the patient who does not accept our management, discuss the bioethical principles, learn to conduct the cases that challenge us, and document the patient's refusal. We should not back down on encouraging the patient with information about their true health status and their expectations in face of non-acceptance of the treatment proposed, and the consequences of refusal, since many times, the autonomy of the patient is distorted by misinformation, and doubts about the therapeutic proposal, which once clarified, could change their position. We need to attempt to convince the patients of the best, and if not, give them support to guide them in face of the refusal.In face of the mentally capable dysphagic patients with risk of laryngotracheal aspiration who says that they do not accept restriction of the oral route NPO, the physician faces a conflict of ethical and moral values. Our study demonstrated that the majority of participants were sympathetic with the patient's decision and argued that autonomy is isolatedly sovereign and/or despite the risks, balance between the principles of beneficence and nonmaleficence. Additionally, the decision should be respected in individuals who are mentally capable, as well as the right to change opinion. Among the non-sympathetic participants, the balance between the principles of beneficence and nonmaleficence guided their decision, justifying the risk of clinical worsening with increased morbidity and mortality. Regardless of awareness of hierarchy of the principles that orient the decision process in our sample, the primary principle considered in this process was that of autonomy among the participants sympathetic with the decision contrary to the proposal offered. The principle of justice predominated among the non-sympathetic participants with more time since graduation. Ethical concerns arise of non-acceptance of the action proposed, and it is necessary to formalize the refusal in the medical record, by means of an informed refusal document, with legal protective purposes.  seja por alteração anatomofuncional, ou por comprometimento neuromuscular. Esta condição pode resultar na interrupção do prazer de se alimentar, por suas repercussões na segurança e conforto da alimentação, na nutrição e hidratação, e até mesmo no controle das secreções orais, implicando em mudança de hábitos e, algumas vezes, em restrição da alimentação por via oral e no consequente declínio da qualidade de vida.Disfagia é qualquer dificuldade no processo de deglutição, no transporte do bolo alimentar da boca ao estômago, A disfagia tem se tornado preocupação emergente entre os profissionais de saúde, especialmente aqueles que tratam pacientes idosos, com impacto na qualidade de vida e tendendo a ser um problema de saúde pública.(–)Pelo alto risco de aspiração causada pela disfagia, é difícil distinguir a linha tênue que separa disfagia das síndromes aspirativas, muitas vezes silenciosas e que predispõem não apenas à pneumonia, mas também ao comprometimento estrutural e funcional dos pulmões, deteriorando o estado frágil de saúde dos idosos; aumentando a morbimortalidade.A prevalência da disfagia varia de acordo com o grupo estudado: 13% dos indivíduos com 65 anos de idade, 16% na faixa etária de 70-79 anos e 33% entre os indivíduos acima de 80 anos que vivem de forma independente. visando à valorização do ser humano (integridade/dignidade); à busca por fazer o bem (maximizar o benefício) −beneficência, e evitar o mal (a ação do médico sempre deve causar o menor prejuízo à saúde do paciente) −não maleficência; respeitando as escolhas do paciente (autonomia); e procurando ser justos em todo ato (justiça).A relação médico-paciente é regida por fundamentos e princípios éticos,Diante da impossibilidade da ingesta oral pelos riscos acima expostos, uma proposta de restrição da via oral, com indicação de sonda nasoenteral (SNE) ou gastrostomia (GTM) é feita ao paciente. Esta conduta pode ser prontamente aceita ou não. Diante da recusa pelo paciente, devemos esclarecer os riscos inerentes da manutenção da via oral e, com adicionais informações, o paciente e seus familiares podem aceitar tal proposta. O profissional deve se esforçar ao máximo para explicar a importância, baseado no princípio da beneficência e não da autonomia.O atual estudo se justifica baseado no seguinte dilema: paciente que está em risco de broncoaspirar quando se alimenta, mas insiste em se alimentar por via oral, recusando a conduta proposta de via alternativa para garantir aporte hídrico e calórico, visto que está desnutrido e assumindo o risco de aspirar.Analisar o comportamento médico diante da recusa da proposta de restrição de via oral no paciente disfágico com risco de broncoaspiração à luz da bioética.Trata-se de estudo observacional, realizado de setembro a novembro de 2017. Durante o processo de recrutamento, apresentamos o desenho do nosso estudo aos médicos assistencialistas de diferentes instituições na cidade de São Paulo. Aqueles interessados em participar voluntariamente foram incluídos e convidados a assinar o Termo de Consentimento Livre e Esclarecido (TCLE). O estudo foi aprovado pelo Comitê de Ética do Hospital São Paulo e está registrado na Plataforma Brasil, sob certificado de apresentação para apreciação ética, CAAE: 78089717.8.00005505 e parecer 2.423.709.Apresentamos um caso real, de idoso de 86 anos, lúcido, que vivia de forma independente, com vida social ativa, mentalmente capaz, com dificuldade para deglutir todas as consistências alimentares nos últimos 2 anos, com perda ponderal não intencional de 12kg , engasgos com a própria saliva e piores com a oferta alimentar, pigarro e tosse. Negava pneumonia, referia antecedente de acidente vascular encefálico isquêmico há 1 ano, sem sequelas. Não aceitava mudança de dieta, nem fonoterapia.Realizada videoendoscopia da deglutição, que mostrou estase de saliva em valéculas, seios piriformes e região retrocricoídea, com penetração e aspiração laringotraqueal, com tentativa de limpeza da fenda glótica, mas sem sucesso . A ofertApresentamos um questionário autoexplicativo, por escrito, a cem médicos que podiam assistir o paciente disfágico , sobre o processo de decisão do paciente à luz da bioética. Nesse questionário, foram avaliados: (1) se o médico era solidário ou não à decisão do paciente e, em seguida, foi solicitado para justificar sua resposta, que foi enquadrada dentro dos princípios e fundamentos que regem o processo de decisão , e (2) se o participante tinha ou não ciência da hierarquia dos princípios éticos diante de um processo de decisão, e qual o principal princípio que norte avasua decisão. O questionário proposto foi desenhado pelos próprios pesquisadoresO cálculo amostral foi calculado usando o programa G-Power 3.1, com confiança de 90%, composto por cem pacientes.2 ou teste exato (teste exato de Fisher) na análise da hierarquia dos princípios.Foram descritas as características avaliadas segundo grupos de tempo de formação e foi verificada a existência de associação com o teste da razão de verossimilhanças (TRV) quando utilizamos o principal argumento e o principal princípio, e utilizamos o teste χ2 ou teste exato de Fisher na análise da hierarquia dos princípios. Os testes foram realizados com nível de significância de 5%.Para cada grupo, foram avaliadas as associações da solidariedade e o principal argumento utilizado na decisão, e consideramos também a resposta de ciência da hierarquia, com a ordenação do principal princípio (excludente dos demais princípios) utilizado individualmente e voluntariamente escolhido, que rege o processo de decisão na conduta proposta com uso de TRV, e o primeiro princípio na hierarquia (não excludente dos demais) com uso do teste χfellows, colaboradores, e docentes ; e Grupo II (GII), composto por profissionais com mais de 10 anos de formados (42%),sendo 19 otorrinolaringologistas e 23 de outras especialidades. Os demais 66 participantes prestavam assistência tanto na área privada como pública. Quanto ao sexo,52% eram mulheres.Os 100 participantes foram divididos em 2 grupos: Grupo I (GI), com médicos com até 10 anos de formados (58%), sendo 34 residentes de serviço público exclusivo , e demais classificados como A A Porém, o principal argumento para se tornar solidário à decisão do paciente foi a autonomia isoladamente, seguido do balanço entre os três princípios . Entre os não solidários, o argumento utilizado foi o balanço entre os dois princípios: fazer o bem e evitar fazer o mal .A Não houve associação estatisticamente significativa entre os grupos em relação à ciência da hierarquia dos princípios que regem a decisão , mas, no GII, a justiça como principal princípio utilizado foi estatisticamente mais frequente comparada ao GI .A No GII, a autonomia como principal princípio na decisão foi estatisticamente maior nas pessoas solidárias , enquanto a justiça como principal princípio na decisão foi estatisticamente mais frequente nos não solidários .Não houve associação estatisticamente significativa da ciência da hierarquia com o principal princípio escolhido na decisão entre os dois grupos .fellows, colaboradores e docentes. O principal argumento utilizado (autonomia) apresentou associação estatisticamente significativa com a solidariedade em ambos os grupos . O principal argumento para se tornar solidário à decisão do paciente foi a autonomia isoladamente, seguida do balanço entre os três princípios: autonomia, beneficência e não maleficência. Entre os não solidários, o argumento utilizado foi o balanço entre os dois princípios: fazer o bem e evitar fazer o mal .Analisamos em separado o grupo dos otorrinolaringlogistas, composto por 57 participantes, divididos em dois grupos: Grupo Otorrino I, para aqueles até 10 anos de formados (63%), e Grupo Otorrino II, para aqueles com mais de 10 anos de formados (37%). Os otorrinolaringologistas eram residentes, Avaliamos o principal princípio de decisão voluntariamente escolhido na decisão ser ou não solidário entre os dois grupos de otorrinolaringologistas, e se tinham ciência da hierarquia dos princípios. Não houve associação estatisticamente significativa entre os grupos em relação à ciência sobre a hierarquia dos princípios que regem a decisão , nem quanto ao principal princípio utilizado em sua tomada de decisão de ser ou não solidário.Entre os otorrinolaringologistas, não houve associação estatisticamente significativa entre eles, em relação à ciência da hierarquia dos princípios que regem a decisão  e ao tempo de formado, mas, no G Otorrino II, a justiça como primeiro princípio utilizado foi estatisticamente mais frequente comparada ao G Otorrino I . Aplicando o teste exato de Fisher na hierarquização dos princípios, como primeiro princípio na decisão, a autonomia mostrou-se estatisticamente maior nas pessoas solidárias , e a justiça entre os não solidários , G Otorrino II.A Entre os desafios no manejo da disfagia, está a discussão legal, ética e moral da necessidade de restringir alimentação por via oral e propor alimentação por via alternativa, por SNE ou GTM, para garantir o suporte hídrico e nutricional, e minimizar o risco de broncoaspirar, até que se restabeleça a segurança da deglutição, que deve ter o consentimento do paciente. Quando esta conduta não é acatada pelo paciente, surge um dilema, e o principal objetivo do trabalho foi definir o comportamento médico diante da recusa da proposta de restrição de via oral no paciente disfágico com risco de broncoaspiração à luz da bioética. e existe proposta de que a desnutrição seja incluída entre os gigantes da síndrome geriátrica, pois a relação entre disfagia orofaríngea e aumento da morbimortalidade em pacientes hospitalizados está bem estabelecida. A European Society for Swallowing Disorders (ESSD) definiu diretrizes para a avaliação e a segurança da deglutição, e determinou que o suporte nutricional seja assegurado, até que ocorram recuperação do estado nutricional e reabilitação da deglutição. Se a desnutrição estiver presente, programa individualizado deveria ser desenvolvido, considerando diferentes aspectos do idoso, como crenças, atitudes, preferências, expectativas e aspirações.A nutrição é um direito humano básico que simplesmente não pode ser negado e dever de proteção aos idosos frágeis com demência. Para outros, é um desrespeito ao direito de escolha (autonomia) em recusar a proposta terapêutica em questão, mesmo entre os idosos fragilizados, mas com cognitivo preservado. Nosso trabalho mostrou que a análise entre os médicos solidários à decisão do paciente disfágico em recusar a alimentação por via alternativa, apesar dos riscos de broncoaspiração, foi o respeito pela autonomia de decisão, seguido pelo balanço entre os três princípios: autonomia, beneficência e não maleficência. O mesmo foi encontrado entre os otorrinolaringologistas.Porém, obrigar o paciente a receber alimentação por via alternativa contrário à sua vontade é objeto de discussão. Alguns consideram o meio de preservar a vida, moralmente obrigatório para garantir a integridade e a dignidade humana; A melhor forma de aprimorar a autonomia dos pacientes é por meio da provisão de informações e tomada de decisão compartilhada.As informações devem ser claras e suficientes, para garantir que os pacientes entendam a decisão médica, ponderando o dever de cuidar e o interesse do paciente. Propomos uma discussão ampla dos riscos e benefícios da proposta, do risco de não aceitar a conduta e a busca pelo consentimento, diante de um indivíduo mentalmente capaz. Deve haver ainda o direito de mudar de opinião a qualquer momento, tanto a favor como contrário à conduta proposta. A autonomia do paciente capaz deve ser respeitada, mesmo que a recusa possa resultar em morte, sendo bem estabelecida pela lei 10.241 e discutida em direitos dos pacientes e legislação.Entre os não solidários, o principal argumento utilizado foi o balanço entre os dois princípios: fazer o bem e evitar fazer o mal. Optamos em incluir o fundamento da integridade e da dignidade no nosso questionário. Sempre que o profissional propuser qualquer intervenção terapêutica, primeiramente devemos reconhecer a dignidade do paciente e considerá-lo em sua totalidade , visando oferecer-lhes o melhor tratamento, tanto no que diz respeito à técnica quanto no que se refere ao reconhecimento de suas necessidades físicas, psicológicas ou sociais.Os princípios bioéticos são aplicados aos distúrbios da deglutição e na tomada de decisões na prática clínica. Beneficência significa “fazer o bem”, e não maleficência significa “evitar o mal”, garantindo respeito pela autonomia do paciente e justiça.Um profissional deve, acima de tudo, desejar o melhor para seu paciente (beneficência), para restabelecer sua saúde, prevenir um agravo ou promover sua saúde. No caso em questão, resultaria em propor tratamento efetivo para a disfagia, visando à recuperação nutricional, garantindo aporte nutricional e hídrico, e restringir a via oral, até que haja reabilitação da deglutição por meio da fonoterapia.Sentimos que há dificuldade em considerar em separados estes dois princípios , porque sempre avaliamos o binômio – como em um balanço entre risco e benefício  de qualquer proposta em cuidados médicos. Por outro lado, quando os resultados são incertos e é provável que o dano seja causado , a abstenção de tratamento é justificável tanto por razões morais quanto éticas. No idoso, a aplicação do princípio da beneficência deveria superar todas as outras considerações, de acordo com Eibling et al.Intuitivamente, o médico sabe argumentar sobre sua posição em se tornar ou não solidário à decisão do paciente de recusar a conduta médica. Geralmente suas respostas são pautadas nos princípios, mas nem todos têm ciência da existência de hierarquia dos princípios, e mesmo os que sabem de sua existência não necessariamente se baseiam no primeiro princípio hierárquico como o principal, nem mostram relação de ciência da hierarquia com o tempo de formado. Considerando a hierarquização dos princípios, como primeiro princípio na decisão, a autonomia mostrou-se mais frequente entre os médicos solidários , e a justiça entre os não solidários (embora seja o último princípio hierarquicamente) no GII. O mesmo foi encontrado entre os otorrinolaringologistas.status social, raça, etnia ou crença religiosa. Na prática, os profissionais de saúde precisam desenvolver sensibilidade para a diversidade de opinião. O princípio da justiça sobrepôs entre os médicos com mais tempo de formado; justificado pela ideia que não seria ética uma decisão que levasse um dos personagens envolvidos  a se prejudicar. Essa ideia também é reforçada entre aqueles que não se tornaram solidários, nesse contexto de dar a cada pessoa o que ela necessita.Os pacientes devem ser tratados de forma justa, sem discriminação com base no A ingestão oral é um processo complexo essencial para a vida. Não só é essencial para a existência, mas também desempenha papel importante na felicidade e na socialização, e a restrição da via oral reflete no prazer/felicidade e, consequentemente, na qualidade de vida, provocando-nos reflexão ética. Para alguns pacientes, há perda da qualidade de vida, causando prejuízo ao principal fundamento, que é a integridade/dignidade.Consciente da capacidade única dos seres humanos de refletir sobre sua própria existência e sobre seu meio ambiente; perceber a injustiça; evitar o perigo; assumir responsabilidade; buscar cooperação e demonstrar o sentido moral que dá expressão a princípios éticos, de modo que devemos sempre procurar seu consentimento.nil per os, ou seja, nada por via oral. Assim, fica garantido o gerenciamento da oferta oral por cuidadores e/ou familiares e, em algumas condições, pode ser ofertada dieta com textura modificada, ou haver restrição de uma ou mais consistência de alimento, de acordo com a avaliação médica e fonoaudiológica.Os pacientes que apresentam deglutição não segura, mas têm capacidade mental, devem ser encorajados a seguir o conselho médico e iniciar fonoterapia para manter a via oral, reabilitando mais rapidamente, do que aqueles que permanecem em O risco da autonomia deve ser esclarecido. Nem sempre o paciente tem condições de avaliar qual o melhor tratamento para ele . O profissional deve se esforçar ao máximo para explicar ao paciente a importância da conduta, afinal o princípio da beneficência (e não o da autonomia) deve ser respeitado em primeiro lugar para alguns, e procurar sempre o consentimento, deixando clara a possibilidade de o paciente mudar de ideia. O paciente aqui descrito, por exemplo, retornou ao médico que o assistia convencido da conduta proposta, e foram passados alimentação por SNE e fonoterapia. Ele recuperou o estado nutricional e a segurança da alimentação oral.Uma das limitações deste trabalho é nossa amostra, com poder de confiança de 90%. Por se tratar de estudo observacional, permite estabelecer associações, mas não definir a relação de causalidade e risco. Salientamos sua importância clínica da necessidade de iniciarmos discussão mais ampla entre todas as especialidades médicas sobre a decisão do paciente que não aceita nossa conduta, discutir os princípios bioéticos e aprendermos a conduzir os casos que nos desafiam e documentar a recusa do paciente. Não devemos desistir de fomentar o paciente com informações sobre seu real estado de saúde e suas expectativas diante da não aceitação do tratamento proposto, e as consequências da recusa, pois, muitas vezes, a autonomia do paciente é falseada por desinformação, e dúvidas sobre a proposta terapêutica, e uma vez esclarecido ele poderá mudar o seu posicionamento. Temos que nos esforçarmos para convencer os pacientes do melhor, e, caso contrário, darmos suporte para conduzi-los diante da recusa.O médico diante do paciente disfágico com risco de aspiração laringotraqueal e mentalmente capaz que não aceita a restrição da via oral enfrenta um conflito de valores éticos e morais. Nosso estudo demonstrou que a maioria dos participantes foram solidários à decisão do paciente e argumentaram que a autonomia é soberana isoladamente e/ou apesar dos riscos, ponderando os princípios da beneficência e não maleficência. Além disso, a decisão deve ser respeitada em indivíduos mentalmente capazes, assim como o direito de mudar de opinião. Entre os participantes não solidários, o balanço entre os princípios beneficência e não maleficência nortearam sua decisão, justificando o risco de piora clínica com aumento da morbimortalidade. Independente da ciência sobre a hierarquia dos princípios que regem o processo de decisão na nossa amostra, o principal princípio considerado neste processo foi o da autonomia entre os participantes solidários à decisão contrária à proposta oferecida. O princípio da justiça preponderou entre os participantes não solidários com mais tempo de formado. Preocupações éticas surgem diante da não aceitação da conduta proposta, surgindo a necessidade de formalizar a recusa no prontuário médico, por meio de documento de recusa informada, com finalidade protetiva legal.