1st Forum of the Southern Cone End-of-Life Study Group: proposal for care of patients, bearers of terminal disease staying in the ICU

Abstracts

As condutas de limitação de tratamento oferecidas a pacientes portadores de doenças terminais, internados em Unidades de Terapia Intensiva, tem aumentado a sua freqüência nos últimos anos em todo o mundo. Apesar disto, ainda existe uma grande dificuldade dos intensivistas brasileiros em oferecer o melhor tratamento àqueles pacientes que não se beneficiariam com terapêuticas curativas. O objetivo deste comentário é apresentar uma sugestão de fluxograma para atendimento de pacientes com doenças terminais que foi elaborado, baseado na literatura e experiência de experts, pelos membros do comitê de ética e de terminalidade da AMIB.

Doente terminal; Estado terminal; Cuidados paliativos; Morte; Unidades de terapia intensiva

SPECIAL ARTICLE

^IAssociação de Medicina Intensiva Brasileira – AMIB – Brasil

^IISociedad Uruguaya de Medicina Intensiva – SUMI - Uruguai

^IIISociedad Argentina de Terapia Intensiva - SATI - Argentina

Author for Correspondence

ABSTRACT

Withholding of treatment in patients with terminal disease is increasingly common in intensive care units, throughout the world. Notwithstanding, Brazilian intensivists still have a great difficulty to offer the best treatment to patients that have not benefited from curative care. The objective of this comment is to suggest an algorithm for the care of terminally ill patients. It was formulated based upon literature and the experience of experts, by members of the ethics committee and end-of-life of AMIB - Brazilian Association of Intensive Care.

Keywords: Terminally ill; Critical illness; Palliative care; Death; Intensive care units

Intensive care has undergone major advances in the last 20 years, worldwide and also in Brazil. Currently, critically ill patients who would evolve to death may be kept alive by artificial means. Although intensive care aims to diagnose, manage and sustain patients under imminent risk of life, but potentially reversible, some critically ill patients may evolve with multiple organ and systems failure and become victims, bearers of terminal disease with no curative therapeutic possibilities. Such a situation creates a dilemma for intensivist physicians, commonly facing the need to decide on withholding or withdrawing of so-called futile treatments.^(1-4)

Various studies carried out worldwide have shown the increasing frequency of withholding treatment receding death in the ICUs.^(5-10) In Brazil, studies made in various regions showed that palliative care practices have increased in the last years, however, they differ from the conduct assumed in countries of the Northern Hemisphere, where proactive conducts such as withdrawal of mechanical ventilation are frequent Analysis of these reports discloses a significant variation in the adherence to therapy withholding measures by intensivist physicians and that cultural, religious, social, economic and legal diversities certainly explain the differences found.^(11-16)

There is growing acknowledgment of the need to establish guidelines and protocols enabling the physician to decide on withdrawing or withholding of futile therapies.^(17-21) Pellegrino, when addressing this subject stated that any ethical decision must take into account, as a fundamental pre-requisite, the value of human life and must consider the theoretical bases that justify decisions from an ethical point of view.⁽²¹⁾ It is noteworthy that, although it is pointed out that physicians more often decide against new therapies, instead of withholding a treatment considered futile, these options are the same from an ethical-legal standpoint.^(18,19)

Despite this worldwide debate, aiming to define the best care to a terminally ill patient, this issue continues without a definitive answer. However, unquestionably, end-of-life practices must prioritize the patient's best interest, respecting his feelings and wishes of the family members as well as adequate communication among all those involved in the process.^(4,13)

To provide adequate treatment at the end-of-life, the Brazilian (AMIB), Uruguayan (SUMI) and Argentinean (SATI) Intensive Care Associations participated in the 1st Forum of the Southern Cone End-of-Life Study Group, in the city of Porto Alegre on May 23, 2009. The objective of this forum was to set forth pertinent recommendations for diagnosis and treatment of the critically ill, terminal patient.

As a result, participants suggested the steps to be taken for diagnosis of end-of-life of the critically ill patient and for decision making with regard to the conduct to be taken with this patient (Chart 1, Figure 1).

ACKNOWLEDGMENTS

The following professionals participated in the fórum:

Alberto Deicas (physician/SUMI), Cristine Nilson (nurse/AMIB), Fernando Osni Machado (physician/AMIB), Jairo Othero (physician/AMIB), Jefferson Piva (physician/AMIB), Juan Pablo Rossini (physician/SATI), Karla Rovatti (psychologist/AMIB), Nara Azeredo (nurse/AMIB), Newton Brandão (physician/AMIB), Patrícia Lago (physician/AMIB), Rachel Duarte Moritz (physician/AMIB) and Raquel Pusch (psychologist /AMIB).

REFERENCES

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1^st Forum of the Southern Cone End-of-Life Study Group: proposal for care of patients, bearers of terminal disease staying in the ICU

Rachel Duarte Moritz^I; Patrícia Miranda do Lago^I; Alberto Deicas^II; Cristine Nilson^I; Fernando Osni Machado^I; Jairo Othero^I; Jefferson Pedro Piva^I; Juan Pablo Rossini^III; Karla Rovatti^I; Nara Azeredo^I; Nilton Brandão da Silva^I; Raquel Pusch^I

Publication Dates

• Publication in this collection
  30 Oct 2009
• Date of issue
  Aug 2009

History

• Accepted
  23 June 2009
• Received
  23 June 2009