Patricia Miranda do Lago

Terminalidade e cuidados paliativos na unidade de terapia intensiva

The objective of this review was to evaluate current knowledge regarding terminal illness and palliative care in the intensive care unit, to identify the major challenges involved and propose a research agenda on these issues The Brazilian Critical Care Association organized a specific forum on terminally ill patients, to which were invited experienced and skilled professionals on critical care. These professionals were divided in three groups: communication in the intensive care unit, the decision making process when faced with a terminally ill patient and palliative actions and care in the intensive care unit. Data and bibliographic references were stored in a restricted website. During a twelve hour meeting and following a modified Delphi methodology, the groups prepared the final document. Consensual definition regarding terminality was reached. Good communication was considered the cornerstone to define the best treatment for a terminally ill patient. Accordingly some communication barriers were described that should be avoided as well as some approaches that should be pursued. Criteria for palliative care and palliative action in the intensive care unit were defined. Acceptance of death as a natural event as well as respect for the patients autonomy and the nonmaleficence principles were stressed. A recommendation was made to withdraw the futile treatment that prolongs the dying process and to elected analgesia and measures that alleviate suffering in terminally ill patients. To deliver palliative care to terminally ill patients and their relatives some principles and guides should be followed, respecting individual necessities and beliefs. The intensive care unit staff involved with the treatment of terminally ill patients is subject to stress and tension. Availability of a continuous education program on palliative care is desirable.

End-of-life care in children: the Brazilian and the international perspectives

OBJECTIVE To analyze the medical practices and the end-of-life care provided to children admitted to pediatric intensive care units in different parts of the globe. SOURCES Articles on end-of-life care published during the last 20 years were selected from the PubMed, MEDLINE and LILACS databases, with emphasis on studies of death in pediatric intensive care units in Brazil, Latin America, Europe and North America, using the following keywords: death, bioethics, pediatric intensive care, cardiopulmonary resuscitation and life support limitation. SUMMARY OF THE FINDINGS Publications on life support limitation (LSL) are concentrated in North America and Europe. In North American pediatric intensive care units there is a greater incidence of LSL (approximately 60%) than in Europe or Latin America (30-40%). These differences appear to be related to cultural, religious, legal and economic factors. Over the last decade, LSL in Brazilian pediatric intensive care units has increased from 6 to 40%, with do not resuscitate orders as the most common method. Also of note is the low level of family participation in the decision-making process. A recent resolution adopted by the Federal Medical Council (Conselho Federal de Medicina) regulated LSL in our country, demystifying a certain apprehension of a legal nature. The authors present a proposal for a protocol to be followed in these cases. CONCLUSIONS The adoption of LSL with children in the final phases of irreversible diseases has ethical, moral and legal support. In Brazil, these measures are still being adopted in a timid manner, demanding a change in behavior, especially in the involvement of families in the decision-making process.

End-of-life practices in seven Brazilian pediatric intensive care units.

Objective: To evaluate the incidence of life support limitation and medical practices in the last 48 hrs of life of children in seven Brazilian pediatric intensive care units (PICUs). Design: Cross-sectional multicenter retrospective study based on medical chart review. Setting: Seven PICUs belonging to university and tertiary hospitals located in three Brazilian regions: two in Porto Alegre (southern region), two in São Paulo (southeastern region), and three in Salvador (northeastern region). Patients: Medical records of all children who died in seven PICUs from January 2003 to December 2004. Deaths in the first 24 hrs of admission to the PICU and brain death were excluded. Interventions: Two pediatric intensive care residents from each PICU were trained to fill out a standard protocol (&kgr; = 0.9) to record demographic data and all medical management provided in the last 48 hrs of life (inotropes, sedatives, mechanical ventilation, full resuscitation maneuvers or not). Students t-test, analysis of variance, chi-square test, and relative risk were used for comparison of data. Measurements and Main Results: Five hundred and sixty-one deaths were identified; 97 records were excluded (61 because of brain death and 36 due to <24 hrs in the PICU). Thirty-six medical charts could not be found. Cardiopulmonary resuscitation was performed in 242 children (57%) with a significant difference between the southeastern and northeastern regions (p = .0003). Older age (p = .025) and longer PICU stay (p = .001) were associated with do-not-resuscitate orders. In just 52.5% of the patients with life support limitation, the decision was clearly recorded in the medical chart. No ventilatory support was provided in 14 cases. Inotropic drug infusions were maintained or increased in 66% of patients with do-not-resuscitate orders. Conclusions: The incidence of life support limitation has increased among Brazilian PICUs but with significant regional differences. Do-not-resuscitate orders are still the most common practice, with scarce initiatives for withdrawing or withholding life support measures.

Profile and consequences of children requiring prolonged mechanical ventilation in three Brazilian pediatric intensive care units

Objective: To describe the characteristics of children submitted to prolonged mechanical ventilation (MV), and evaluate their mortality, and associated factors as well as the potential impact at admissions to the pediatric intensive care unit (PICU). Methods: We conducted a retrospective study enrolling all children admitted to three Brazilian PICUs between January 2003 and December 2005 submitted to MV ≥21 days. The three selected PICUs were located in university-affiliated hospitals. From the medical charts were reported anthropometric data, diagnosis, ventilator parameters on the 21st day, length of MV, length of stay in the PICU, specific interventions (e.g., tracheostomy), and outcome. Results: One hundred eighty-four children (190 admissions) were submitted to prolonged MV (2.5% of all admissions to these 3 Brazilian PICUs), with a median age of 6 months. The mortality rate was 48% and the median time on MV was 32 days. Tracheostomy was performed on only 19% of the patients and, on average after 32 days of intubation. Mortality was associated with peak inspiratory pressure >25 cm H2O (odds ratio = 2.3; 1.1–5.1), fraction of inspired oxygen >0.5 (odds ratio = 6.3; 2.2–18.1), and vasoactive drug infusion (odds ratio = 2.6; 1.1–5.9) on the 21st day of MV. Seventy-six children (1% of the all admissions) were dependent on MV without other organ failures were 830 PICU admissions and were potentially prevented. Conclusions: A small group of children admitted to the PICU requires prolonged MV. The elevated mortality rate is associated with higher ventilatory parameters and vasoactive drug support on the 21st day of MV. Stable children requiring prolonged MV in the PICU potentially prevent additional admissions of a large number of acute and unstable patients.

Terminalidade e condutas de final de vida em unidades de terapia intensiva pediátrica

BACKGROUND AND OBJECTIVES: To analyze and discuss the medical practices related to the end-of-life care provided to children admitted to pediatric intensive care unit (PICU) in Brazil and in some countries located in the northern hemisphere. CONTENTS: Selected articles on end-of-life care published during the last years searching the PubMed, MedLine and LILACS database, with special interest on studies of death conducted in pediatric intensive care units in Brazil, Latin America, Europe and North America, using the following key words: death, bioethics, PICU, cardiopulmonary resuscitation and life support limitation (LSL). CONCLUSIONS: In North America and North Europe, the incidence of LSL is greater (60%-80%) than in south Europe and Latin America (30%-40%). In Brazil the incidence of LSL depends on the region and in the last decade it is increasing from 6% to 40%; being the do-not-reanimated order the most frequent mode of LSL. The family participation in the decision making process is not stimulated and incipient. Based on the literature review and on their experience the authors present the measures that they consider most efficient and recommended for managing this situation in our region. Despite of LSL in children with terminal and irreversible disease be considered ethically, morally and legally; these measures are still adopted in a very few circumstances in our region. Urgent changes in this behavior are necessary, specially related to family participation in the decision-making process.

Analgesia and sedation in emergency situations and in the pediatric intensive care unit

OBJETIVO: Revisar as atuais estrategias de uso de analgesicos e sedativos em salas de emergencia e em unidades de tratamento intensivo pediatrico. FONTES DOS DADOS: Revisao de bibliografia realizada na base de dados da Medline, alem de capitulos de livros de terapia intensiva pediatrica e da experiencia dos servicos dos autores. SINTESE DOS DADOS: Apesar de todos os avancos e pesquisas no campo da dor, o uso de sedativos e analgesicos em unidades intensivas pediatricas continua deficitario. A dor e o desconforto associados a situacoes de urgencia, procedimentos invasivos e internacoes prolongadas ainda resultam em significativa morbidade aos pacientes pediatricos criticamente enfermos. A dificuldade de comunicacao do paciente pediatrico com a equipe medica, a grande quantidade de procedimentos invasivos necessarios a manutencao da vida, aliados a antiga premissa de que os mecanismos de dor nao estao bem desenvolvidos nas criancas, fazem desse tema um desafio nas unidades de terapia intensiva pediatrica. Neste estudo, revisamos as drogas mais utilizadas no manejo da dor e sedacao, apresentando novas opcoes terapeuticas mais largamente estudadas recentemente. CONCLUSOES: Nos ultimos dez anos, desenvolveu-se uma consciencia mais critica em relacao a necessidade de promover um adequado alivio da dor e da ansiedade inerentes aos ambientes de emergencia e de UTI, devendo ser esta uma prioridade no planejamento terapeutico de criancas extremamente doentes.

Brain death: medical management in seven Brazilian pediatric intensive care units

OBJECTIVE To assess the incidence of brain death (BD) and its medical management and adopted protocols after its diagnosis in seven pediatric intensive care units (PICUs) located in three Brazilian regions. METHODS A cross-sectional and multicenter study was conducted, based on the retrospective review of medical records regarding all deaths that occurred between January 2003 and December 2004 in seven Brazilian PICUs of tertiary hospitals located in Porto Alegre (two), São Paulo (two) and Salvador (three). Two pediatric intensive care residents from each hospital were previously trained and filled out a standard protocol for the investigation of demographic data, cause of death, diagnosis of BD, related protocols and subsequent medical management. RESULTS A total of 525 death patients were identified and 61 (11.6%) were defined as BD. The incidence of BD was different (p = 0.015) across the seven PICUs, but with no difference across the three regions. Intracranial hemorrhage was the most frequent cause of BD (31.1%). In 80% of the cases the diagnosis of BD was confirmed by complementary exams (south = 100%, southeast = 68% and northeast = 72%; p = 0.02). The interval between the diagnosis of BD and the withdrawal of life support was different (p < 0.01) across the three regions, being faster (p = 0.04) in the south (1.8+/-1.9 h) than in the southeast (28.6+/-43.2 h) and than in the northeast (15.5+/-17.1 h). Only six (9.8%) children with BD were organ donors. CONCLUSION Although a Brazilian law defining the criteria for the determination of BD has been in place since 1997, we verified that it is not followed as strictly as it should be. Consequently, unnecessary life support is offered to deceased individuals, and there is a discrete involvement of PICUs in organ donation.

II Forum of the "End of Life Study Group of the Southern Cone of America": palliative care definitions, recommendations and integrated actions for intensive care and pediatric intensive care units

Palliative care is aimed to improve the quality of life of both patients and their family members during the course of life-threatening diseases through the prevention, early identification and treatment of the symptoms of physical, psychological, spiritual and social suffering. Palliative care should be provided to every critically ill patient; this requirement renders the training of intensive care practitioners and education initiatives fundamental. Continuing the Technical Council on End of Life and Palliative Care of the Brazilian Association of Intensive Medicine activities and considering previously established concepts, the II Forum of the End of Life Study Group of the Southern Cone of America was conducted in October 2010. The forum aimed to develop palliative care recommendations for critically ill patients.

Cuidados de final de vida em crianças: perspectivas no Brasil e no mundo

OBJECTIVE: To analyze the medical practices and the end-of-life care provided to children admitted to pediatric intensive care units in different parts of the globe. SOURCES: Articles on end-of-life care published during the last 20 years were selected from the PubMed, MEDLINE and LILACS databases, with emphasis on studies of death in pediatric intensive care units in Brazil, Latin America, Europe and North America, using the following keywords: death, bioethics, pediatric intensive care, cardiopulmonary resuscitation and life support limitation. SUMMARY OF THE FINDINGS: Publications on life support limitation (LSL) are concentrated in North America and Europe. In North American pediatric intensive care units there is a greater incidence of LSL (~ 60%) than in Europe or Latin America (30-40%). These differences appear to be related to cultural, religious, legal and economic factors. Over the last decade, LSL in Brazilian pediatric intensive care units has increased from 6 to 40%, with do not resuscitate orders as the most common method. Also of note is the low level of family participation in the decision-making process. A recent resolution adopted by the Federal Medical Council (Conselho Federal de Medicina) regulated LSL in our country, demystifying a certain apprehension of a legal nature. The authors present a proposal for a protocol to be followed in these cases. CONCLUSIONS: The adoption of LSL with children in the final phases of irreversible diseases has ethical, moral and legal support. In Brazil, these measures are still being adopted in a timid manner, demanding a change in behavior, especially in the involvement of families in the decision-making process.

1º Forum do Grupo de Estudos do Fim da Vida do Cone Sul: proposta para atendimento do paciente portador de doença terminal internado em UTI

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.