End-of-Life Practices in an Intensive Care Unit of a Private Hospital in Mexico.

Background: Many factors, such as religion, geography, and customs, influence end-of-life practices. This variability exists even between different physicians. Objective: To observe and describe the end-of-life actions of patients in the intensive care unit (ICU) and document the variables that might influence decision-making at the end of life. Materials and Methods: This is a cross-sectional study performed in the ICU patients of a private hospital from March 2017 to March 2022. We used the Philips Tasy Electronic Medical Record database of clinical records; 298 patients were included in the study during these five years (2017-2022). The data analysis was done with the statistical package SPSS version 23 for Windows. Results: A total of 297 patients were included in this study, of which more than half were men. About 60% of our sample had private health insurance, whereas the remaining paid out of pocket. Most patients had withholding treatment, followed by failed cardiopulmonary resuscitation, withdrawal treatment, and brain death, and none of the patients had acceleration of the dying process. The main cause of admission to the ICU in our center was respiratory complications. Most of our samples were Catholics. Conclusions: Decision-making at the end of life is a complex process. Active participation of the patient, when possible, the patient's family, doctors, and nurses, can give different perspectives and a more compassionate and individualized approach to end-of-life care.

End-of-Life Care for Newborn Infants: A Multicenter Real-Life Prospective Study.

INTRODUCTION: Most neonatal deaths in industrialized countries follow a process of redirection of care. The objectives of this study were to describe how neonates die in a middle-income country, whether there was redirection of care, and the reason for this decision. METHODS: This was a prospective, multicenter, cross-sectional study. Neonates who died in the delivery room or in the neonatal intensive care unit in 97 hospitals over a 6-month period were included. After each neonatal death, one investigator interviewed a member of the healthcare team who had been involved in the end-of-life care process. Perinatal data, conditions that led to death, whether there was redirection of care, and details of the end-of-life process were recorded. RESULTS: Data from 697 neonatal deaths were analyzed, which represent 80% of the total deaths occurring in Argentina in that period. The main causes of death were complications of prematurity (47%) and congenital anomalies (27%). Overall, 32% of neonates died after a process of redirection of care, and this was less frequent in the neonatal intensive care unit (28%) than in the delivery room (70%, p < 0.001). The reasons for withholding/withdrawing care were inevitable death (75%) and severe compromise of expected quality of life (25%). Redirection of care consisted in withholding therapies in 66% and withdrawal in 34%. A diagnosis of a major congenital anomaly increased the odds of redirection of care (OR 5.45; 95% CI: 3.59-8.27). CONCLUSION: Most neonates who die in Argentina do so while receiving full support. Redirection of care mainly follows a condition of inevitable death.

Adecuación del esfuerzo terapéutico: retos en pediatría / Adequacy of therapeutic effort: Challenges in pediatrics

La adecuación del esfuerzo terapéutico reemplaza la expresión limitación terapéutica y se define como la decisión de no iniciar medidas diagnósticas y terapéuticas o de suspenderlas en respuesta a la condición del paciente, para evitar conductas potencialmente inapropiadas y redireccionar los objetivos de tratamiento hacia el confort y el bienestar. En la población pediátrica, esta decisión es aún más desafiante debido a la naturaleza de la relación médico-paciente-familia y a la escasez de guías que orienten su implementación. La adecuación del esfuerzo terapéutico está enmarcada en principios éticos y legales, pero existen diversos retos a nivel práctico. Cada proceso de adecuación es único y dinámico, y debe abordarse contemplando a quién realizarlo, cuándo, cómo y con qué medidas.

The term "therapeutic limitation" has been replaced by "adequacy of therapeutic effort" and is defined as the decision to withhold or withdraw diagnostic and therapeutic measures in response to the patient's condition, avoiding potentially inappropriate behaviors and redirectong treatment goals towards comfort and well-being. In the pediatric population, this decision is even more challenging given the nature of the physician-patient-family relationship and the paucity of guidelines to address treatment goals. The adequacy of therapeutic effort is framed by ethical and legal principles, but, in practice, there are several challenges. Each adequacy process is unique and dynamic, and should be addressed by taking into account with what measures, how, when, and in whom it should be implemented

COVID-19: isolamento social e suas consequências na vida de crianças com transtorno do espectro autista / COVID-19: social isolation and consequences in the lives of children with autistic spectrum disorder / COVID-19: el aislamiento social y sus consecuencias en la vida de los niños con trastorno del espectro autista

Objetivo: conhecer as percepções de profissionais de saúde acerca das consequências do isolamento social, causado pela pandemia da COVID-19, no desenvolvimento e na vida de crianças com Transtorno do Espectro Autista. Método: estudo exploratório, descritivo e de abordagem qualitativa, apoiado nos referenciais do Cuidado Centrado na Família e da Análise de Conteúdo de Bardin e aprovado pelo Comitê de Ética em Pesquisa. Desenvolvido em municípios do interior paulista, de setembro a outubro/2021, com participação de doze profissionais de saúde. Resultados: as experiências apreendidas estiveram representadas nas categorias temáticas: "Interrupção das terapêuticas e estratégias profissionais", "Implicações da pandemia no desenvolvimento da criança autista" e "Isolamento social da pandemia e a dinâmica familiar da criança com autismo". Conclusão: o isolamento social decorrente da pandemia do coronavírus interferiu na vida das crianças autistas e suas famílias, com consequências ao desenvolvimento social, motor, linguístico e pedagógico(AU)

Objective: to know the guidelines of health professionals about the consequences of social isolation, caused by the COVID-19 pandemic, on the development and lives of children with Autistic Spectrum Disorder. Method: field study, exploratory, descriptive and with a qualitative approach, supported by the references of Family-Centered Care and Bardin's Content Analysis and approved by the Research Ethics Committee. Developed in municipalities in the interior of São Paulo, from September to October/2021, with the participation of twelve health professionals. Results: the experiences learned followed instructions in the thematic categories: "Interruption of therapies and professional strategies", "Implications of the pandemic on the development of the autistic child" and "Social isolation of the pandemic and the family dynamics of the child with autism". Conclusion: the social isolation resulting from the coronavirus pandemic interfered in the lives of autistic children and their families, with consequences for social, motor, linguistic and pedagogical development(AU)

Objetivo: conocer las percepciones de los profesionales de la salud en cuanto a las consecuencias del aislamiento social, provocado por la pandemia de la COVID-19, en el desarrollo y la vida de los niños con Trastorno del Espectro Autista. Método: estudio exploratorio, descriptivo y con enfoque cualitativo, apoyado en los referenciales del Cuidado Centrado en la Familia y el Análisis de Contenido de Bardin y aprobado por el Comité de Ética en Investigación. El estudio tuvo lugar en municipios del interior de São Paulo, de septiembre a octubre/2021, contando con la participación de doce profesionales de la salud. Resultados: las experiencias aprendidas se representaron por las categorías temáticas: "Interrupción de terapias y estrategias profesionales", "Implicaciones de la pandemia en el desarrollo del niño autista" y "Aislamiento social de la pandemia y la dinámica familiar del niño con autismo". Conclusión: el aislamiento social resultante de la pandemia del coronavirus interfirió en la vida de los niños autistas y sus familias, con consecuencias para el desarrollo social, motor, lingüístico y pedagógico(AU)

The Mapping of Influencing Factors in the Decision-Making of End-of-Life Care Patients: A Systematic Scoping Review.

Decisions in end-of-life care are influenced by several factors, many of which are not identified by the decision maker. These influencing factors modify important decisions in this scenario, such as in decisions to adapt to therapeutic support. This presented scoping review aims to map the factors that influence end-of-life care decisions for adult and older adult patients, by a scoping review. The review was carried out in 19 databases, with the keyword 'clinical decision-making' AND 'terminal care' OR 'end-of-life care' and its analogues, including publications from 2017 to 2022. The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews. The search resulted in 3474 publications, where the presence of influencing factors in end-of-life decision-making for adults and the elderly was applied as a selection criterion. Fifty-four (54) of them were selected, which means 1.5% of all the results. Among the selected publications, 89 influencing factors were found, distributed in 54 (60.6%) factors related to the health team, 18 (20.2%) to patients, 10 (11.2%) related to family or surrogates and 7 (7.8%) factors related to the decision environment. In conclusion, we note that the decision-making in end-of-life care is complex, mainly because there is an interaction of different characters (health team, patient, family, or surrogates) with a plurality of influencing factors, associated with an environment of uncertainty and that result in a critical outcome, with a great repercussion for the end of life, making it imperative the recognition of these factors for more competent and safe decision-making.

Adequacy of therapeutic effort: Challenges in pediatrics. / Adecuación del esfuerzo terapéutico: retos en pediatría.

The term "therapeutic limitation" has been replaced by "adequacy of therapeutic effort" and is defined as the decision to withhold or withdraw diagnostic and therapeutic measures in response to the patient's condition, avoiding potentially inappropriate behaviors and redirectong treatment goals towards comfort and well-being. In the pediatric population, this decision is even more challenging given the nature of the physician-patient-family relationship and the paucity of guidelines to address treatment goals. The adequacy of therapeutic effort is framed by ethical and legal principles, but, in practice, there are several challenges. Each adequacy process is unique and dynamic, and should be addressed by taking into account with what measures, how, when, and in whom it should be implemented.

La adecuación del esfuerzo terapéutico reemplaza la expresión limitación terapéutica y se define como la decisión de no iniciar medidas diagnósticas y terapéuticas o de suspenderlas en respuesta a la condición del paciente, para evitar conductas potencialmente inapropiadas y redireccionar los objetivos de tratamiento hacia el confort y el bienestar. En la población pediátrica, esta decisión es aún más desafiante debido a la naturaleza de la relación médico-paciente-familia y a la escasez de guías que orienten su implementación. La adecuación del esfuerzo terapéutico está enmarcada en principios éticos y legales, pero existen diversos retos a nivel práctico. Cada proceso de adecuación es único y dinámico, y debe abordarse contemplando a quién realizarlo, cuándo, cómo y con qué medidas.

Cancelamento cirúrgico ambulatorial: uma revisão integrativa / Cancellation of outpatient surgery: an integrative review / Cancelación quirúrgica ambulatoria: una revisión integradora

Objetivo: discutir as evidências científicas sobre as causas de cancelamento em cirurgia ambulatorial. Método: trata-se de uma revisão integrativa com busca nas bases de dados eletrônicas Medline, Embase, Lilacs, Cinahl, Web of Science e Scopus, a partir dos termos controlados Ambulatory Surgical Procedures, Ambulatory Surgery, Suspension e termos livres sinônimos. Resultados: selecionaram-se 13 estudos. O país com menor taxa de cancelamento cirúrgico ambulatorial foram os Estados Unidos com 0,5%, e o maior, a Nigéria com 25,40%. Foram encontradas 53 causas de cancelamento em cirurgia ambulatorial, das quais agrupou-se em três categorias: fatores do paciente, clínicos e institucionais. Conclusão: Evidencia-se que as causas de cancelamento cirúrgico ambulatorial foram diversas e comuns nas instituições, sendo o absenteísmo do paciente no dia do procedimento agendado a causa mais frequente, demonstrando que estratégias assistenciais e de gestão precisam ser realizadas.

Objective: to discuss the scientific evidence on the causes of cancellation in outpatient surgery. Method: this integrative review involved searching the Medline, Embase, Lilacs, Cinahl, Web of Science and Scopus electronic databases using the controlled terms Ambulatory Surgical Procedures, Ambulatory Surgery, Suspension and free synonyms. Results: 13 studies were selected. By country, the United States, with 0.5%, had the lowest outpatient surgery cancellation rate, and Nigeria, with 25.40%, the highest. The fifty-three causes of outpatient surgery cancellation found were grouped into three categories: patient, clinical, and institutional factors. Conclusion: the causes of outpatient surgical cancellation were found to be diverse and common in institutions, the most frequent cause being patient absence on the day of the scheduled procedure, demonstrating that care and management strategies need to be developed and applied.

Objetivo: discutir la evidencia científica sobre las causas de cancelación en cirugía ambulatoria. Método: se trata de una revisión integradora con búsqueda en las bases electrónicas de datos Medline, Embase, Lilacs, Cinahl, Web of Science y Scopus, utilizando los términos controlados Ambulatory Surgical Procedures, Ambulatory Surgery, Suspension y términos sinónimos libres. Resultados: se seleccionaron 13 estudios. El país con la tasa de cancelación quirúrgica ambulatoria más baja fue Estados Unidos con un 0,5% y el de más alta Nigeria, con un 25,40%. Se encontraron 53 causas de cancelación en cirugía ambulatoria, las cuales se agruparon en tres categorías: factores del paciente, clínicos e institucionales. Conclusión: Se pone en evidencia que las causas de cancelación de cirugía ambulatoria fueron diversas y comunes en las instituciones, siendo la causa más frecuente el absentismo del paciente el día del procedimiento programado, demostrando que es necesario realizar estrategias de atención y de gestión.

Factibilidad, eficacia y satisfacción lograda por la intervención transdisciplinaria de un comité de ética clínico-hospitalario. Un estudio cualicuantitativo / Feasibility, effectiveness, and satisfaction achieved by the transdisciplinary intervention of a clinical-hospital ethics committee. A qualitative and quantitative study

Introducción. Las funciones del Comité de Ética Clínica (CEC) son educativas, normativas, consultivas, mediadoras y reflexivas. Como cualquier servicio de salud, las consultas de casos a un CEC deben ser sujetas a revisión y mejora de la calidad. Los objetivos fueron evaluar la factibilidad, la efectividad y la satisfacción de las recomendaciones ético-asistenciales dadas por el CEC, y evaluar su impacto en el equipo tratante y en la familia. Población y métodos. Estudio descriptivo, retrospectivo, cualicuantitativo, de casos clínicos presentados en el Comité de Ética Clínica del hospital desde el 1 de enero de 2013 hasta el 31 de diciembre de 2017, según datos del libro de actas, historias clínicas, registros de la Oficina de Comunicación a Distancia y entrevistas semiestructuradas al equipo de salud. Resultados. Se analizaron 108 casos (106 pacientes), 73 casos con encuesta y registros, y 35 solamente con registros. Los motivos principales más frecuentes de consulta fueron los siguientes: adecuación del esfuerzo terapéutico (46/42,6 %), compromiso neurológico grave (15/13,9 %), calidad de vida del paciente (11/10,2 %), conflictos entre el paciente, la familia y el sistema de salud (7/6,5 %), y rechazo del tratamiento por la familia (6/5,6 %). Se hallaron niveles altos de satisfacción (> 95 %) y niveles moderados de factibilidad (> 74 %) y efectividad (> 85 %). Solo en 50/108 casos (46,3 %) quedó registro en la historia clínica de la consulta al CEC y el 44 % de los profesionales opinó que la consulta tuvo un impacto positivo en la familia y en el paciente. Conclusiones. Los resultados contribuyeron a descubrir oportunidades de mejora, especialmente en la documentación y en la comunicación en el proceso de consulta.

Introduction. A clinical ethics committee (CEC) has educational, regulatory, advisory, mediation, and reflexive functions. As any health care service, the consults with the CEC should be subjected to review and quality improvement. The study objectives were to assess the feasibility, effectiveness, and satisfaction with the bioethical recommendations made by the CEC and assess their impact on the treating team and the patient's family. Population and methods. Descriptive, retrospective, qualitative, and quantitative study of clinical cases submitted to the hospital's CEC between January 1 st, 2013 and December 31, 2017 using data from the CEC minute book, medical records, registries from the Office for Remote Communication, and semi-structured interviews with health care team members. Results. A total of 108 cases (106 patients) were analyzed: 73 cases with survey and registries and 35 with registries only. The main most frequent reasons for consultation were adequacy of therapeutic effort (46/42.6%), severe neurological involvement (15/13.9%), patient's quality of life (11/10.2%), patient-family-health system conflict (7/6.5%), and family's refusal of treatment (6/5.6%). High levels of satisfaction (> 95%) and moderate levels of feasibility (> 74%) and effectiveness (> 85%) were observed. In only 50/108 cases (46.3%), the consultation with the CEC was registered in the medical record, 44% of health care providers stated that the consultation had a positive impact on the patient and their family. Conclusions. Results helped to establish improvement opportunities, especially in terms of documentation and communication in the consultation process.

Feasibility, effectiveness, and satisfaction achieved by the transdisciplinary intervention of a clinical-hospital ethics committee. A qualitative and quantitative study. / Factibilidad, eficacia y satisfacción lograda por la intervención transdisciplinaria de un comité de ética clínico-hospitalario. Un estudio cualicuantitativo.

INTRODUCTION: A clinical ethics committee (CEC) has educational, regulatory, advisory, mediation, and reflexive functions. As any health care service, the consults with the CEC should be subjected to review and quality improvement. The study objectives were to assess the feasibility, effectiveness, and satisfaction with the bioethical recommendations made by the CEC and assess their impact on the treating team and the patient's family. POPULATION AND METHODS: Descriptive, retrospective, qualitative, and quantitative study of clinical cases submitted to the hospital's CEC between January 1st, 2013 and December 31st, 2017 using data from the CEC minute book, medical records, registries from the Office for Remote Communication, and semi-structured interviews with health care team members. RESULTS: A total of 108 cases (106 patients) were analyzed: 73 cases with survey and registries and 35 with registries only. The main most frequent reasons for consultation were adequacy of therapeutic effort (46/42.6%), severe neurological involvement (15/13.9%), patient's quality of life (11/10.2%), patient-family-health system conflict (7/6.5%), and family's refusal of treatment (6/5.6%). High levels of satisfaction (> 95%) and moderate levels of feasibility (> 74%) and effectiveness (> 85%) were observed. In only 50/108 cases (46.3%), the consultation with the CEC was registered in the medical record, 44% of health care providers stated that the consultation had a positive impact on the patient and their family. CONCLUSIONS: Results helped to establish improvement opportunities, especially in terms of documentation and communication in the consultation process.

Introducción. Las funciones del Comité de Ética Clínica (CEC) son educativas, normativas, consultivas, mediadoras y reflexivas. Como cualquier servicio de salud, las consultas de casos a un CEC deben ser sujetas a revisión y mejora de la calidad. Los objetivos fueron evaluar la factibilidad, la efectividad y la satisfacción de las recomendaciones ético-asistenciales dadas por el CEC, y evaluar su impacto en el equipo tratante y en la familia. Población y métodos. Estudio descriptivo, retrospectivo, cualicuantitativo, de casos clínicos presentados en el Comité de Ética Clínica del hospital desde el 1 de enero de 2013 hasta el 31 de diciembre de 2017, según datos del libro de actas, historias clínicas, registros de la Oficina de Comunicación a Distancia y entrevistas semiestructuradas al equipo de salud. Resultados. Se analizaron 108 casos (106 pacientes), 73 casos con encuesta y registros, y 35 solamente con registros. Los motivos principales más frecuentes de consulta fueron los siguientes: adecuación del esfuerzo terapéutico (46/42,6 %), compromiso neurológico grave (15/13,9 %), calidad de vida del paciente (11/10,2 %), conflictos entre el paciente, la familia y el sistema de salud (7/6,5 %), y rechazo del tratamiento por la familia (6/5,6 %). Se hallaron niveles altos de satisfacción (> 95 %) y niveles moderados de factibilidad (> 74 %) y efectividad (> 85 %). Solo en 50/108 casos (46,3 %) quedó registro en la historia clínica de la consulta al CEC y el 44 % de los profesionales opinó que la consulta tuvo un impacto positivo en la familia y en el paciente. Conclusiones. Los resultados contribuyeron a descubrir oportunidades de mejora, especialmente en la documentación y en la comunicación en el proceso de consulta.

Eutanasia: aclarando conceptos / Clarifying concepts on euthanasia

Euthanasia is a subject of permanent discussion everywhere, mainly about its ethical appropriateness and about its legalization in different countries. This debate includes many ethical, legal, social, political, spiritual, religious, and public health issues. A relevant problem is the frequent misunderstanding that many have about the meaning of the terms and concepts used in different ethical and clinical end of life settings. Many views and even texts are affected by such mistakes, rendering a constructive discussion almost impossible. The goal of this article is to contribute to an improvement of the social and legislative discussion about euthanasia through an elucidation of the main terms and notions linked to this topic. We present definitions and explanations for euthanasia, assisted suicide, withdrawal or foregoing of therapy, treatment rejection, palliative sedation, dignified death and others.

Cancelamento cirúrgico: percepção de enfermeiros do bloco operatório / Surgery cancellation: perception of surgical block nurses / Cancelación quirúrgica: percepción de los enfermeros del quirófano

Objetivo: Identificar a percepção de enfermeiros do bloco operatório sobre os motivos para o cancelamento de cirurgias eletivas e as estratégias para reduzir as taxas de suspensão. Método: Estudo de abordagem qualitativa realizado em um hospital de alta complexidade do Recife, Pernambuco, Brasil, com enfermeiros atuantes no bloco operatório. A coleta de dados foi realizada por meio de entrevistas gravadas com sete enfermeiros responsáveis pelas cirurgias eletivas. Para o tratamento dos dados, utilizou-se a técnica da análise de conteúdo de Bardin. Resultados: Os discursos foram agrupados em duas categorias temáticas: lacunas no planejamento cirúrgico, com três subcategorias, e prevenção de situações evitáveis, com duas subcategorias. Conclusão: Os motivos para o cancelamento de cirurgias estavam relacionados ao planejamento do ambiente cirúrgico e à preparação clínica do paciente. Os enfermeiros identificaram esses motivos como situações evitáveis e consideraram que a comunicação efetiva e atitudes de liderança assertivas são estratégias que reduzem os índices de suspensão cirúrgica.

Objective: To identify the perception of surgical block nurses of the reasons for the cancellation of elective surgeries and strategies to reduce suspension rates. Method: This is a qualitative study carried out in a tertiary hospital of Recife, Pernambuco, Brazil, with nurses working in the surgical block. Data were collected through recorded interviews with seven nurses responsible for elective surgeries. Data treatment was based on Bardin's content analysis technique. Results: The statements were grouped into two thematic categories: gaps in surgical planning, with three subcategories, and prevention of avoidable situations, with two subcategories. Conclusion: The causes for surgery cancellation were related to surgical environment planning and the patient's clinical preparation. The nurses defined these reasons as avoidable situations and considered effective communication and assertive leadership attitudes as strategies that reduce surgical suspension rates.

Objetivo: Identificar la percepción de los enfermeros en el quirófano sobre los motivos de cancelación de las cirugías electivas y las estrategias para reducir las tasas de suspensión. Método: Estudio cualitativo, realizado en un hospital de alta complejidad en Recife, Pernambuco, Brasil, con enfermeros trabajando en quirófano. La recolección de datos se realizó mediante entrevistas grabadas con siete enfermeros responsables de cirugías electivas. Para el tratamiento de los datos se utilizó la técnica de Análisis de Contenido de Bardin (Bardin Content Analysis). Resultados: Los discursos se agruparon en dos categorías temáticas: brechas en la planificación quirúrgica, con tres subcategorías, y prevención de situaciones evitables, con dos subcategorías. Conclusión: Los motivos para cancelar cirugías estaban relacionados con la planificación del entorno quirúrgico y la preparación clínica del paciente. Los enfermeros identificaron estos motivos como situaciones prevenibles y consideraron que la comunicación eficaz y las actitudes de liderazgo asertivo son estrategias que reducen las tasas de suspensión quirúrgica.

Frequência e Motivos para a não Administração e Suspensão de Medicamentos durante um Evento de Síndrome Coronariana Aguda. Estudo ERICO / Frequency and Reasons for Non-Administration and Suspension of Drugs During an Acute Coronary Syndrome Event. The ERICO Study

Resumo Fundamentos: Poucos estudos discutiram causas para o subtratamento medicamentoso na SCA. Objetivos: Avaliar a não-administração e suspensão de medicamentos durante o tratamento intra-hospitalar da SCA na Estratégia de Registro de Síndrome Coronariana Aguda (estudo ERICO). Métodos: Analisamos prontuários de 563 participantes ERICO para avaliar a frequência e motivos da não administração e/ou suspensão de medicamentos. Construímos modelos de regressão logística para avaliar se sexo, idade ≥65 anos, nível educacional ou subtipo de SCA estavam associados com (a) não administração de ≥1 medicamentos; e (b) não administração ou suspensão de ≥1 medicamentos. O nível de significância foi 5%. Resultados: A amostra é composta por 58,1% de homens e com idade mediana de 62 anos. Em 183 (32,5%) participantes ≥1 medicamentos não foram administrados e 288 (51,2%) apresentaram ≥1 medicamentos não administrados ou suspensos. As causas mais frequentes foram risco de sangramento (aspirina, clopidogrel e heparina), insuficiência cardíaca (betabloqueadores) e hipotensão (inibidores da enzima conversora da angiotensina e bloqueadores dos receptores da angiotensina). Indivíduos com idade ≥65 anos (razão de chances [RC]:1,51; intervalo de confiança de 95% [IC95%]:1,05-2,19) e com angina instável (RC:1,72; IC95%:1,07-2,75) tiveram maior chance de não-administração. Considerando apenas pacientes com infarto do miocárdio, idade ≥65 anos foi associada tanto à não administração quanto à não administração ou suspensão. Conclusões: A não administração ou suspensão de ≥1 medicamento não foi rara no estudo ERICO. Indivíduos com idade ≥65 anos ou com angina instável tiveram maior chance de não administração e podem ser subtratados nesse cenário.

Abstract Background: Few studies have discussed the reasons for pharmacological undertreatment of Acute Coronary Syndrome (ACS). Objectives: To determine the frequency and reasons for the non-administration and suspension of medications during in-hospital treatments of ACS in the Strategy of Registry of Acute Coronary Syndrome (ERICO) study. Methods: The present study analyzed the medical charts of the 563 participants in the ERICO study to evaluate the frequency and reasons for the non-administration and/or suspension of medications. Logistic regression models were built to analyze if sex, age ≥65 years of age, educational level, or ACS subtype were associated with (a) the non-administration of ≥1 medications; and (b) the non-administration or suspension of ≥1 medications. The significance level was set at 5%. Results: This study's sample included 58.1% males, with a median of 62 years of age. In 183 (32.5%) participants, ≥1 medications were not administered, while in 288 (51.2%), ≥1 medications were not administered or were suspended. The most common reasons were the risk of bleeding (aspirin, clopidogrel, and heparin), heart failure (beta blockers), and hypotension (angiotensin-converting enzyme inhibitors and angiotensin receptor blockers). Individuals aged ≥65 (odds ratio [OR]:1.51; 95% confidence interval [95% CI]:1.05-2.19) and those with unstable angina (OR:1.72; 95% CI:1.07-2.75) showed a higher probability for the non-administration of ≥1 medication. Considering only patients with myocardial infarction, being ≥65 years of age was associated with both the non-administration and the non-administration or suspension of ≥1 medication. Conclusions: Non-administration or suspension of ≥1 medication proved to be common in this ERICO study. Individuals of ≥65 years of age or with unstable angina showed a higher probability of the non-administration of ≥1 medication and may be undertreated in this scenario. (Arq Bras Cardiol. 2020; 115(5):830-839)

Preditores do abandono inicial em psicoterapia psicodinâmica / Predictors of initial abandonment in psychodynamic psychotherapy / Predictores del abandono inicial en psicoterapia psicodinámica

O abandono em psicoterapia é um fator amplamente estudado, tendo em vista sua relevância para a prática clínica. Algumas variáveis têm sido preditoras da interrupção da psicoterapia; no entanto, há poucos estudos que diferenciam os períodos do abandono. Este estudo objetiva identificar os preditores do abandono inicial no processo psicoterapêutico de 1.272 prontuários de pacientes adultos jovens. Os instrumentos utilizados foram: a ficha de contato inicial, a avaliação e a alta institucional e o SCL-90-R. Os resultados foram obtidos por meio da análise de Regressão Logística Binária Multivariada, que indicaram como preditoras do abandono inicial, as variáveis sociodemográfica: baixa renda; clínica: ansiedade fóbica; e as de tratamento: não ter realizado psicoterapia anteriormente; e razões do término de tratamento: tipo de abandono (não compareceu à sessão e não justificou); paciente (outros motivos: mudança de cidade, falta de recursos e motivos de saúde); fatores organizacionais; insatisfação. Os resultados sugerem uma atenção às consultas iniciais para auxiliar na adesão ao tratamento.

Abandonment in psychotherapy is a widely studied factor, considering its relevance to clinical practice. Some variables have been predictive of the interruption of psychotherapy; however, there are few studies that differentiate periods of abandonment. This study aims to identify the predictors of initial abandonment in the psychotherapeutic process of 1,272 medical records of young adult patients. The instruments used were the initial contact sheet, the evaluation, the institutional discharge and the SCL-90-R. The results were obtained through the analysis of Multivariate Binary Logistic Regression, which indicated as predictors of initial abandonment, the following variables: sociodemographic: low income; clinical: phobic anxiety; and treatment: not having previously performed psychotherapy; and reasons for termination of treatment: type of abandonment (did not attend the session and did not justify); patient (other reasons: change of city, lack of resources and reasons for health); organizational factors; dissatisfaction. The results suggest an attention to the initial appointments to help in treatment accession.

El abandono en psicoterapia es un factor ampliamente estudiado, teniendo en vista su relevancia para la práctica clínica. Algunas variables han sido predictores de la interrupción de la psicoterapia; sin embargo, hay pocos estudios que diferencian los períodos del abandono. Este estudio tiene como objetivo identificar los predictores del abandono inicial en el proceso psicoterapéutico de 1.272 prontuarios de pacientes adultos jóvenes. Los instrumentos utilizados fueron la ficha de contacto inicial, la evaluación y alta institucional y el SCL-90-R. Los resultados fueron obtenidos por medio del análisis de Regresión Logística Binaria Multivariada, que indicaron como predictores del abandono inicial, las variables: sociodemográfica: baja renta; clínica: ansiedad fóbica; y las de tratamiento: no haber realizado psicoterapia anteriormente; y razones del término de tratamiento: tipo de abandono (no compareció a la sesión y no justificó); paciente (otros motivos: cambio de ciudad, falta de recursos y motivos de salud); factores organizacionales; insatisfacción. Los resultados sugieren una atención a las consultas iniciales para ayudar en la adhesión al tratamiento.

Do-not-resuscitate and treatment limitation decisions - Six years of experience from a Portuguese General Intensive Care Unit

SUMMARY OBJECTIVE Treatment limitation, as well as do-not-resuscitate (DNR) directives, are difficult but important to improve patients' quality of life and minimize dysthanasia. We aimed to study the approach to withholding, withdrawal, and DNR decisions, patients' characteristics, and process documentation in a general Intensive Care Unit (ICU) in Portugal. METHODS A retrospective analysis of data regarding the limitation of treatment decisions collected from previously-designed forms and complemented by medical record consultation. RESULTS A total of 1602 patients were admitted to the ICU between 2011 and 2016. DNR decisions were documented in 127 cases (7.9%). Patients with treatment limitations were older and had higher Simplified Acute Physiology Score II. The most frequent diagnosis preceding these decisions was sepsis (52.0%, n = 66); the most common main reason for limiting treatment was a poor prognosis of acute illness. Of the patients to whom a DNR was implemented, 117 (92.1%) died in the ICU (40.1% of the total number of ICU deaths), and hospital mortality was 100%. Participants in these decisions, as well as types of treatment withdrawn and their respective timings, were not registered in medical records. CONCLUSION Treatment limitation and DNR decisions were relatively common, in line with other Southern European studies, but behind Northern European and North American centers. Patients with these limitations were older and more severely ill than patients without such decisions. Documentation of these processes should be clear and detailed, either in specific forms or computerized clinical records; there is room for improvement in this area.

RESUMO OBJETIVO Decisões de limitação terapêutica (DLT) e de não reanimação (DNR) são difíceis, mas importantes, visando melhorar a qualidade de vida dos doentes e minimizar distanásia. O objetivo deste estudo foi avaliar a abordagem das DNR e DLT, as características dos doentes e a documentação dessas decisões numa Unidade de Cuidados Intensivos Polivalente (Ucip) em Portugal. MÉTODOS Análise retrospectiva dos dados referentes a DLT e DNR, recolhidos a partir de formulários previamente elaborados e complementados por consulta de processo clínico. RESULTADOS Um total de 1.602 doentes foi internado na Ucip entre 2011 e 2016. DNR foi documentada em 127 casos (7,9%). Doentes com DLT eram mais velhos e tinham um Simplified Acute Physiology Score II mais elevado. O diagnóstico mais frequente que precedeu essas decisões foi sepse (52,0%, n=66); A razão mais comum para limitar o tratamento foi mau prognóstico da doença aguda. Dos doentes nos quais a DNR foi implementada, 117 (92,1%) morreram na Ucip (40,1% do total de óbitos na Ucip) e a mortalidade hospitalar foi de 100%. Os intervenientes nessas decisões, bem como os tipos de tratamento retirados, não foram rotineiramente registrados. CONCLUSÃO As DLT e DNR foram relativamente comuns, em consonância com outros estudos do sul da Europa, mas atrás dos centros do norte da Europa e da América do Norte. Os doentes com essas limitações eram mais velhos e mais gravemente doentes. A documentação dessas decisões deve ser clara e detalhada, seja em formulários específicos, seja em registros clínicos informatizados. Há espaço para melhorias nessa área.

Características de la limitación de terapia de soporte vital en pacientes fallecidos en unidades de medicina intensiva / Characteristics of limiting life support therapies in patients who died in the ICU

Introducción: la limitación de terapias de soporte vital (LTSV) es una práctica habitual y éticamente aceptada. La misma se enmarca en el concepto de adecuación del esfuerzo terapéutico. Objetivo: determinar la frecuencia, las directivas de implementación y los factores asociados a LSTV en los pacientes fallecidos en unidades de cuidados intensivos (UCI). Conocer la frecuencia y características del registro de este proceso en la historia clínica. Diseño: estudio observacional multicéntrico de corte transversal. Ámbito: se analizaron las historias clínicas de ocho UCI polivalentes públicas y privadas de Uruguay. Pacientes: se incluyeron todos los pacientes mayores de 18 años fallecidos en un período de seis meses consecutivos en el año 2011. Intervenciones: análisis de las características de los pacientes mediante revisión de historias clínicas. Resultados: analizamos 210 pacientes fallecidos. Se identificó LSTV en 63 (30%). El 75% de las decisiones consistió en la retirada de medidas terapéuticas. Los factores independientemente asociados a LTSV fueron: mayor edad (OR 1,04 (IC 95% 1,01-1,07), p = 0,001), mayor estadía en UCI (OR 1,06 (IC 95% 1,02 - 1,11), p = 0,001) y limitación para las actividades de la vida diaria (OR 4,65 (IC 95% 1,1-19,6), p=0,035). El 70% de las directivas LTSV fueron registradas en la historia clínica. Los soportes vitales más frecuentemente retirados fueron: nutrición parenteral (100%), vasopresores (79%), nutrición enteral (64%) y antimicrobianos (52%). La asistencia ventilatoria mecánica invasiva se retiró en el 33% de los casos. Conclusiones: un tercio de los pacientes fallece con LTSV. Este tipo de decisiones se asocian a mala calidad de vida previa, mayor edad y mayor estadía en UCI. Un tercio de las decisiones de LTSV no son registradas. (AU)

Introduction: withdraw and withhold life support therapies is an usual and ethically accepted practice. Objectives: to determine the frequency, the directives and factors associated with withdrawing and withholding life support therapies in patients who died in ICU. Determine the frequency and characteristics of the record of this process in clinical history. Design: multicentric observational study of cross section. Setting: clinical histories of 8 public and private mixed ICUs in Uruguay were analyzed. Patients: all patients over 18 years who died in a period of 6 consecutive months in 2011 were included. Interventions: analysis of the characteristics of patients through review of clinical histories. Results: we analyzed 210 patients who died. Withdrawing or withholding was identified in 63 (30%). 75% of the decisions consisted in withdraw therapeutic measures. Factors independently associated to withdrowing or withholding therapies were: an older age (OR 1.04 (95% CI 1.01-1.07), p = 0.001), a longer stay in ICU (OR 1.06 (95% CI 1, 02 - 1.11), p = 0.001), and the limitation for activities of daily living (OR 4.65 (95% CI 1.1 -19.6), p = 0.035). 70% of the decisions were recorded in the clinical history. The most frequently removed vital supports were: parenteral nutrition (100%), vasopressors (79%), enteral nutrition (64%) and antimicrobials (52%). Invasive mechanical ventilatory assistance was removed in 33% of the cases. Conclusions: one third of patients die with LSTL. These types of decisions are associated with a poor quality of life, an older age and a longer stay in the ICU. One third of LTSV decisions are not registered.

Introdução: a limitação do emprego de terapias de suporte vital (LTSV) é uma prática habitual e eticamente aceitada. Esta decisão está compreendida no conceito de adequação do esforço terapêutico. Objetivos: determinar a frequência, as normas de implementação e os fatores associados à LSTV nos pacientes falecidos em unidades de cuidados intensivos (UCI). Conhecer a frequência e as características do registro deste processo no prontuário do paciente. Tipo de estudo: estudo observacional multicêntrico de corte transversal. Escopo: foram analisados os prontuários dos pacientes de 8 UCIs polivalentes públicas e privadas do Uruguai. Pacientes: foram incluídos todos os pacientes maiores de 18 anos falecidos em um período de 6 meses consecutivos em 2011. Intervenções: análise das características dos pacientes pela revisão dos prontuários dos pacientes. Resultados: analisamos 210 pacientes falecidos. Em 63 (30%) pacientes foi registrada a LTSV. 75% das decisões consistiam na retirada de medidas terapêuticas. Os fatores independentemente associados a LTSV foram: idade mais avançada (OR 1,04 (IC 95 % 1,01-1,07), p = 0,001), maior permanência na UCI (OR 1,06 (IC 95% 1,02 - 1,11), p = 0,001), e limitação para as atividades da vida diária (OR 4,65 (IC 95% 1,1 -19,6), p=0,035). 70% das diretivas LTSV foram registradas no prontuário do paciente. Os suportes vitais mais frequentemente retirados foram: nutrição parenteral (100%), vasopressores (79%), nutrição enteral (64%) e antimicrobianos (52%). A assistência ventilatória mecânica invasiva foi retirada em 33% dos casos. Conclusões: um terço dos pacientes falece com LTSV. Este tipo de decisão está associada à má qualidade de vida previa, idade mais avançada e maior permanência em UCI. Um terço das decisões de LTSV não é registrado.

Renouncement of renal replacement therapy: withdrawal and refusal / Renúncia à terapia renal substitutiva: descontinuação e sonegação

Abstract Renouncement of renal replacement therapy (RRT) is a medical dilemma. This review covers the concept, the magnitude, the prognosis, and discusses strategies and management approaches about this subject in patients with CKD and AKI. Evidence suggests that refusal is more frequent and carries a more guarded prognosis than withdrawal of RRT. When RRT is not expected to be beneficial in terms of survival or quality of life, conservative treatment and palliative care are alternatives. We review the historical evolution of guidelines about renouncement of RRT and palliative care, and highlight the absence of specific recommendations in Brazil. However renouncement of RRT may be ethically and legally accepted in Brazil, as the right to a dignified death. Longer life expectancy, economic pressures, and greater awareness will require a more detailed discussion about indications and sustainable use of RRT, and possibly the elaboration of national guidelines.

Resumo A renúncia à terapia renal substitutiva (TRS) é um dilema. Essa revisão aborda o conceito, magnitude, prognóstico, estratégias e condutas sobre o tema, em pacientes com doença renal crônica e com injúria renal aguda. Evidências indicam ser a recusa mais comum e de prognóstico mais incerto do que a suspensão da TRS. Quando a TRS não agrega sobrevida ou qualidade de vida, o tratamento conservador com cuidados paliativos pode ser uma alternativa. A evolução das diretrizes sobre a renúncia à TRS e a instituição de cuidados paliativos é revista, com ressalva à ausência de tais recomendações no Brasil. Em certos casos, a renúncia à TRS pode ter sustentação ética e legal no país, amparada pelo direito à morte digna. A maior expectativa de vida e pressões econômicas exigem maior discussão sobre indicações e uso sustentável da TRS, demandando maior conscientização e, possivelmente, a elaboração de diretrizes nacionais sobre o tema.

Palliative extubation: case analysis in an intensive care unit / Extubação paliativa: análise de casos em uma unidade de terapia intensiva

Current technological advancements have allowed for the prolongation of the dying process, especially in IntensiveCare Units (ICU). This has increased the need for decisions on the limitation of therapeutic effort (LTE), such as the useof palliative extubation that, although difficult from an emotional standpoint, has legal and ethical justifications, and hasincreased family acceptance. The objective was to evaluate the clinical and demographical profile of patients submittedto palliative extubation (PT) in the ICU of the University Hospital of the Universidade Federal de Santa Catarina (HU/UFSC), Brazil. This was a historical cohort whose data were obtained from forms filled out by critical care doctors fromthe Hospital Death Commission at the HU/UFSC. Patients submitted to LTE that died between January 2011 andDecember 2014 were included in the study. The use of PT and clinical and epidemiological data were collected. LTEwas indicated in 374 (53.8%) patients, with 23 (6.1%) receiving PT. Average age of patients undergoing PT was 73.8years; 10 patients were over 60, and 9 were over 80 years of age. Ten (43.4%) patients had been previously in the ICU.The average time from checking in at the ICU and extubation was 4.4 days, and between extubation and death it was2.5 days. Neurological disease was the main cause of death of patients subjected to PT. All family members were awareof the extubation. Family members from 2 families witnessed the extubation. Morphine was the most common analgesicprescribed. It is concluded that patients submitted to PT were older, with neurological diseases, and the average timefrom extubation to death was 2.5 days

O desenvolvimento tecnológico do mundo atual tem permitido o prolongamento do morrer, principalmente em unidadesde terapia intensiva (UTI). Torna-se crescente a necessidade de decisões de limite de esforço terapêutico (LET), do qualse destaca a extubação paliativa (EP), que embora difícil de ser aceita do ponto de vista emocional, tem respaldo éticolegale aumenta a satisfação familiar. O estudo teve como objetivo avaliar o perfil clínico-demográfico dos pacientesextubados paliativamente (ExPl) na UTI do HU/UFSC. Trata-se de coorte histórico, cujos dados foram coletados atravésdas fichas preenchidas por médicos intensivistas que constituem a Comissão de Óbito da instituição. Foram incluídosos pacientes que morreram na UTI/HU/UFSC, após indicação de LET, entre janeiro/2011 e dezembro/2014. Foramselecionados os pacientes que foram ExPl, sendo anotados seus dados clínicos e epidemiológicos. LET foi apontado em374 (53,8%) pacientes, sendo 23 (6,1%) ExPl. A média da idade dos ExPl foi de 73,8 anos, 10 tinham mais de 60 e 9 maisde 80 anos. Dez (43,4%) pacientes já haviam sido internados previamente em UTI. O tempo médio entre a internaçãoextubaçãofoi 4,4 dias e entre extubação-morte foi de 2,5 dias. Doença neurológica foi a principal causa da morte dospacientes ExPl. Todos os familiares estavam cientes da EP. Familiares de 2 pacientes acompanharam a EP. Morfina foia medicação analgésica mais prescrita. Concluiu-se que os pacientes que foram ExPl eram mais idosos, acometidospreferencialmente por doenças neurológicas e o tempo médio entre a EP e óbito foi de 2,5 dias

Opinión de los miembros de la Justicia Nacional en lo Penal y Civil (Familia) en situaciones de limitación del soporte vital en pediatría / Opinions of members of the National Civil (Family Proceedings) and Criminal Courts in withholding or withdrawing of life support situations in pediatrics

Introducción. La posibilidad de sostener artificialmente las funciones vitales hace más difícil diferenciar al paciente en agonía terminal del paciente con posibilidades de supervivencia, lo que pone al grupo que lo rodea frente a un dilema. Por un lado, se presenta la continuación de soporte que solo prolongue un proceso irreversible, que causa daños físicos, psíquicos y a su dignidad. Por otro, la abstención o retiro de soporte vital sin la reflexión y el esfuerzo diagnóstico-terapéutico apropiado puede dejar sin esperanza y llevar a la muerte a un niño potencialmente recuperable. Además, la toma de decisiones, en estas circunstancias, enfrenta diversas barreras que dificultan lograr el mejor interés del paciente. Entre ellas, los temores legales son un factor importante. ¿En qué medida esos temores están justificados? Objetivo. Explorar la opinión del Poder Judicial de la Nación respecto al enfoque que, desde el derecho, se da a situaciones de limitación de soporte vital. Población y métodos. Profesionales activos del ámbito penal, civil y médico forense. Encuesta semiestructurada sobre tres casos hipotéticos con decisiones sobre la limitación del soporte vital. Resultados. Se repartieron 185 encuestas; se contestaron 68 (36,76%) y 51 (30,3%) fueron respondidas en forma completa. No tipificaron ningún delito en ninguno de los tres casos 28 (55%) encuestados. Trece (25%) interpretaron como delitos las decisiones de los tres casos; 6 (12%), alguno de los casos; y 4 (8%), 2 de los 3 casos. Los delitos seleccionados por los encuestados incluyeron homicidio doloso, homicidio culposo y abandono de persona. Conclusiones. El 45% de los encuestados consideraron que hubo alguna forma de delito en las decisiones tomadas.

Introduction. The possibility of sustaining life functions makes it difficult to distinguish between a dying patient and a patient with chances of survival, raising a dilemma for everyone around them. On the one side, continuing with life support techniques that would only extend an irreversible process and result in physical and psychological damage and harm their dignity. On the other side, withholding or withdrawing life support without an adequate reflection and diagnostic-therapeutic effort which may lead to the death of a potentially recoverable child. In addition, making decisions in this context implies facing barriers that hinder the possibility of pursuing the patient's best interest. Among such barriers, the fear of litigation plays a major role. To what extent is this fear justified? Objective. To explore the opinions of the members of the National Judiciary regarding the approach to withholding or withdrawing of life support from a legal stance. Population and methods. Professionals working in the criminal, civil and forensic medicine settings. Semistructured survey on three hypothetical case histories that implied making a decision to withhold or withdraw life support. Results. One hundred and eighty-five surveys were distributed; 68 (36.76%) were partially completed and 51 (30.3%), in full. Twenty-eight (55%) survey respondents did not criminalize any of the three cases presented. Thirteen (25%) respondents considered that the decisions made in the three cases constituted a crime; 6 (12%), only in one case; and 4 (8%), in two out of the three. Crimes described by survey respondents included intentional homicide, wrongful death, and failure to render assistance. Conclusions. Forty-five percent of survey respondents considered that decisions made involved some form of crime.

Opinions of members of the National Civil (Family Proceedings) and Criminal Courts in withholding or withdrawing of life support situations in pediatrics. / Opinión de los miembros de la Justicia Nacional en lo Penal y Civil (Familia) en situaciones de limitación del soporte vital en pediatría.

INTRODUCTION: The possibility of sustaining life functions makes it difficult to distinguish between a dying patient and a patient with chances of survival, raising a dilemma for everyone around them. On the one side, continuing with life support techniques that would only extend an irreversible process and result in physical and psychological damage and harm their dignity. On the other side, withholding or withdrawing life support without an adequate reflection and diagnostic-therapeutic effort which may lead to the death of a potentially recoverable child. In addition, making decisions in this context implies facing barriers that hinder the possibility of pursuing the patient's best interest. Among such barriers, the fear of litigation plays a major role. To what extent is this fear justified? OBJECTIVE: To explore the opinions of the members of the National Judiciary regarding the approach to withholding or withdrawing of life support from a legal stance. POPULATION AND METHODS: Professionals working in the criminal, civil and forensic medicine settings. Semistructured survey on three hypothetical case histories that implied making a decision to withhold or withdraw life support. RESULTS: One hundred and eighty-five surveys were distributed; 68 (36.76%) were partially completed and 51 (30.3%), in full. Twenty-eight (55%) survey respondents did not criminalize any of the three cases presented. Thirteen (25%) respondents considered that the decisions made in the three cases constituted a crime; 6 (12%), only in one case; and 4 (8%), in two out of the three. Crimes described by survey respondents included intentional homicide, wrongful death, and failure to render assistance. CONCLUSIONS: Forty-five percent of survey respondents considered that decisions made involved some form of crime.

INTRODUCCIÓN: La posibilidad de sostener artificialmente las funciones vitales hace más difícil diferenciar al paciente en agonía terminal del paciente con posibilidades de supervivencia, lo que pone al grupo que lo rodea frente a un dilema. Por un lado, se presenta la continuación de soporte que solo prolongue un proceso irreversible, que causa daños físicos, psíquicos y a su dignidad. Por otro, la abstención o retiro de soporte vital sin la reflexión y el esfuerzo diagnóstico-terapéutico apropiado puede dejar sin esperanza y llevar a la muerte a un niño potencialmente recuperable. Además, la toma de decisiones, en estas circunstancias, enfrenta diversas barreras que dificultan lograr el mejor interés del paciente. Entre ellas, los temores legales son un factor importante. ¿En qué medida esos temores están justificados? OBJETIVO: Explorar la opinión del Poder Judicial de la Nación respecto al enfoque que, desde el derecho, se da a situaciones de limitación de soporte vital. POBLACIÓN Y MÉTODOS: Profesionales activos del ámbito penal, civil y médico forense. Encuesta semiestructurada sobre tres casos hipotéticos con decisiones sobre la limitación del soporte vital. RESULTADOS: Se repartieron 185 encuestas; se contestaron 68 (36,76%) y 51 (30,3%) fueron respondidas en forma completa. No tipificaron ningún delito en ninguno de los tres casos 28 (55%) encuestados. Trece (25%) interpretaron como delitos las decisiones de los tres casos; 6 (12%), alguno de los casos; y 4 (8%), 2 de los 3 casos. Los delitos seleccionados por los encuestados incluyeron homicidio doloso, homicidio culposo y abandono de persona. CONCLUSIONES: El 45% de los encuestados consideraron que hubo alguna forma de delito en las decisiones tomadas.

Withdrawal of biologic agents in rheumatoid arthritis: a systematic review and meta-analysis.

The aim of this study is to assess the efficacy of withdrawing biologics from patients with rheumatoid arthritis in sustained remission or low disease activity. This is a systematic review of clinical trials that randomized withdrawal or continuation of biologics. We searched MEDLINE, Embase, and other databases. Three authors independently selected and extracted the data from the studies. The GRADE approach was employed to assess the quality of the evidence. We calculated meta-analyses of random effects model and estimated the heterogeneity by I (2). The number needed to treat (NNT) was calculated for significant outcomes. We included six trials (N = 1927 patients), most were industry-sponsored. Compared to withdrawing, continuing biologics increased the probability of low disease activity (relative risk [RR] = 0.66, 95 % CI 0.51-0.84, I (2) = 91 %, NNT = 4, low quality), remission (0.57, 0.44-0.74, I (2) = 82 %, NNT = 3, low quality), and radiographic progression (RR = 0.91, 95 % CI 0.85-0.98, I (2) = 13 %, NNT = 12, moderate quality). No significant difference was detected in the incidence of serious adverse events, serious infection, malignancy, and scores of improvement of tender and swollen joints between these strategies (low quality). A worse profile of outcomes was experienced by those patients when compared to the ones that continued biologics, but almost half of patients maintained low disease activity after withdrawal. As the quality of evidence was low, the conclusions may change as new results become available. The potential harms and benefits of this decision must be discussed with patients.