Assessment of the Relationship between Nurses' Perception of Ethical Climate and Job Burnout in Intensive Care Units.

OBJECTIVES: To determine the relationship between ethical climate and burnout in nurses working in Intensive Care Units (ICUs). METHODS: This cross-sectional and multi-center study was conducted among 212 nurses working in adult ICUs of six hospitals affiliated to Shiraz University of Medical Sciences, Iran in 2019. The participants were selected using systematic random sampling technique. Data was collected using valid instruments of Olson's Hospital Ethical Climate Survey (HECS) and Maslach Burnout Inventory (MBI). RESULTS: Ethical climate was favorable (3.5±0.6). The intensity (32.2±12.4) and frequency (25.5±12.4) of burnout were high. Ethical climate had significant and inverse relationships with frequency of burnout (r =-0.23, p=0.001) and with intensity of burnout (r=-0.186, p=0.007). Ethical climate explained 5.9% of burnout. Statistically significant relationships were also found between these factors: age with ethical climate (p=0.001), work shifts with burnout (p=0.02), and gender and with intensity frequency of burnout in ICU nurses (p=0.038). The results of Spearman correlation coefficient showed significant and inverse relationships between ethical climate and job burnout (r=-0.243, p < 0.001). CONCLUSIONS: Nurses in ICUs perceived that ethical climate was favorable however, burnout was high. Therefore, burnout can be affected by many factors and it is necessary to support ICU nurses since they undertake difficult and complicated task. It is recommended to assess factors that increase burnout and adopt specific measures and approaches to relieve nursing burnout.

Ethical allocation of scarce health care resources in the context of the COVID-19 crisis. / Asignación ética de recursos sanitarios escasos en el contexto de crisis por COVID-19.

The current COVID-19 pandemic has the potential to overwhelm the capacity of hospitals and Intensive Care Units in Chile and Latin America. Thus local authorities have an ethical obligation to be prepared by implementing pertinent measures to prevent a situation of rationing of scarce healthcare resources, and by defining ethically acceptable and socially legitimate criteria for the allocation of these resources. This paper responds to recent ethical guidelines issued by a Chilean academic institution and discusses the main moral principles for the ethical foundations of criteria for rationing during the present crisis. It argues that under exceptional circumstances such as the current pandemic, the traditional patient-centered morality of medicine needs to be balanced with ethical principles formulated from a public health perspective, including the principles of social utility, social justice and equity, among others. The paper concludes with some recommendations regarding how to reach an agreement about rationing criteria and about their implementation in clinical practice.

La actual pandemia por COVID-19 tiene el potencial de sobrepasar la capacidad de hospitales y unidades de cuidados intensivos en Chile y América Latina. Por lo tanto, las autoridades locales tienen la obligación ética de estar preparadas mediante la implementación de medidas tendientes a evitar una situación de racionamiento de recursos sanitarios escasos, y a través de la definición de criterios éticamente aceptables y socialmente legítimos para la asignación de estos recursos. Este artículo presenta una respuesta a orientaciones éticas recientes emitidas por una institución académica chilena y analiza los principios éticos relevantes para la fundamentación ética de criterios de racionamiento. Se argumenta que, frente a circunstancias excepcionales como la actual pandemia, la moral centrada en el paciente de la medicina tradicional necesita ser ponderada con principios éticos formulados desde una perspectiva de salud pública, incluyendo los principios de utilidad social, justicia social y equidad, entre otros. Se concluye con algunas recomendaciones sobre cómo llegar a acuerdo sobre criterios de racionamiento y sobre la implementación de estos en la práctica clínica.

Asignación ética de recursos sanitarios escasos en el contexto de crisis por COVID-19 / Ethical allocation of scarce health care resources in the context of the COVID-19 crisis

La actual pandemia por COVID-19 tiene el potencial de sobrepasar la capacidad de hospitales y unidades de cuidados intensivos en Chile y América Latina. Por lo tanto, las autoridades locales tienen la obligación ética de estar preparadas mediante la implementación de medidas tendientes a evitar una situación de racionamiento de recursos sanitarios escasos, y a través de la definición de criterios éticamente aceptables y socialmente legítimos para la asignación de estos recursos. Este artículo presenta una respuesta a orientaciones éticas recientes emitidas por una institución académica chilena y analiza los principios éticos relevantes para la fundamentación ética de criterios de racionamiento. Se argumenta que, frente a circunstancias excepcionales como la actual pandemia, la moral centrada en el paciente de la medicina tradicional necesita ser ponderada con principios éticos formulados desde una perspectiva de salud pública, incluyendo los principios de utilidad social, justicia social y equidad, entre otros. Se concluye con algunas recomendaciones sobre cómo llegar a acuerdo sobre criterios de racionamiento y sobre la implementación de estos en la práctica clínica.

The current COVID-19 pandemic has the potential to overwhelm the capacity of hospitals and Intensive Care Units in Chile and Latin America. Thus local authorities have an ethical obligation to be prepared by implementing pertinent measures to prevent a situation of rationing of scarce healthcare resources, and by defining ethically acceptable and socially legitimate criteria for the allocation of these resources. This paper responds to recent ethical guidelines issued by a Chilean academic institution and discusses the main moral principles for the ethical foundations of criteria for rationing during the present crisis. It argues that under exceptional circumstances such as the current pandemic, the traditional patient-centered morality of medicine needs to be balanced with ethical principles formulated from a public health perspective, including the principles of social utility, social justice and equity, among others. The paper concludes with some recommendations regarding how to reach an agreement about rationing criteria and about their implementation in clinical practice.

Dilemas éticos en la práctica clínica en las unidades de cuidados intensivos y paros cardiorrespiratorios / Ethical dilemmas in clinical practice in the intensive care units and cardiorespiratory arrests

Antecedentes. La bioética entiende que toda propuesta terapéutica o diagnóstica debe definir la meta por lograr, el provecho por obtener y los riesgos por enfrentar. Requiere conocer la historia natural de la enfermedad y sus complicaciones, así como la estimación de las posibilidades de éxito y fracaso ajustadas a cada paciente en particular. Fuentes: búsqueda bibliográfica en Medline, ProQuest, SCOPUS, usando las palabras claves "ética en el acto quirúrgico" "bioética" "ética clínica" "ética en obstetricia "aborto terapéutico", "consideraciones éticas en el embarazo y cáncer" "ética y cirugía oncológica" "dilemas éticos en la práctica anestésica", tanto en castellano e inglés, limitada al periodo 2014- 2018. Los modelos más citados son los incluidos en la presente revisión. Desarrollo: El comportamiento ético no sólo debe estar limitado al acto quirúrgico, sino a toda la conducta del cirujano, aceptando que sus actos deben ser éticamente válidos, desde el estudio clínico del paciente y solicitud de estudios auxiliares de diagnóstico basados en un criterio razonado hasta la información otorgada al paciente y familiar, el acto quirúrgico y vigilancia postoperatoria Conclusiones: Cada día nos enfrentamos a dilemas éticos por lo que es evidente la necesidad de capacitación del personal de salud tanto médico, enfermería y todo personal que tiene contacto con paciente en aras de evitar el ensañamiento terapéutico y lograr el máximo bienestar del enfermo y sus familiares, desde un punto de vista integral. La principal e inicial obligación ética de todo médico es estar preparado...(AU)

Difficult decisions in pediatric practice and moral distress in the intensive care unit. / As difíceis decisões na prática pediátrica e sofrimento moral em unidade de terapia intensiva.

In an ethical dilemma, there is always an option that can be identified as the best one to be chosen. When it is impossible to adopt such option, the situation can lead professionals to experience moral distress. This review aims to define the issue of moral distress and propose coping strategies. Systematic searches in the MEDLINE/PubMed and SciELO databases were conducted using the keywords "moral distress" and "moral suffering" in articles published between 2000 and 2017. This review was non-exhaustive and contextual, with a focus on definitions, etiologies and methods of resolution for moral distress. In the daily practice of intensive care, moral distress was commonly related to the prolongation of patients' suffering and feelings of helplessness, as well as difficulties in communication among team members. Coping strategies for moral distress included organizational, personal and administrative actions. Actions such as workload management, mutual support among professionals and the development of techniques to cultivate open communication, reflection and questioning within the multidisciplinary team were identified. In clinical practice, health professionals need to be recognized as moral agents, and the development of moral courage was considered helpful to overcome ethical dilemmas and interprofessional conflicts. Both in pediatric and adult intensive care, professionals are challenged by questions about their practice, and they may experience moral distress. This suffering can be minimized and solved by understanding that the focus is always on the patient and acting with moral courage and good communication in an environment of mutual respect.

Em um dilema ético, há sempre uma conduta identificada como a melhor a ser tomada. A impossibilidade de adotar tal conduta leva o profissional a experimentar o sofrimento moral. Esta revisão objetivou definir este problema e propor estratégias para seu enfrentamento. Foram buscadas as palavras-chaves "moral distress" e "sofrimento moral" nas bases de dados internacionais MEDLINE/PubMed e SciELO, em artigos publicados entre 2000 - 2017. A revisão foi não exaustiva, contextual, enfocando definições, etiologia e métodos de resolução do problema. No cotidiano da prática em terapia intensiva, o sofrimento moral esteve comumente relacionado ao prolongamento do sofrimento do paciente e ao sentimento de impotência, bem como a dificuldades na comunicação entre os membros da equipe. As estratégias de enfrentamento para o sofrimento moral incluíram ações organizacionais, pessoais e administrativas. Foram recomendadas ações como manejo da carga de trabalho, apoio mútuo entre profissionais e desenvolvimento de técnicas para cultivar a comunicação aberta, a reflexão e o questionamento dentro da equipe multidisciplinar. Na prática clínica, os profissionais de saúde foram reconhecidos como agentes morais, tendo sido fundamental o desenvolvimento da coragem moral para suplantar os dilemas éticos e os conflitos interprofissionais. Tanto na terapia intensiva pediátrica como de adultos, os professionais encontram-se desafiados pelos questionamentos sobre sua prática e podem experimentar sofrimento moral. Este sofrimento pode ser minimizado e resolvido ao se compreender que o foco sempre é o paciente e agir com coragem moral e boa comunicação, em um ambiente de respeito mútuo.

Responsibility: from its conceptual foundations to its practical application in intensive care units / Responsabilidad: desde el fundamento conceptual a la aplicación práctica en unidades de cuidado intensivo / Responsabilidade: de suas bases conceituais para a sua aplicação prática em unidades de terapia intensiva

Abstract: 16. There has been a shift in the language of responsibility because the threat of malpractice litigation is encouraging physicians to assume a more responsible role in caring for their patients. Consequently, instead of paying attention to the moral dimension of this principle, professionals are sometimes much more concerned about legal repercussions. This article aims therefore at analyzing the recent literature on responsibility in intensive care, focusing on its ethical dimension. By analyzing the contributions of Emmanuel Levinas, Hans Jonas and Paul Ricoeur, who placed special emphasis on the theme of "moral responsibility", we will attempt to shed some light on this ethical principle within the specific context of Intensive Care Medicine. This paper underlines the importance of responsibility in order to draw attention to the need to establish an appropriate balance between autonomy and self/other-oriented responsibilities. A tridimensional approach is suggested to frame responsibility within the context of intensive care.

Resumen: 20. Ha habido un cambio en el lenguaje sobre la responsabilidad, debido a que la amenaza de demandas por mala práctica fuerza a los médicos a asumir un rol más responsable en el cuidado de sus pacientes. Por consiguiente, en lugar de prestar atención a la dimensión moral de este principio, muchas veces los profesionales están más preocupados de las repercusiones legales. Este artículo tiene como objetivo analizar la bibliografía reciente sobre responsabilidad en cuidados intensivos, enfocándose en la dimensión ética. Al analizar las contribuciones de Emmanuel Levinas, Han Jonas y Paul Ricoeur, que pusieron especial énfasis en el tema de la "responsabilidad moral", tratamos de iluminar este principio ético en el contexto de la Medicina del Cuidado Intensivo. Este trabajo enfatiza la importancia de en dirigir la atención a la necesidad de establecer un balance apropiado entre la autonomía y las responsabilidades orientadas hacia uno mismo o hacia el otro. Se sugiere una aproximación tridimensional para enmarcar la responsabilidad en el contexto del cuidado intensivo.

Resumo: 25. Tem havido uma mudança na linguagem da responsabilidade uma vez que a ameaça de litígio por imperícia está incentivando os médicos a assumir um papel mais responsável no cuidado de seus pacientes. Por conseguinte, em vez de prestar atenção à dimensão moral deste princípio, os profissionais algumas vezes estão muito mais preocupados com as repercussões legais. Portanto, este artigo visa analisar a literatura recente sobre responsabilidade nos cuidados intensivos, com foco em sua dimensão ética. Analisando as contribuições de Emmanuel Levinas, Hans Jonas e Paul Ricoeur, que deram ênfase especial sobre o tema da "responsabilidade moral", vamos tentar lançar alguma luz sobre este princípio ético dentro do contexto específico da medicina de cuidado intensivo. Este artigo sublinha a importância da responsabilidade a fim de chamar a atenção para a necessidade de estabelecer um equilíbrio adequado entre a autonomia e responsabilidades orientadas para si e para o outro. Sugere-se uma abordagem tridimensional para enquadrar a responsabilidade para dentro do contexto de cuidados intensivos.

As difíceis decisões na prática pediátrica e sofrimento moral em unidade de terapia intensiva / Difficult decisions in pediatric practice and moral distress in the intensive care unit

RESUMO Em um dilema ético, há sempre uma conduta identificada como a melhor a ser tomada. A impossibilidade de adotar tal conduta leva o profissional a experimentar o sofrimento moral. Esta revisão objetivou definir este problema e propor estratégias para seu enfrentamento. Foram buscadas as palavras-chaves "moral distress" e "sofrimento moral" nas bases de dados internacionais MEDLINE/PubMed e SciELO, em artigos publicados entre 2000 - 2017. A revisão foi não exaustiva, contextual, enfocando definições, etiologia e métodos de resolução do problema. No cotidiano da prática em terapia intensiva, o sofrimento moral esteve comumente relacionado ao prolongamento do sofrimento do paciente e ao sentimento de impotência, bem como a dificuldades na comunicação entre os membros da equipe. As estratégias de enfrentamento para o sofrimento moral incluíram ações organizacionais, pessoais e administrativas. Foram recomendadas ações como manejo da carga de trabalho, apoio mútuo entre profissionais e desenvolvimento de técnicas para cultivar a comunicação aberta, a reflexão e o questionamento dentro da equipe multidisciplinar. Na prática clínica, os profissionais de saúde foram reconhecidos como agentes morais, tendo sido fundamental o desenvolvimento da coragem moral para suplantar os dilemas éticos e os conflitos interprofissionais. Tanto na terapia intensiva pediátrica como de adultos, os professionais encontram-se desafiados pelos questionamentos sobre sua prática e podem experimentar sofrimento moral. Este sofrimento pode ser minimizado e resolvido ao se compreender que o foco sempre é o paciente e agir com coragem moral e boa comunicação, em um ambiente de respeito mútuo.

ABSTRACT In an ethical dilemma, there is always an option that can be identified as the best one to be chosen. When it is impossible to adopt such option, the situation can lead professionals to experience moral distress. This review aims to define the issue of moral distress and propose coping strategies. Systematic searches in the MEDLINE/PubMed and SciELO databases were conducted using the keywords "moral distress" and "moral suffering" in articles published between 2000 and 2017. This review was non-exhaustive and contextual, with a focus on definitions, etiologies and methods of resolution for moral distress. In the daily practice of intensive care, moral distress was commonly related to the prolongation of patients' suffering and feelings of helplessness, as well as difficulties in communication among team members. Coping strategies for moral distress included organizational, personal and administrative actions. Actions such as workload management, mutual support among professionals and the development of techniques to cultivate open communication, reflection and questioning within the multidisciplinary team were identified. In clinical practice, health professionals need to be recognized as moral agents, and the development of moral courage was considered helpful to overcome ethical dilemmas and interprofessional conflicts. Both in pediatric and adult intensive care, professionals are challenged by questions about their practice, and they may experience moral distress. This suffering can be minimized and solved by understanding that the focus is always on the patient and acting with moral courage and good communication in an environment of mutual respect.

[Medical futility and family obstinacy in intensive therapy. When to stop and when to keep going?] / Futilidad médica y obstinación familiar en terapia intensiva. ¿Hasta cuándo seguir y cuándo parar?

There have been several recent publications related to therapeutic obstinacy and futility in the Intensive Care Unit. However, little has been published about "the family obstinacy" in persisting with invasive measures in seriously ill patients, despite the appropriate information provided to them about the patient's poor short-term prognosis. On certain occasions, these critical patients are unable to make decisions on the proposed treatments and, unfortunately, many of them have not previously indicated their preferences in terms of limits to invasive measures (advanced directives). Thus, the patient's relatives are the ones who finally assume this arduous task and, in several occasions, they make decisions that do not correspond with the patient's actual wishes. Palliative medicine is of invaluable help in the difficult goal of improving communication among doctors, patients and patients relatives. Limits to intervention can be difficult and vague, generating multiple problems in the decision-making process. On certain occasions and despite adequate information provided by therapists and palliative care doctors, patients' relatives do not accept professional directives indicating to stop invasive interventions. Understanding futility justification may be relevant to the appropriate resolution of these disputes. In this article, we intend to discuss the subject "futility in Intensive Care Unit" and how to face the seldom addressed "family obstinacy" issue in potentially unrecoverable situations, despite adequate medical information.

Futilidad médica y obstinación familiar en terapia intensiva: ¿Hasta cuándo seguir y cuándo parar? / Medical futility and family obstinacy in intensive therapy. When to stop and when to keep going?

En las últimas décadas han aparecido múltiples publicaciones sobre obstinación terapéutica y futilidad en la Unidad de Terapia Intensiva. Sin embargo, poco se ha publicado sobre la "obstinación familiar" en continuar con medidas invasivas en pacientes graves, a pesar de una adecuada información sobre su muy mal pronóstico a corto plazo. En determinadas ocasiones, estos pacientes críticos no están en condiciones de tomar decisiones sobre los tratamientos propuestos y lamentablemente muchos de ellos no han dejado testimonio previo sobre sus preferencias en cuanto hasta dónde avanzar en medidas invasivas (directivas anticipadas). De esta manera, son los familiares quienes quedan a cargo de estas decisiones, que pueden no coincidir con lo que el paciente hubiera deseado. Con la medicina paliativa se ha generado una invalorable ayuda a la difícil tarea de la comunicación entre el médico, el paciente y la familia. Los límites de las intervenciones pueden ser difíciles e imprecisos, generando múltiples problemas en la toma de decisiones. En determinadas ocasiones, a pesar de una adecuada información de los médicos intensivistas y paliativistas, algunos familiares no aceptan las directivas de no avanzar con medidas invasivas. Comprender la justificación de la futilidad puede ser relevante para resolver disputas de la forma más adecuada. Este trabajo propone discutir el tema de la futilidad en Terapia Intensiva y cómo encarar el problema tan poco abordado de la "obstinación familiar" ante situaciones potencialmente irrecuperables, pese a una adecuada información médica.

There have been several recent publications related to therapeutic obstinacy and futility in the Intensive Care Unit. However, little has been published about "the family obstinacy" in persisting with invasive measures in seriously ill patients, despite the appropriate information provided to them about the patient's poor short-term prognosis. On certain occasions, these critical patients are unable to make decisions on the proposed treatments and, unfortunately, many of them have not previously indicated their preferences in terms of limits to invasive measures (advanced directives). Thus, the patient's relatives are the ones who finally assume this arduous task and, in several occasions, they make decisions that do not correspond with the patient's actual wishes. Palliative medicine is of invaluable help in the difficult goal of improving communication among doctors, patients and patients relatives. Limits to intervention can be difficult and vague, generating multiple problems in the decision-making process. On certain occasions and despite adequate information provided by therapists and palliative care doctors, patients' relatives do not accept professional directives indicating to stop invasive interventions. Understanding futility justification may be relevant to the appropriate resolution of these disputes. In this article, we intend to discuss the subject "futility in Intensive Care Unit" and how to face the seldom addressed "family obstinacy" issue in potentially unrecoverable situations, despite adequate medical information.

Diagnóstico matemático de dinámica cardiaca en 16 horas y evaluación de variables hemodinámicas en la Unidad de Cuidados Intensivos / Mathematical diagnosis of cardiac dynamics in 16 hours and evaluation of hemodynamic variables in the Intensive Care Unit

Antecedentes: desde los sistemas dinámicos se desarrolló un diagnóstico de la dinámica cardiaca de aplicación clínica en 16 horas, de utilidad en pacientes de Unidad de Cuidados Intensivos. Objetivos: confirmar la capacidad diagnóstica de la nueva metodología de evaluación de la dinámica cardiaca en 16 horas y determinar la evolución de la presión arterial y venosa de oxígeno y dióxido de carbono. Metodología: se tomaron 50 dinámicas, 10 normales y 40 con patologías agudas, tomando la frecuencia cardiaca mínima y máxima, y número de latidos cada hora. Se construyeron atractores y se evaluaron los espacios de ocupación y la dimensión fractal en 21 y 16 horas, comparando ambos diagnósticos físico-matemáticos entre sí. Posteriormente se realizó una confirmación del diagnóstico establecido en 16 horas mediante un estudio ciego de comparación con el diagnóstico convencional. Adicionalmente se tomaron los valores de la presión arterial y venosa de oxígeno y dióxido de carbono de 7 pacientes de Unidad de Cuidados Intensivos y se construyeron atractores caóticos, evaluando los valores mínimos y máximos del atractor en el mapa de retardo. Resultados: se confirmó la capacidad diagnóstica de la metodología en 16 horas para la dinámica cardiaca, con sensibilidad y especificidad de 100 por ciento y coeficiente kappa de 1 respecto al diagnóstico convencional; los valores mínimos y máximos de los atractores de la presión arterial y venosa de oxígeno y dióxido de carbono se encontraron entre 29,60 y 194,40; 24,20 y 56,10; 16,40 y 65,60 y 21,40 y 97,90 respectivamente. Conclusiones: se confirmaron predicciones diagnósticas en 16 horas diferenciando normalidad, enfermedad crónica y enfermedad aguda, útiles para el seguimiento clínico en pacientes de Unidad de Cuidados Intensivos. Las variables se comportaron caóticamente; estos resultados podrían fundamentar aplicaciones clínicas y predicciones de mortalidad. Palabras claves: frecuencia cardiaca, presión arterial de oxígeno, presión arterial de dióxido de carbono, presión venosa de oxígeno, presión venosa de dióxido de carbono, Sistemas Dinámicos, caos, fractales, dinámica no lineal(AU)

Objectives: to confirm the diagnostic ability of the new assessment methodology of cardiac dynamics in 16 hours and determine the evolution of the arterial and venous pressure of oxygen and carbon dioxide. Methodology: 50 dynamic were taken, 10 normal and 40 with acute pathologies, taking the minimum and maximum heart rate, and number of beats per minute. Attractors were constructed and areas of occupation and the fractal dimension in 21 and 16 hours were evaluated, comparing both physical and mathematical diagnosis each other. Subsequently a confirmation of the diagnosis made in 16 hours by a blinded study compared to conventional diagnosis. Additionally, values of the arterial and venous pressure of oxygen and carbon dioxide from 7 Intensive Care Unit patients were taken and chaotic attractors were constructed to evaluate the minimum and maximum values of the attractor on the delay map. Results: The diagnostic capability of the methodology in 16 hours for cardiac dynamic was confirmed, with sensitivity and specificity of 100 percent and kappa coefficient 1 over conventional diagnosis; the minimum and maximum values of the arterial and venous pressure of oxygen and carbon dioxide were found between 29.60 and 194.40; 24.20 and 56.10; 16,40 and 65,60 and 21,40 and 97,90 respectively. Conclusions: Diagnostic predictions were confirmed in 16 hours differentiating normal, chronic and acute disease useful for clinical monitoring in Intensive Care Unit patients. The variables behaved chaotically; these results may inform clinical applications and predictions of mortality. Keywords: heart rate, arterial oxygen pressure, carbon dioxide arterial pressure, venous oxygen pressure, carbon dioxide venous pressure, dynamical systems, chaos, fractals, nonlinear dynamics(AU)

Decision-Making on Withholding or Withdrawing Life Support in the ICU: A Worldwide Perspective.

BACKGROUND: Many critically ill patients who die will do so after a decision has been made to withhold/withdraw life-sustaining therapy. The objective of this study was to document the characteristics of ICU patients with a decision to withhold/withdraw life-sustaining treatment, including the types of supportive treatments used, patterns of organ dysfunction, and international differences, including gross national income (GNI). METHODS: In this observational cohort study conducted in 730 ICUs in 84 countries, all adult patients admitted between May 8, 2012, and May 18, 2012 (except admissions for routine postoperative surveillance), were included. RESULTS: The analysis included 9,524 patients, with a hospital mortality of 24%. A decision to withhold/withdraw life-sustaining treatment was reported during the ICU stay in 1,259 patients (13%), including 820 (40%) nonsurvivors and 439 (5%) survivors. Hospital mortality in patients with a decision to withhold/withdraw life-sustaining treatment was 69%. The proportion of deaths in patients with a decision to withhold/withdraw life-sustaining treatment ranged from 10% in South Asia to 67% in Oceania. Decisions to withhold/withdraw life-sustaining treatment were less frequent in low/lower-middle GNI countries than in high GNI countries (6% vs 14%; P < .001). Greater disease severity, presence of ≥ 2 organ failures, severe comorbidities, medical and trauma admissions, and admission from the ED or hospital floor were independent predictors of a decision to withhold/withdraw life-sustaining treatment. CONCLUSIONS: There is considerable worldwide variability in decisions to withhold/withdraw life-sustaining treatments. Interestingly, almost one-third of patients with a decision to withhold/withdraw life-sustaining treatment left the hospital alive.

Toma de decisiones éticas: ¿cuándo una limitación es realmente correcta? / Ethical decision making: when a limitation is really true?

El objetivo del presente artículo es realizar el análisis de una situación acontecida en una unidad de cuidado intensivo (UCI) que requiere una toma de decisión, la cual tiene como consecuencia la limitación del esfuerzo terapéutico en una paciente, generando implicaciones éticas para el personal a cargo. Se describe el caso clínico y a continuación se realiza el análisis mediante el Modelo de Toma de Decisiones del Hastings Center. Este modelo permite la aproximación a la situación a partir de los valores subyacentes. Como comentarios especiales, resaltar la necesidad de realizar la toma de decisiones en equipo, brindar información clara, oportuna y veraz a los familiares del paciente y respetar las decisiones que estos puedan tomar.

The aim of this paper is to perform the analysis of a situation, given in an intensive care unit that requires a decision-making which results in the limitation of treatment in a patient, generating ethical implications for staff in charge. We describe the clinical case and then the analysis is performed using the model of decision making Hastings Center. This model allows the approach to the situation from the underlying values. As special comments, highlight the need for decision making in teams, providing clear, timely and reliable information to relatives of the patient and respect the decisions that they can make.

[Ethical dilemmas in ICU: contributions of Max Scheler's Theory of Values]. / Dilemas éticos em UTI: contribuições da Teoria dos Valores de Max Scheler.

The study aimed to reflect, based on the theoretical framework of Max Scheler, about the ethical dilemmas experienced by nurses in the ICU, and about the values that guide their actions and decisions,. This is qualitative research, and ten ICU nurses have been interviewed at a university hospital. It was identified the experience of ethical dilemmas related to the terminality related to the limits of intervention and use of material resources, as well as the issue of blood transfusion in case of religious restrictions. The values identified were: respect, dignity of the patient, scientific knowledge, humility, passion for the profession and love of God. The theory of values is an important tool for nursing because it allows the approach of an ethics of humanizing praxis, especially in situations of ethical dilemmas.

Suspensão de tratamentos em unidades de terapia intensiva e seus fundamentos éticos / Treatment suspension and the ethical values in Intensive Care Units: a survey on the Portuguese reality

Apesar dos sofisticados e dispendiosos recursos disponíveis nas unidades de terapia intensiva, por vezes, em determinadas situaçães, é decidido suspender tratamentos extraordinários. Este trabalho surgiu da necessidade de saber quais são os fundamentos éticos que os enfermeiros portugueses consideram estar na base da decisão de suspender tratamentos extraordinários em unidades de terapia intensiva. Foi realizada intensa pesquisa bibliográfica e colocadas várias questães orientadoras, tendo por campo de estudo um total de nove unidades de terapia intensiva e uma amostra de 146 enfermeiros, e os dados obtidos foram estatisticamente tratados com base no programa SPSS 11,0. Concluiu-se que os enfermeiros consideram que na base da decisão de suspender tratamentos extraordinários se encontra uma preocupação com aspectos relativos ao cuidado, que se traduzem na morte no tempo certo, sem adiamento ou antecipação, sem sofrimento e com base nos princípios da beneficência e não maleficência, valorizando mais o bem individual do que o bem comum.

[Education in the intensive care unit.]

Intensive care medicine is a newly formed specialty. Intensive care is characterized by a multidisciplinary activity focused on patients whose vital organs are compromised or who are at risk of multiorgan failure. Education in the intensive care unit is a complex activity where the educational and pedagogical process interacts with research, continuous improvement, professionalism, and bioethics. This model provides leadership and excellence in care with high standards of quality, security, solidarity and humanism.

Questões éticas do cotidiano profissional e a formação do enfermeiro / Cuestiones éticas del cotidiano profesional y la formación del enfermero / Ethical issues in daily work routine and nursing training

Estudo de natureza qualitativa que objetivou conhecer as percepções das enfermeiras sobre como vivenciam os principais problemas éticos do cotidiano do trabalho e se a formação profissional recebida na graduação mostrou-se suficiente para o enfrentamento destes problemas. Os dados foram coletados entre março e abril de 2009, junto a cinco enfermeiras de uma unidade de terapia intensiva de um hospital universitário do Rio Grande do Sul, por meio de observações livres seguidas de entrevista semi-estruturada. Utilizou-se a técnica de análise textual qualitativa no tratamento dos dados. Dos resultados emergiram duas categorias: a dimensão ética do cuidado e na formação profissional. Mostrou-se necessária uma reflexão mais profunda sobre o cotidiano do trabalho ainda na graduação, fortalecendo as futuras enfermeiras para o enfrentamento do exercício profissional. Paralelamente, precisa-se priorizar a construção de espaços para a reflexão e discussão coletiva dos profissionais atuantes, identificando e construindo novas maneiras de atuar eticamente.

This qualitative study aimed to learn nurses’ perceptions of how they experience the main ethical problems of their day-to-day work and whether the professional training they received in their undergraduate studies has proved sufficient to meet these problems. Data were collected from March to April 2009 by free observation followed by semi-structured interviews of five nurses at a university hospital intensive care unit (ICU) in Rio Grande do Sul, and were treated using the technique of qualitative textual analysis. Two categories emerged from the results: the ethical dimension in care and in professional training. There was found to be a need for undergraduate studies to consider in greater depth the day-to-day experience of nursing work, so as to strengthen future nurses to exercise the profession. There is a parallel need to prioritize construction of settings where practicing nurses can think and discuss together with a view to identifying and building new ways to act ethically.

Estudio de naturaleza cualitativa que objetivó conocer las percepciones de las enfermeras, acerca de como vivencian los principales problemas éticos del trabajo diario y sí la formación profesional recibida en el pregrado se ha mostrado suficiente para hacer frente a estos problemas. Los datos fueron recolectados entre marzo y abril de 2009, con cinco enfermeras en una unidad de cuidados intensivos (UCI) de un hospital universitario de Río Grande do Sul-Brasil, por medio de observaciones libres, seguidas de entrevista semiestructurada. Se utilizó la técnica de análisis textual cualitativa en el tratamiento de los datos. Los resultados destacan dos categorías: dimensión ética de la atención y en la formación profesional. Se ha mostrado necesaria una reflexión más profunda sobre el trabajo diario aun en los estudios de graduación, fortaleciendo las futuras enfermeras para enfrentar el futuro de la profesión. Al mismo tiempo, es necesario dar prioridad a la construcción de espacios de reflexión y discusión colectiva de los profesionales actuantes, identificando y construyendo nuevas formas de actuar éticamente.

Protocolo de atendimento à família em UTI adulto / Treatment protocols for adult intensive care unit for the family

A internação em UTI adulto implica processo de alteração do movimento natural da família, provocando nos familiares reações emocionais que precisam ser compreendidas e trabalhadas, do ponto de vista emocional, num contexto de crise. O Protocolo de Atendimento à Família em UTI Adulto é um instrumento que direciona este trabalho. A ferramenta descreve rotinas que visam a sistematizar processos. Essa sistematização é necessária, viável e facilita a operacionalização dos atendimentos prestados pelo Serviço de Psicologia Hospitalar, favorecendo as diretrizes de Qualidade, Ética, Bioética e Humanização, em comunhão com os processos que envolvem toda a equipe de saúde.(AU)

The adult Intensive Care Unit stay implies a process of changing the natural routine of the family, causing the family emotional reactions that need to be understood and worked in an emotional point of view, in times of crisis. The treatment protocols for the family in an adult Intensive Care Unit stay is an instrument that directs such work. The tool is a description of routines aimed to the systematization of the process. This classification is necessary, feasible and facilitates the operation of the care provided by the Department of Health Psychology, favoring the guidelines of Quality, Ethics, Bioethics and Humanization, in communion with the processes that involve the entire health care team.(AU)

Implantação de tecnologias de cuidado em unidade de terapia intensiva aos usuários e seus familiares / Implanting technologies of care in the intensive care unit for Patients and their relatives / Implantación de tecnologías de cuidado en unidad de cuidados Intensivos a los usuarios y sus familiares

A unidade de terapia intensiva (UTI), por ser local de alta complexidade tecnológica, frequentemente provocasentimentos como angústia, insegurança e medo nos familiares de usuários ali internados. Objetivamos com esteestudo analisar a contribuição da implantação de tecnologias de cuidado aos usuários internados na UTI e seusfamiliares durante o seu processo de internação. Para seu alcance, optamos por uma abordagem qualitativa combase na Teoria da Relação Interpessoal proposta por Travelbee, em trabalho desenvolvido junto a familiares deusuários internados na UTI de um hospital universitário. A partir da análise, evidenciamos as seguintescategorias: Valorizando as interações na UTI; Preparando os familiares para a visita; e Avaliando as tecnologiasde cuidado. Implementar tecnologias de cuidado a partir de uma proposta de relação pessoa a pessoa constituisena construção de um processo contínuo e crescente de aproximação, diálogo e humanização do ambiente.Daí a dimensão ética do uso de tecnologias de cuidado como a aplicação do saber da Enfermagem, que sejustifica por ir ao encontro do atendimento das necessidades de cuidado de nossos clientes, usuários efamiliares, consistindo em ações menos verticalizadas e em um permanente processo de reflexão, interpretaçãoe construção.

The Intensive Care Unit (ICU) is a place of high technological complexity that frequently provokes feelings suchas anguish, insecurity and fear in the patients’ relatives. The purpose of this study was to analyze the contributionof implanting care technologies for patients admitted in the ICU and their relatives during a hospitalizationprocess. This is a qualitative approach based on Travelbee's Interpersonal Relation Theory, carried out withrelatives of patients admitted in the ICU of a University Hospital. From the analysis, the following categories wereevidenced: Appreciating the interactions in the ICU; Preparing relatives for the visit; and Evaluating the caretechnologies. To implement care technologies from a proposal of relationship person to person represents the construction of a continuous and growing process of approach, dialogue and humanization of the atmosphere.That explains the ethical dimension of the use of care technologies, such as the nursing knowledge, which isjustified for meeting the need of care for our clients, users and family, therefore, actions less verticalized, in apermanent reflection process, interpretation and construction.

La Unidad de Cuidados Intensivos (UCI) es un local de alta complejidad tecnológica, que frecuentementeprovoca sentimientos como angustia, inseguridad y miedo en los familiares de usuarios allí ingresados.Objetivamos con este estudio analizar la contribución de la implantación de tecnologías de cuidados a losusuarios ingresados en la UCI y sus familiares durante su proceso de ingreso. Para su alcance, optamos por unabordaje cualitativa con base en la Teoría da Relación Interpersonal propuesta por Travelbee, siendodesarrollada junto a familiares de usuarios ingresados en la UCI de un Hospital Universitario. A partir del análisis,evidenciamos las siguientes categorías: Valorando las interacciones en la UCI; Preparando los familiares para lavisita; y Evaluando las tecnologías de cuidado. Implementar tecnologías de cuidado, a partir de una propuesta derelación persona a persona, se constituye en la construcción de un proceso continuo y creciente deaproximación, diálogo y de humanización del ambiente. De ahí la dimensión ética del uso de tecnologías decuidado, como la aplicación del saber de la enfermería, que se justifica por ir al encuentro de la atención de lasnecesidades de cuidado de nuestros clientes, usuarios y familiares, por tanto, acciones menos verticalizadas, enpermanente proceso de reflexión, interpretación y construcción.