Puesta al día y recomendaciones en la toma de decisiones de limitación de tratamientos de soporte vital / Update and recommendations in decision making referred to limitation of advanced life support treatment

El Grupo de Trabajo de Bioética de la SEMICYUC ha elaborado las recomendaciones en la toma de decisiones de limitación de tratamientos de soporte vital con la aspiración de disminuir la variabilidad en la práctica clínica observada y de contribuir a la mejora de los cuidados al final de la vida del paciente crítico. Además de abordar el marco conceptual de la limitación de tratamientos de soporte vital y de la futilidad, desarrolla las nuevas formas de limitación extendiéndola a la adecuación de otros tratamientos y métodos diagnósticos, además de planificar los posibles cursos evolutivos tras la decisión de limitación de tratamientos de soporte vital. Se enfatiza la importancia de la planificación compartida de la asistencia sanitaria en la toma de decisiones, se presentan los cuidados intensivos orientados a la donación y se promueve la integración de los cuidados paliativos en el tratamiento del paciente crítico en estadios del final de la vida en UCI

The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) Bioethics Working Group has developed recommendations on the Limitation of Advanced Life Support Treatment (LLST) decisions, with the aim of reducing variability in clinical practice and of improving end of life care in critically ill patients. The conceptual framework of LLST and futility are explained. Recommendations referred to new forms of LLST encompassing also the adequacy of other treatments and diagnostic methods are developed. In addition, planning of the possible clinical courses following the decision of LLST is commented. The importance of advanced care planning in decision-making is emphasized, and intensive care oriented towards organ donation at end of life in the critically ill patient is described. The integration of palliative care in the critical patient treatment is promoted in end of life stages in the Intensive Care Unit

Update and recommendations in decision making referred to limitation of advanced life support treatment. / Puesta al día y recomendaciones en la toma de decisiones de limitación de tratamientos de soporte vital.

The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) Bioethics Working Group has developed recommendations on the Limitation of Advanced Life Support Treatment (LLST) decisions, with the aim of reducing variability in clinical practice and of improving end of life care in critically ill patients. The conceptual framework of LLST and futility are explained. Recommendations referred to new forms of LLST encompassing also the adequacy of other treatments and diagnostic methods are developed. In addition, planning of the possible clinical courses following the decision of LLST is commented. The importance of advanced care planning in decision-making is emphasized, and intensive care oriented towards organ donation at end of life in the critically ill patient is described. The integration of palliative care in the critical patient treatment is promoted in end of life stages in the Intensive Care Unit.

Limitación del tratamiento de soporte vital en pacientes con ingreso prolongado en UCI. Situación actual en España a la vista del Estudio EPIPUSE / Limitation of life-sustaining treatment in patients with prolonged admission to the ICU. Current situation in Spain as seen from the EPIPUSE Study

OBJETIVO: La limitación de tratamientos de soporte vital (LTSV) es una práctica recomendada en determinadas circunstancias. Las formas de limitación son variadas y su aplicación es diferente entre unos centros y otros. Conocer la situación actual de la LTSV en pacientes que presentan un ingreso prolongado en UCI y que sufren un empeoramiento es el objetivo de este trabajo. DISEÑO: Cohorte, observacional, prospectivo. ÁMBITO: Un total de 75 UCI españolas. PACIENTES: Se estudia a 589 pacientes que presentan 777 complicaciones o eventos adversos con repercusión orgánica a partir del séptimo día de ingreso, reclutados durante 3 meses.VARIABLES DE INTERÉS PRINCIPALES: Estudiamos el momento en que se propone la limitación, el actor que la propone, el grado de acuerdo dentro del equipo, la influencia de este hecho en la relación médico-paciente-familia y sus formas de aplicación. RESULTADOS: Se plantea alguna limitación al tratamiento en el 34,3% de los pacientes con estancia prolongada en UCI que sufren complicaciones graves. La incidencia es mayor en pacientes con neumopatía moderada o grave, enfermedad oncológica, tratamientos inmunosupresores y en pacientes dependientes. En el 97% de los casos en los que se propone realizar la LTSV, finalmente se acuerda la misma. La decisión dentro del equipo médico fue unánime en el 87,9% de casos. Habitualmente la relación médico-paciente-familia no cambia o incluso mejora ante esta situación. CONCLUSIÓN: La LTSV en las UCI es una práctica que se suele llevar a cabo con la decisión unánime del equipo médico, se realiza con más frecuencia en pacientes con comorbilidad grave y no suele deteriorar la relación con pacientes y familiares

OBJECTIVE: Limitation of life-sustaining treatment (LLST) is a recommended practice in certain circumstances. Limitation practices are varied, and their application differs from one center to another. The present study evaluates the current situation of LLST practices in patients with prolonged admission to the ICU who suffer worsening of their condition. DESIGN: A prospective, observational cohort study was carried out. SETTING: Seventy-five Spanish ICUs. PATIENTS: A total of 589 patients suffering 777 complications or adverse events with organ function impairment after day 7 of admission, during a three-month recruitment period. Main variables of interest: The timing of limitation, the subject proposing LLST, the degree of agreement within the team, the influence of LLST upon the doctor-patient-family relationship, and the way in which LLST is implemented. RESULTS: LLST was proposed in 34.3% of the patients presenting prolonged admission to the ICU with severe complications. The incidence was higher in patients with moderate to severe lung disease, cancer, immunosuppressive treatment or dependence for basic activities of daily living. LLST was finally implemented in 97% of the cases in which it was proposed. The decision within the medical team was unanimous in 87.9% of the cases. The doctor-patient-family relationship usually does not change or even improves in this situation. CONCLUSION: LLST in ICUs is usually carried out under unanimous decision of the medical team, is performed more frequently in patients with severe comorbidity, and usually does not have a negative impact upon the relationship with the patients and their families

Limitation of life-sustaining treatment in patients with prolonged admission to the ICU. Current situation in Spain as seen from the EPIPUSE Study.

OBJECTIVE: Limitation of life-sustaining treatment (LLST) is a recommended practice in certain circumstances. Limitation practices are varied, and their application differs from one center to another. The present study evaluates the current situation of LLST practices in patients with prolonged admission to the ICU who suffer worsening of their condition. DESIGN: A prospective, observational cohort study was carried out. SETTING: Seventy-five Spanish ICUs. PATIENTS: A total of 589 patients suffering 777 complications or adverse events with organ function impairment after day 7 of admission, during a three-month recruitment period. MAIN VARIABLES OF INTEREST: The timing of limitation, the subject proposing LLST, the degree of agreement within the team, the influence of LLST upon the doctor-patient-family relationship, and the way in which LLST is implemented. RESULTS: LLST was proposed in 34.3% of the patients presenting prolonged admission to the ICU with severe complications. The incidence was higher in patients with moderate to severe lung disease, cancer, immunosuppressive treatment or dependence for basic activities of daily living. LLST was finally implemented in 97% of the cases in which it was proposed. The decision within the medical team was unanimous in 87.9% of the cases. The doctor-patient-family relationship usually does not change or even improves in this situation. CONCLUSION: LLST in ICUs is usually carried out under unanimous decision of the medical team, is performed more frequently in patients with severe comorbidity, and usually does not have a negative impact upon the relationship with the patients and their families.

Conferencia de consenso sobre información de eventos adversos a pacientes y familiares / Consensus conference on providing information of adverse events to patients and relatives

Objetivo. Elaborar unas recomendaciones sobre «Información de eventos adversos a pacientes y familiares», mediante la realización de una conferencia de consenso. Material y métodos. Se realizó una revisión bibliográfica de la evidencia disponible, de las principales publicaciones de políticas y guías internacionales y la legislación específica desarrollada en algunos países sobre dicho proceso. La revisión bibliográfica constituyó la base para dar respuesta a una serie de preguntas planteadas en una sesión pública. Un grupo de expertos presentaron la mejor evidencia disponible interaccionando con las partes interesadas. Al término de la sesión un jurado, interdisciplinario y multiprofesional, estableció las recomendaciones finales de la conferencia de consenso. Resultados. Las principales recomendaciones abogan por el interés de elaborar políticas y guías institucionales en nuestro ámbito que favorezcan el proceso de información sobre eventos adversos a los pacientes. Se destaca la necesidad de formación de los profesionales en habilidades de comunicación y en seguridad del paciente, así como el desarrollo de estrategias de soporte a los profesionales que se ven implicados en un evento adverso. Se considera evaluar el interés e impacto de legislación específica que ayudará a la implantación de dichas políticas. Conclusiones. Es necesario un cambio cultural a todos los niveles, matizado y adaptado a las circunstancias específicas sociales y culturales de nuestro ámbito social y sanitario, e implicar a todos los actores del sistema para crear un marco de confianza y credibilidad en el que pueda hacerse efectivo el proceso de información sobre eventos adversos (AU)

Objective: To develop recommendations regarding «Information about adverse events to patients and their families», through the implementation of a consensus conference. Material and methods: A literature review was conducted to identify all relevant articles, the major policies and international guidelines, and the specific legislation developed in some countries on this process. The literature review was the basis for responding to a series of questions posed in a public session. A group of experts presented the best available evidence, interacting with stakeholders. At the end of the session, an interdisciplinary and multi-professional jury established the final recommendations of the consensus conference. Results: The main recommendations advocate the need to develop policies and institutional guidelines in our field, favouring the patient adverse events disclosure process. The recommendations emphasize the need for the training of professionals in communication skills and patient safety, as well as the development of strategies for supporting professionals who are involved in an adverse event. The assessment of the interest and impact of specific legislation that would help the implementation of these policies was also considered. Conclusions: A cultural change is needed at all levels, nuanced and adapted to the specific social and cultural aspects of our social and health spheres, and involves all stakeholders in the system to create a framework of trust and credibility in which the processing of information about adverse events may become effective (AU)

[Consensus conference on providing information of adverse events to patients and relatives]. / Conferencia de consenso sobre información de eventos adversos a pacientes y familiares.

OBJECTIVE: To develop recommendations regarding «Information about adverse events to patients and their families¼, through the implementation of a consensus conference. MATERIAL AND METHODS: A literature review was conducted to identify all relevant articles, the major policies and international guidelines, and the specific legislation developed in some countries on this process. The literature review was the basis for responding to a series of questions posed in a public session. A group of experts presented the best available evidence, interacting with stakeholders. At the end of the session, an interdisciplinary and multi-professional jury established the final recommendations of the consensus conference. RESULTS: The main recommendations advocate the need to develop policies and institutional guidelines in our field, favouring the patient adverse events disclosure process. The recommendations emphasize the need for the training of professionals in communication skills and patient safety, as well as the development of strategies for supporting professionals who are involved in an adverse event. The assessment of the interest and impact of specific legislation that would help the implementation of these policies was also considered. CONCLUSIONS: A cultural change is needed at all levels, nuanced and adapted to the specific social and cultural aspects of our social and health spheres, and involves all stakeholders in the system to create a framework of trust and credibility in which the processing of information about adverse events may become effective.

Confidencialidad. Recomendaciones del Grupo de Bioética de la Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias (SEMICYUC) / No disponible

No disponible

[Treatment recommendations at the end of the life of the critical patient]. / Recomendaciones de tratamiento al final de la vida del paciente crítico.

Admission of a patient in the Intensive Care Unit (ICU) is justified when the critical situation can be reverted or relieved. In spite of this, there is high mortality in the ICU in regard to other hospital departments. End-of-life treatment of critical patients and attention to the needs of their relatives is far from being adequate for several reasons: society denies or hides the death, it is very difficult to predict it accurately, treatment is frequently fragmented between different specialists and there is insufficient palliative medicine training, including communication skills. There are frequent conflicts related to the decisions made regarding the critical patients who are in the end of their life, above all, with the limitation of life-sustaining treatments. Most are conflicts of values between the different parties involved: the patient, his relatives and/or representatives, health professionals, and the institution. The SEMICYUC Working Group of Bioethics elaborates these Recommendations of treatment at the end of the life of the critical patient in order to contribute to the improvement of our daily practice in such a difficult field. After analyzing the role of the agents involved in decision making (patient, familiar, professional, and health care institutions), of the ethical and legal foundations of withholding and withdrawal of treatments, guidelines regarding sedation in the end of the life and withdrawal of mechanical ventilation are recommended. The role of advance directives in intensive medicine is clarified and a written form that reflects the decisions made is proposed.

Recomendaciones de tratamiento al final de la vida del paciente crítico / Treatment recommendations at the end of the life of the critical patient

El ingreso de un paciente en la Unidad de Medicina Intensiva (UMI) está justificado cuando es posible revertir o paliar su situación crítica; a pesar de ello, en las UMI se produce una alta mortalidad con respecto a otros servicios hospitalarios. El tratamiento al final de la vida de los pacientes críticos y la atención a las necesidades de sus familiares están lejos de ser adecuados, por diversos motivos: la sociedad niega u oculta la muerte, es muy difícil predecirla con exactitud, con frecuencia el tratamiento está fragmentado entre diferentes especialistas y hay una insuficiente formación en medicina paliativa, incluyendo habilidades de comunicación. Se producen frecuentes conflictos relacionados con las decisiones que se toman en torno a los enfermos críticos que están en el final de su vida, especialmente con la limitación de tratamientos de soporte vital (LTSV). La mayoría son conflictos de valores entre las diversas partes implicadas: el paciente, sus familiares y/o representantes, los profesionales sanitarios y la institución. El Grupo de trabajo de Bioética de la SEMICYUC elabora estas Recomendaciones de tratamiento al final de la vida del paciente crítico con el propósito de contribuir a la mejora de nuestra práctica diaria en tan difícil campo. Tras el análisis del papel de los agentes implicados en la toma de decisiones (pacientes, familiares, profesionales e instituciones sanitarias) y de los fundamentos éticos y legales de la omisión y retirada de tratamientos, se aconsejan unas pautas de actuación en lo referente a la sedación en el final de la vida y la retirada de la ventilación mecánica, se matiza el papel de las instrucciones previas en medicina intensiva y se propone un formulario que refleje de forma escrita las decisiones adoptadas

Admission of a patient in the Intensive Care Unit (ICU) is justified when the critical situation can be reverted or relieved. In spite of this, there is high mortality in the ICU in regard to other hospital departments. End-of-life treatment of critical patients and attention to the needs of their relatives is far from being adequate for several reasons: society denies or hides the death, it is very difficult to predict it accurately, treatment is frequently fragmented between different specialists and there is insufficient palliative medicine training, including communication skills. There are frequent conflicts related to the decisions made regarding the critical patients who are in the end of their life, above all, with the limitation of life-sustaining treatments. Most are conflicts of values between the different parties involved: the patient, his relatives and/or representatives, health professionals, and the institution. The SEMICYUC Working Group of Bioethics elaborates these Recommendations of treatment at the end of the life of the critical patient in order to contribute to the improvement of our daily practice in such a difficult field. After analyzing the role of the agents involved in decision making (patient, familiar, professional, and health care institutions), of the ethical and legal foundations of withholding and withdrawal of treatments, guidelines regarding sedation in the end of the life and withdrawal of mechanical ventilation are recommended. The role of advance directives in intensive medicine is clarified and a written form that reflects the decisions made is proposed

Medicina de cuidados intensivos / Intensive care medicine

No disponible

Estado vegetativo persistente postanoxia en la Unidad de Cuidados Intensivos / Persistent vegetative state secondary to anoxia in the intensive care unit

En este artículo se plantean las dificultades que existen hoy para definir, en una fase temprana, el nivel de conciencia en los casos de sospecha de estado vegetativo persistente (EVP) postanoxia cerebral y los dilemas que aparecen respecto a la toma de decisiones terapéuticas en estos enfermos. Se confirma que sin soporte vital avanzado este tipo de secuelas no tendría lugar. El diagnóstico de EVP se hace constar en un 0,9 por ciento de altas de las Unidades de Cuidados Intensivos (UCI) en España; en el EVP, la causa postanóxica es la tercera en frecuencia después de la etiología hemorrágica y el traumatismo craneoencefálico. Un estudio prospectivo, multicéntrico, español, de EVP postanoxia realizado en 2001 demostró la necesidad de reconsiderar las recomendaciones para el diagnóstico de certeza de EVP, revisar si se dispone de evidencia científica de pruebas instrumentales útiles para dicho diagnóstico y qué actitud debe tomar el médico intensivista ante esta posible eventualidad. Se plantean las siguientes preguntas: ¿cuándo puede establecerse que existe una situación de EV?, ¿qué actitud debe tomarse ante un EV? (AU)

[Joint clinical rounds in the ICU and satisfaction of the professionals]. / Sesiones clínicas conjuntas en UCI y satisfacción de los profesionales.

It is unknown if multidisciplinary clinical rounds provide a greater degree of satisfaction among the professionals than the traditional work methods.The objective was to compare the satisfaction of the physicians and nurses who evaluate the patients jointly with those of the professionals who do so separately and transmit the information «at bedside¼ (traditional method). An anonymous survey that examined eleven dimensions of expectations, motivation and satisfaction on the common work method was used. Greater global satisfaction was observed in regards to the joint work method both with the substitute nurses (8.3 ± 0.8 versus 3.1 ± 2.8; p < 0.001) as well as those of the staff (7.2 ± 1.3 versus 2.1 ± 1.3; p = 0.01). In the remaining dimensions examined, the scores of the professionals who participated in the joint clinical rounds were also significantly better. Among the physicians, there were no significant differences in the different dimensions or in the global satisfaction.As a conclusion, it can be stated that the joint and consensual work method for the assessment of the patients produces an improvement in all the dimensions of satisfaction, expectations, and professional performance in the nursing area that is not detected among the physicians.

Limitación del esfuerzo terapéutico en medicina intensiva / Limitation of therapeutic activity in intensive care medicine

El grupo de trabajo de Bioética de la Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias (SEMICYUC) ha elaborado una reflexión sobre los aspectos clínicos y fundamentos de la limitación del esfuerzo terapéutico (LET) en los servicios de medicina intensiva y una serie de recomendaciones para evitar el "encarnizamiento terapéutico" y permitir una muerte digna a aquellos de nuestros pacientes que han de fallecer. Se ha basado en la bibliografía actual sobre el tema así como en los principios básicos de la bioética clínica, entendiendo la bioética como una disciplina joven, flexible, plural y laica, que se adapta a las circunstancias de cada época teniendo como base los derechos humanos y los tratados internacionales que nos afectan, como el Convenio sobre Derechos y Humanos y Biomedicina, conocido como el Convenio de Oviedo. Las recomendaciones son sólo orientaciones que pretenden fomentar la discusión bioética en todos y cada uno de los servicios de medicina intensiva de nuestro país, estimular a la SEMICYUC y a otras sociedades científicas a desarrollar trabajos y estudios multicéntricos para elaborar recomendaciones concretas frente a problemas determinados y así ayudar, en la medida de lo posible, a sus miembros en la difícil tarea de la toma de decisiones clínicas ante el paciente terminal (AU)

Sesiones clínicas conjuntas en UCI y satisfacción de los profesionales / Joint clinical rounds in the ICU and satisfaction of the professionals

Se desconoce si las sesiones clínicas multidisciplinarias (clinical rounds) comportan mayor grado de satisfacción, entre los profesionales que los métodos tradicionales de trabajo. El objetivo fue comparar la satisfacción de médicos y enfermeras que valoran los pacientes conjuntamente con la de aquellos profesionales que lo realizan por separado y transmiten la información «a pie de cama» (método tradicional). Se empleó una encuesta anónima donde se exploraron once dimensiones de expectativas, motivación y satisfacción sobre el método de trabajo habitual. Se observó una mayor satisfacción global respecto al método de trabajo conjunto tanto en las enfermeras suplentes (8,3 ± 0,8 versus 3,1 ± 2,8; p < 0,001) como en las de plantilla (7,2 ± 1,3 versus 2,1 ± 1,3; p = 0,01). En el resto de dimensiones exploradas también fueron significativamente mejores las puntuaciones de las profesionales que participaban en sesiones conjuntas. Entre los médicos no existieron diferencias significativas en las diferentes dimensiones ni en la satisfacción global. Como conclusión puede afirmarse que el método de trabajo conjunto y consensuado para la valoración de los enfermos produce, en enfermería, una mejora en todas las dimensiones de satisfacción, expectativas y desempeño profesional que no se detecta entre los médicos (AU)

It is unknown if multidisciplinary clinical rounds provide a greater degree of satisfaction among the professionals than the traditional work methods. The objective was to compare the satisfaction of the physicians and nurses who evaluate the patients jointly with those of the professionals who do so separately and transmit the information «at bedside» (traditional method). An anonymous survey that examined eleven dimensions of expectations, motivation and satisfaction on the common work method was used. Greater global satisfaction was observed in regards to the joint work method both with the substitute nurses (8.3± 0.8 versus 3.1 ± 2.8; p < 0.001) as well as those of the staff (7.2 ± 1.3 versus 2.1 ± 1.3; p = 0.01). In the remaining dimensions examined, the scores of the professionals who participated in the joint clinical rounds were also significantly better. Among the physicians, there were no significant differences in the different dimensions or in the global satisfaction. As a conclusion, it can be stated that the joint and consensual work method for the assessment of the patients produces an improvement in all the dimensions of satisfaction, expectations, and professional performance in the nursing area that is not detected among the physicians (AU)