Legislation in Hospital Dentistry: Gaps, Perspectives and Desires

Abstract Objective: To analyze the existing state legislation, including not only the ordinary laws, but also their infralegal regulation and the state legislation on Hospital Dentistry. Material and Methods: A survey was carried out in the databases of the Legislative Assemblies of the Brazilian States and the Federal District, as well as the Regional and Federal Councils of Dentistry in Brazil. Subsequently, a survey was carried out in the databases of the Ministry of Health, State Dental Councils and Federal Dental Council in Brazil. Results: Only 8 Brazilian states have legislation in force regarding hospital dentistry, which represents 29.63% of the federative units. Among the Brazilian regions, the Midwest presented the highest prevalence of the laws found (37.50%), followed by the North (25%) and the other regions with the same coverage (12.50%). Also, an orientation and an ordinance from the Ministry of Health, six resolutions from the Federal Council of Dentistry, and a technical note from the National Health Surveillance Agency were found. Conclusion: Several States do not have rules on the subject, making it imperative to create a federal rule that not only imposes the presence of the dentist, but also regulates the proportion of the team, workload, and availability.

Fatores associados as solicitações judiciais para acesso a leitos de UTI no estado de São Paulo / Factors associated with judicial requests for access to ICU beds in the State of São Paulo / Factores asociados a lassolicitudes judiciales de acceso a camas de UCI en el Estado de São Paulo

Introdução: A busca pela judicialização da saúde vem crescendo exponencialmente no país e por isso uma análise de seus efeitos e resultados no sistema de saúde é de extrema importânciapara o correto planejamento em saúde pública. Objetivos: analisar o perfil dos processos de judicialização em saúde referentes às necessidades por leitos de Unidade de Tratamento Intensivo no estado de São Paulo.Métodos: Estudo transversal constituído por todos os acórdãos no Tribunal de Justiça do Estado de São Paulo, no período compreendido entre 2009 e 2019. Os dados foram analisados de forma descritiva e expressos em frequências absolutas. Resultados: Foram selecionadas 299 ações para a análise, sendo a maior demanda tendo como autor principal no âmbito privado (n=292). Houve aumento de 0,66% no número de processos de demanda de leitos de 2009 a 2019 (n=66).Conclusões: Apesar da maioria dos pedidos de processo de judicialização advirem de pacientes com origem na esfera pública de saúde, a maioria dos processos são iniciados pela iniciativa privada. Nesse contexto, o estado necessita elaborar uma maior padronização nos acórdãos de modo a viabilizar com precisão a caracterização do perfil de autoria (AU).

Introduction: The search for healthcare judicialization has been increasing exponentially nationwide. Accordingly, an analysis of its effects and results in the health system is of utmost importance for correct planning in public health.Objectives: To analyze the profile of health lawsuits related to the need for Intensive Care Unit beds in the state of São Paulo.Methods: Crosssectional study consisting of all the judgments in the Court of Justice of the State of São Paulo from 2009 to 2019. The data were analyzed descriptively and expressed as absolute frequencies.Results: Two hundred ninety-nine (299) actions were selected for analysis, with the largest lawsuit having the private sector as the main plaintiff (n=292). There was a 0.66% increase in the number of bed cases from 2009 to 2019 (n=66).Conclusions: Although most lawsuit claims come from patients arising from the public health sphere, most lawsuits are initiated by the private sector. In this context, the state needs to elaborate a greater standardization in the judgments in order to make it possible to characterize plaintiffs' profiles accurately (AU).

Introducción: La búsqueda por la judicialización de la salud viene creciendoexponencialmente en el país y, por lo tanto, un análisis de sus efectos y resultados en el sistema de salud es de suma importancia para una correcta planificación en salud pública.Objetivos: Analizar el perfil de los procesos de judicialización de la salud con relación a las necesidades de camas de la Unidad de Terapia Intensiva en el Estado de São Paulo.Métodos: Estudio transversal compuesto por todas las sentencias del Tribunal de Justicia del Estado de São Paulo, en el período comprendido entre 2009 y2019. Los datos se analizaron descriptivamente y se expresaron en frecuencias absolutas.Resultados: Se seleccionaron para el análisis un total de 299 acciones, de las cuales la mayor demanda tenía como principal demandante el ámbito privado (n=292). Huboun aumento del 0,66% en el número de demandas de camas de 2009 a 2019 (n=66).Conclusiones: Aunque la mayoría de las solicitudes de procesos de judicialización provienen de pacientes procedentes del ámbito sanitario público, la mayoría de los procedimientos son iniciados por la iniciativa privada. En este contexto, el Estado necesita desarrollar juicios más normalizados para caracterizar con precisión el perfil de autoría (AU).

Management of bed availability in intensive care in the context of hospitalization by court order.

OBJECTIVE: to identify, from the nurse perspective, situations that interfere with the availability of beds in the intensive care unit in the context of hospitalization by court order. METHOD: qualitative exploratory, analytical research carried out with 42 nurses working in adult intensive care. The selection took place by non-probabilistic snowball sampling. Data collected by interview and analyzed using the Discursive Textual Analysis technique. RESULTS: three categories were analyzed, entitled deficiency of physical structure and human resources; Lack of clear policies and criteria for patient admission and inadequate discharge from the intensive care unit. In situations of hospitalization by court order, there is a change in the criteria for the allocation of intensive care beds, due to the credibility of professionals, threats of medico-legal processes by family members and judicial imposition on institutions and health professionals. CONCLUSION: nurses defend the needs of the patients, too, with actions that can positively impact the availability of intensive care beds and adequate care infrastructure.

Inapropriate use of antibiotics effective against gram positive microorganisms despite restrictive antibiotic policies in ICUs: a prospective observational study.

BACKGROUND: Gram-positive spectrum antibiotics such as vancomycin, teicoplanin, daptomycin, and linezolid are frequently used in empirical treatment combinations in critically ill patients. Such inappropriate and unnecessary widespread use, leads to sub-optimal utilisation. However they are covered by the antibiotics restriction programme. This prospective observational study, evaluates gram-positive anti-bacterial utilisations in intensive care units (ICUs) with various evaluation criteria, to determine the frequency of inappropriate usage and the intervention targets required to ensure optimum use. METHODS: This clinical study was conducted prospectively between 01.10.2018 and 01.10.2019 in the medical and surgical ICUs of Gazi University Faculty of Medicine Hospital, Turkey. The total bed capacity was 55. Patients older than 18 years and who were prescribed gram-positive spectrum antibiotics (vancomycin, teicoplanin, linezolid, and daptomycin) were included. Patients under this age or immunosuppressed patients (neutropenic,- HIV-infected patients with hematologic or solid organ malignancies) were not included in the study. During the study period, 200 treatments were evaluated in 169 patients. The demographic and clinical features of the patients were recorded. Besides observations by the clinical staff, the treatments were recorded and evaluated by two infectious diseases specialists and two clinical pharmacists at 24-h intervals from the first day to the last day of treatment. SPSS software for Windows, (version 17, IBM, Armonk, NY) was used to analyse the data. Categorical variables were presented as number and percentage, and non-categorical variables were presented as mean ± standard deviation. RESULTS: It was found that inappropriate gram-positive antibiotic use in ICUs was as high as 83% in terms of non-compliance with the selected quality parameters. Multivariate analysis was performed to evaluate the factors associated with inappropriate antibiotic use, increased creatinine levels were found to increase the risk of such use. CONCLUSIONS: In spite of the restricted antibiotics programme, inappropriate antibiotic use in ICUs is quite common. Thus, it is necessary to establish local guidelines in collaboration with different disciplines for the determination and follow-up of de-escalation of such use and optimal treatment doses.

Nurses' experiences of ICU diaries following implementation of national recommendations for diaries in intensive care units: A quality improvement project.

OBJECTIVES: To evaluate critical care nurses' experiences of ICU diaries following the implementation of national recommendations for the use of diaries for critically ill patients. DESIGN: A quality improvement project describing the development and implementation of national recommendations (2011), as well as the assessment of the use of diaries in intensive care nursing practice (2014). SETTING: Norwegian intensive care units (ICUs). PARTICIPANTS: Thirty-nine Norwegian ICUs took part in the study. INTERVENTION: A multi-component process for developing national recommendations for the use of diaries in Norwegian ICUs, including recommendations for the target group, when to start, health professionals as authors, diary content, structure, language, use of photographs, handover, access and storage within patient medical records. MAIN OUTCOME MEASURE: A questionnaire asking about experiences of implementing national recommendations on diaries in Norwegian ICUs, as well as their impact and how they are used. RESULTS: Three years after the implementation of the national recommendations, diaries were provided in 24 (61.5%) of the responding ICUs. Fifty-six per cent of the ICUs had revised their routines, of which 62% had updated and 38% had developed new protocols. Most ICUs kept the diary along with other medical information describing patient care, but only 50% of the ICUs scanned handwritten diaries into the electronic medical records before handing them over to patients or the bereaved. ICU nurses reported that implementing national recommendations had increased their awareness and knowledge on patient and family needs, as well as the long-term effects of critical illness. CONCLUSION: The results of this quality improvement project indicate that access to national recommendations on the use of diaries for critically ill patients have a potential of changing routines and increase standardisation.

Investigación clínica a pie de cama. Sepsis / Clinical research at the bedside. Sepsis / Recerca clínica a peu de llit. Sèpsia

La investigación clínica en sepsis es una prioridad y una obligación cuyo objetivo primordial ha de ser tanto el conocimiento de su compleja fisiopatología como la búsqueda de herramientas diagnósticas precoces y eficaces para mejorar el tratamiento y disminuir la tasa de mortalidad. Los principios éticos de la investigación biomédica ayudan a determinar el equilibrio entre el avance de la ciencia y la protección de los derechos y bienestar de los sujetos de la investigación

Clinical research in sepsis is a priority and an obligation whose primary objective must be both knowledge of its complex pathophysiology and the search for early and effective diagnostic tools to improve treatment and reduce the mortality rate. The ethical principles of biomedical research help to determine the balance between the advancement of science and the protection of the rights and welfare of research subjects

La recerca clínica en la sèpsia és una prioritat I una obligació l'objectiu primordial de la qual ha de ser tant el coneixement de la seva complexa fisiopatología, com la cerca d'eines diagnòstiques precoces I eficaces per a millorar-ne el tractament I disminuir la taxa de mortalitat. Els principis ètics de la recerca biomèdica ajuden a determinar l'equilibri entre l'avanç de la ciència I la protecció dels drets I benestar dels subjectes de la recerca

Estructura de las unidades de cuidados intensivos de anestesia: recomendaciones de la Sección de Cuidados Intensivos de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR) / Structure of the anesthesia intensive care units: recommendations of the Intensive Care Section of the Spanish Society of Anaesthesiology

ANTECEDENTES Y OBJETIVO: Los objetivos de la Sección de Cuidados Intensivos de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SCI-SEDAR) con el presente trabajo son: establecer nuevas recomendaciones adaptando los estándares publicados por el Ministerio de Sanidad y Política Social, y alineadas con las principales guías internacionales, y desarrollar una herramienta de mejora de la calidad y la eficiencia. MATERIALES Y MÉTODO: A lo largo de 2018, 3 miembros de la SCI-SEDAR definieron la metodología, desarrollaron las recomendaciones y seleccionaron al panel de expertos. Debido a la limitada evidencia de buena parte de las recomendaciones y a la importante variabilidad estructural de las unidades de cuidados intensivos de anestesia actuales, se optó por un abordaje Delphi modificado para determinar el grado de consenso. RESULTADOS: Un total de 24 expertos de 21 instituciones constituyeron el grupo de expertos del presente trabajo. Se establecieron 175 recomendaciones sobre 8 apartados, incluyendo 129 con consenso fuerte y 46 con consenso débil. CONCLUSIONES: La SCI-SEDAR estableció las recomendaciones estructurales de las unidades de cuidados intensivos de anestesia que deberán guiar la renovación o la creación de nuevas unidades

BACKGROUND AND OBJECTIVE: In this article, the Intensive Care Section of the Spanish Society of Anesthesiology (SCI-SEDAR) establishes new recommendations based on the standards published by the Ministry of Health, Consumer Affairs and Social Welfare and aligned with the principle international guidelines, and develops a tool to improve quality and efficiency. MATERIALS AND METHOD: Over a 12-month period (2018), 3 members of the SCI-SEDAR defined the methodology, developed the recommendations and selected the panel of experts. Due to the limited evidence available for many of the recommendations and the significant structural differences between existing anesthesia intensive care units, we chose a modified Delphi approach to determine the degree of consensus. RESULTS: The panel consisted of 24 experts from 21 institutions. The group put forward 175 recommendations on 8 sections, including 129 with strong consensus and 46 with weak consensus. CONCLUSIONS: The SCI-SEDAR has established a series of structural recommendations that should be used when renovating or creating new anesthesia intensive care units

Legal Perspectives on Telemedicine Part 2: Telemedicine in the Intensive Care Unit and Medicolegal Risk.

Tele-intensive care unit (tele-ICU) implementation has been shown to improve clinical and financial outcomes. The expansion of this new care delivery model has outpaced the development of its accompanying regulatory framework. In the first part of this commentary we discussed legal and regulatory issues of telemedicine in general and expanded on tele-ICU implementation in particular. Major legal and regulatory barriers to expansion remain, including uncertainty regarding license portability and reimbursement. In this second part we discuss the effects of telemedicine implementation on the various aspects of medicolegal risk and risk mitigation, with a particular focus on tele-ICU. There is a paucity of legal data regarding the effect of tele-ICU implementation on medicolegal risk. We will therefore systematically discuss the effects of tele-ICU on the various root causes of medical error. Given the substantial capital and operational investment that must be undertaken to build and run a tele-ICU, any reduction in risk adds to the financial return on investment and further decreases barriers to implementation.

Structure of the Anesthesia Intensive Care Units: Recommendations of the Intensive Care Section of the Spanish Society of Anaesthesiology. / Estructura de las unidades de cuidados intensivos de anestesia: recomendaciones de la Sección de Cuidados Intensivos de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR).

BACKGROUND AND OBJECTIVE: In this article, the Intensive Care Section of the Spanish Society of Anesthesiology (SCI-SEDAR) establishes new recommendations based on the standards published by the Ministry of Health, Consumer Affairs and Social Welfare and aligned with the principle international guidelines, and develops a tool to improve quality and efficiency. MATERIALS AND METHOD: Over a 12-month period (2018), 3 members of the SCI-SEDAR defined the methodology, developed the recommendations and selected the panel of experts. Due to the limited evidence available for many of the recommendations and the significant structural differences between existing anesthesia intensive care units, we chose a modified Delphi approach to determine the degree of consensus. RESULTS: The panel consisted of 24 experts from 21 institutions. The group put forward 175 recommendations on 8 sections, including 129 with strong consensus and 46 with weak consensus. CONCLUSIONS: The SCI-SEDAR has established a series of structural recommendations that should be used when renovating or creating new anesthesia intensive care units.

Intensivistas, perded toda esperanza / Intensivists, lose all hope

No disponible

Documento sobre la situación del modelo español de Medicina Intensiva. Plan estratégico SEMICYUC 2018-2022 / Document on the state of affairs of the Spanish model of Intensive Care Medicine. SEMICYUC Strategic Plan 2018-2022

El modelo español de Medicina Intensiva requiere una revisión y reflexión continuas. Tenemos valores y fortalezas que se concretan en nuestra actividad y en el importante papel que realizamos a diario a nivel hospitalario. Otras especialidades pugnan por compartir actividades de cuidados del paciente crítico y otras circunstancias pueden hacer mermar esa actividad. Este artículo es el reflejo de la reflexión de un importante número de miembros del Grupo de Trabajo de Planificación, Organización y Gestión de nuestra Sociedad (GTPOG-SEMICYUC). Se afrontan las acciones que se deben llevar a cabo para la actualización del modelo de Medicina Intensiva, hacia un modelo más abierto de UCI sin paredes o UCI extendida. Se aborda desde tres puntos de vista que deben ser complementarios: las acciones a nivel de la Administración, las acciones a nivel de nuestra Sociedad Científica y las llevadas a cabo por cada uno de los Servicios (liderados por sus representantes), tanto a nivel hospitalario como a nivel de las autoridades sanitarias en cada comunidad autónoma

The role of Critical Care Medicine in Spain requires continuous revision and reflection. We have values and strengths that are evidenced in our daily work and by their important effects in routine hospital activity. Other medical specialties seeking to assume activities referred to critical patient care, as well as a number of other circumstances, may have a negative impact upon our routine duties. This article reflects the impressions of an important number of members of the Planning, Organization and Management Task Force of the Spanish Society of Critical Medicine Society (Grupo de Trabajo de Planificación, Organización y Gestión; GTPOG-SEMICYUC). The actions required to upgrade our Critical Care Medicine model are presented, evolving towards a broader view such as the 'ICU without walls' or 'Expanded ICU'. The subject is addressed from three complementary standpoints: actions involving the administrative authorities; actions required on the part of our scientific Society; and initiatives to be implemented locally in each Intensive Care Unit (led by the corresponding Unit representatives) at both hospital level and involving the regional authorities

Buenas prácticas asistenciales para garantizar la seguridad del paciente con úlceras por presión. Sentencia núm. 164 dictada por el tribunal superior de justicia de extremadura: comentarios y reflexiones / Good practices to guarantee the safety of the patient with pressure ulcers. Sentence number 164 pronounced by the superior court of justice of Extremadura: comments and thought. Sentencia núm. 164 dictada por el tribunal superior de justicia de Extremadura: comentarios y reflexiones

Las úlceras por presión constituyen, en nuestro entorno sanitario, uno de los eventos adversos más prevalentes relaciona-dos con los cuidados, situándose a su vez entre los que con mayor probabilidad pueden ser evitados. Ante esta realidad, y tomando como referencia una sentencia estimatoria, se analizan todas aquellas cuestiones legales que se han valorado en dicho procedimiento judicial para dictar la correspondiente resolución. Informar y reflejar las intervenciones en la historia clínica es fundamental para la determinación de responsabilidad

Pressure ulcers constitute, in our health system, one of the ad-verse events with a highest prevalence related to care, placing among those more easily to avoid. Attending to this fact, and taking a particular estimated sentence as an example, we have analyzed all those legal questions that have been valued to solve the mentioned judicial procedure in order to adopt a position and give a judgment. Informing and reflecting our interventions in the medical records are considered keys to determine responsibility

French intensive care unit organisation.

Anaesthesia, Critical Care and Pain Medicine is the journal of the French Society of Anaesthesia and Intensive Care Medicine (Société Francaise d'Anesthésie et de Réanimation), aimed at promoting the French approach to anaesthesiology, critical care and perioperative medicine. Here, the Intensive Care Committee of the French Society of Anaesthesia and Intensive Care Medicine provides an overview of the organisation of the 400 French Intensive Care Units (ICU), which are polyvalent (50%), surgical (20%), or medical (12%). Around 150,000 patients are admitted to these units each year. Law Decrees govern the frame of practices, including architecture, nurse staffing - two nurses for five patients and one nurse-assistant for four patients - and 24/7 medical coverage. The daily cost of ICU hospitalisation is around 1425 €, entirely ensured by the National Health System. The clinical practices are variable but guidelines produced by intensivists are invited to adhere to guidelines available and freely accessible. End-of-life practices are framed by a Law Decree (Claeys Léonetti) aiming at protecting patients against stubbornly and unreasonable cares. The biomedical research plays a critical role in the French ICU, and practices are performed under the supervision of the Jardé Law. An Institutional Research Board approval is required for prospective studies. In conclusion, the French ICU practice is surrounded by a legal frame.

Non-readmission decisions in the intensive care unit under French rules: A nationwide survey of practices.

PURPOSE: We investigated, using a multicentre survey of practices in France, the practices of ICU physicians concerning the decision not to readmit to the ICU, in light of current legislation. MATERIALS AND METHODS: Multicentre survey of practices among French ICU physicians via electronic questionnaire in January 2016. Questions related to respondents' practices regarding re-admission of patients to the ICU and how these decisions were made. Criteria were evaluated by the health care professionals as regards importance for non-readmission. RESULTS: In total, 167 physicians agreed to participate, of whom 165 (99%) actually returned a completed questionnaire from 58 ICUs. Forty-five percent were aged <35 years, 74% were full-time physicians. The findings show that decisions for non-readmission are taken at the end of the patient's stay (87%), using a collegial decision-making procedure (89% of cases); 93% reported that this decision was noted in the patient's medical file. While 73% indicated that the family/relatives were informed of non-readmission decisions, only 29% reported informing the patient, and 91% considered that non-readmission decisions are an integral part of the French legislative framework. CONCLUSION: This study shows that decisions not to re-admit a patient to the ICU need to be formally materialized, and anticipated by involving the patient and family in the discussions, as well as the other healthcare providers that usually care for the patient. The optimal time to undertake these conversations is likely best decided on a case-by-case basis according to each patient's individual characteristics.

Patient Outcomes After the Introduction of Statewide ICU Nurse Staffing Regulations.

OBJECTIVES: To assess whether Massachusetts legislation directed at ICU nurse staffing was associated with improvements in patient outcomes. DESIGN: Retrospective cohort study; difference-in-difference design to compare outcomes in Massachusetts with outcomes of other states (before and after the March 31, 2016, compliance deadline). SETTING: Administrative claims data collected from medical centers across the United States (Vizient). PATIENTS: Adults between 18 and 99 years old who were admitted to ICUs for greater than or equal to 1 day. INTERVENTIONS: Massachusetts General Law c. 111, § 231, which established 1) maximum patient-to-nurse assignments of 2:1 in the ICU and 2) that this determination should be based on a patient acuity tool and by the staff nurses in the unit. MEASUREMENTS AND MAIN RESULTS: Nurse staffing increased similarly in Massachusetts (n = 11 ICUs, Baseline patient-to-nurse ratio 1.38 ± 0.16 to Post-mandate 1.28 ± 0.15; p = 0.006) and other states (n = 88 ICUs, Baseline 1.35 ± 0.19 to Post-mandate 1.31 ± 0.17; p = 0.002; difference-in-difference p = 0.20). Massachusetts ICU nurse staffing regulations were not associated with changes in hospital mortality within Massachusetts (Baseline n = 29,754, standardized mortality ratio 1.20 ± 0.04 to Post-mandate n = 30,058, 1.15 ± 0.04; p = 0.11) or when compared with changes in hospital mortality in other states (Baseline n = 572,952, 1.15 ± 0.01 to Post-mandate n = 567,608, 1.09 ± 0.01; difference-in-difference p = 0.69). Complications (Massachusetts: Baseline 0.68% to Post-mandate 0.67%; other states: Baseline 0.72% to Post-mandate 0.72%; difference-in-difference p = 0.92) and do-not-resuscitate orders (Massachusetts: Baseline 13.5% to Post-mandate 15.4%; other states: Baseline 12.3% to Post-mandate 14.5%; difference-in-difference p = 0.07) also remained unchanged relative to secular trends. Results were similar in interrupted time series analysis, as well as in subgroups of community hospitals and workload intensive patients receiving mechanical ventilation. CONCLUSIONS: State regulation of patient-to-nurse staffing with the aid of patient complexity scores in intensive care was not associated with either increased nurse staffing or changes in patient outcomes.

The Deferred Consent Model in a Prospective Observational Study Evaluating Myocardial Injury in the Intensive Care Unit.

BACKGROUND: Informed consent is a hallmark of ethical clinical research. An inherent challenge in critical care research is obtaining consent when patients lack decision-making capacity. One solution is deferred consent, which is often used for studies that are low risk or involve emergency interventions. Our objective was to describe a deferred consent model in a low-risk critical care study. METHODS: Prognostic Value of Elevated Troponins in Critical Illness Study was a prospective, pilot observational study of critically ill patients in 3 intensive care units, involving serial electrocardiograms and cardiac biomarkers. Newly admitted patients were enrolled over 1 month. When possible, informed consent was obtained a priori from the patient or substitute decision maker (SDM); otherwise, consent was deferred until the patient regained consent capacity or until their SDM was available. Logistic regression analysis was used to determine the association between patient's sex, Acute Physiology and Chronic Health Evaluation II score, study center, person providing consent (patient vs SDM), method of consent (telephone vs in person), and the provision or not of informed consent. RESULTS: The overall consent rate was 80.1% (213 of 266 persons approached). Of the 53 persons declining consent, 37 (69.8%) agreed to the use of data collected up until that point. Over half of all consent encounters were with patients rather than SDMs. Median interval delay between enrollment and the consent encounter was 1 day. On multivariate analysis, the only variable associated with consent was male sex of the patient (odds ratio for males 2.59, confidence interval: 1.19-5.63). CONCLUSION: Deferred consent facilitates implementation of time-sensitive research protocols until a consent encounter is possible. As a feasible alternative to exclusive a priori consent, the deferred consent model can be useful in low-risk studies in critically ill patients.

Worldwide end-of-life practice for patients in ICUs.

PURPOSE OF REVIEW: Published data and practice recommendations on end-of-life (EOL) generally reflect Western practice frameworks. Understanding worldwide practices is important because improving economic conditions are promoting rapid expansion of intensive care services in many previously disadvantaged regions, and increasing migration has promoted a new cultural diversity previously predominantly unicultural societies. This review explores current knowledge of similarities and differences in EOL practice between regions and possible causes and implications of these differences. RECENT FINDINGS: Recent observational and survey data shows a marked variability in the practice of withholding and withdrawing life sustaining therapy worldwide. Some evidence supports the view that culture, religion, and socioeconomic factors influence EOL practice, and individually or together account for differences observed. There are also likely to be commonly desired values and expectations for EOL practice, and recent attempts at establishing where worldwide consensus may lie have improved our understanding of shared values and practices. SUMMARY: Awareness of differences, understanding their likely complex causes, and using this knowledge to inform individualized care at EOL is likely to improve the quality of care for patients. Further research should clarify the causes of EOL practice variability, monitor trends, and objectively evaluate the quality of EOL practice worldwide.