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2.
Med. intensiva (Madr., Ed. impr.) ; 44(2): 101-112, mar. 2020. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-188659

RESUMO

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


Assuntos
Humanos , Tomada de Decisões , Cuidados para Prolongar a Vida/normas , Cuidados Críticos/normas , Cuidados para Prolongar a Vida/estatística & dados numéricos , Cuidados Paliativos na Terminalidade da Vida/ética , Cuidados Paliativos na Terminalidade da Vida/normas , Unidades de Terapia Intensiva
4.
Nursing ; 49(2): 46-49, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30676559

RESUMO

In November 2017, the American Heart Association published updates to its adult and pediatric Basic Life Support and Cardiopulmonary Resuscitation guidelines; one year later, it published updates to its Advanced Cardiovascular Life Support and Pediatric Advanced Life Support guidelines. This article reviews these updated guidelines and highlights the key changes and how to integrate them into practice.


Assuntos
Suporte Vital Cardíaco Avançado/normas , Reanimação Cardiopulmonar/normas , Cuidados para Prolongar a Vida/normas , Pediatria/normas , Guias de Prática Clínica como Assunto , Adulto , American Heart Association , Criança , Parada Cardíaca/terapia , Humanos , Lactente , Estados Unidos
5.
Medicine (Baltimore) ; 98(4): e13990, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30681557

RESUMO

Prehospital use of ventilators by emergency medical services (EMS) during 911 calls is increasing. This study described the impact of prehospital mechanical ventilation on prehospital time intervals and on mortality.This retrospective matched-cohort study used 4 consecutive public releases of the US National Emergency Medical Services Information System dataset (2011-2014). EMS activations with recorded ventilator use were randomly matched with activations without ventilator use (1 to 1) on age (range ±â€Š2 years), gender, provider's primary impression, urbanicity, and level of service.A total of 5740 EMS activations were included (2870 patients per group). Patients in the ventilator group had a mean age of 69.1 (±17.3) years with 49.4% males, similar to the non-ventilator group. Activations were mostly in urban settings (83.8%) with an advanced life support level of care (94.5%). Respiratory distress (77.8%) and cardiac arrest (6.8%) were the most common provider's primary impressions. Continuous positive airway pressure was the most common mode of ventilation used (79.2%).Mortality was higher at hospital discharge (29.0% vs 21.1%, P = .01) but not at emergency department (ED) discharge (8.4% vs 7.4%, P = .19) with prehospital ventilator use. Both total on-scene time and total prehospital time intervals increased with reported ventilator use (4.10 minutes (95% confidence interval [CI]: 2.71-5.49) and 3.59 minutes (95% CI: 3.04-4.14), respectively).Ventilator use by EMS agencies in 911 calls in the US is associated with higher prehospital time intervals without observed impact on survival to ED discharge. More EMS outcome research is needed to provide evidence-based prehospital care guidelines and targeted resource utilization.


Assuntos
Serviços Médicos de Emergência/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Cuidados para Prolongar a Vida/normas , Cuidados para Prolongar a Vida/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Características de Residência/estatística & dados numéricos , Estudos Retrospectivos , Fatores Sexuais , Estados Unidos
6.
Neurocrit Care ; 30(1): 33-41, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30143963

RESUMO

BACKGROUND: Withdrawal of life-sustaining treatment (WOLST) is the leading proximate cause of death in patients with perceived devastating brain injury (PDBI). There are reasons to believe that a potentially significant proportion of WOLST decisions, in this setting, are premature and guided by a number of assumptions that falsely confer a sense of certainty. METHOD: This manuscript proposes that these assumptions face serious challenges, and that we should replace unwarranted certainty with an appreciation for the great degree of multi-dimensional uncertainty involved. The article proceeds by offering a taxonomy of uncertainty in PDBI and explores the key role that uncertainty as a cognitive state, may play into how WOLST decisions are reached. CONCLUSION: In order to properly share decision-making with families and surrogates of patients with PDBI, we will have to acknowledge, understand, and be able to communicate the great degree of uncertainty involved.


Assuntos
Lesões Encefálicas/diagnóstico , Lesões Encefálicas/terapia , Tomada de Decisão Clínica/métodos , Cuidados para Prolongar a Vida/normas , Incerteza , Suspensão de Tratamento/normas , Adulto , Tomada de Decisão Clínica/ética , Humanos , Cuidados para Prolongar a Vida/ética , Prognóstico , Suspensão de Tratamento/ética
8.
Rev Bras Enferm ; 71(suppl 6): 2698-2705, 2018.
Artigo em Inglês, Português | MEDLINE | ID: mdl-30540046

RESUMO

OBJECTIVE: to describe the content construction and validation process of the Distance Education Basic Life Support Course. METHOD: methodological study, developed through literature review, outlined in the light of the Bloom's Taxonomy and Ausubel's Meaningful Learning Theory. For validation, the analysis was performed with judges, using a structured tool. RESULTS: the construction of the distance course was complex and challenging, since it was tried to develop it with logical-methodological coherence, considering the constructivist perspective, representing an advance in the process of dissemination of the Urgency and Emergency teaching culture. As for the content validation process, it was verified that of the 16 suggestions made by the judges, 14 were accepted and two rejected. CONCLUSION: the course had its contents validated by experts.


Assuntos
Currículo/normas , Educação a Distância/normas , Cuidados para Prolongar a Vida/normas , American Heart Association/organização & administração , Educação a Distância/métodos , Humanos , Cuidados para Prolongar a Vida/métodos , Determinação de Necessidades de Cuidados de Saúde , Validação de Programas de Computador , Estados Unidos
13.
PLoS One ; 13(6): e0198918, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29894491

RESUMO

BACKGROUND: The 'chain of survival'-including early call for help, early cardiopulmonary resuscitation (CPR) and early defibrillation-represents the most beneficial approach for favourable patient outcome after out-of-hospital cardiac arrest (OHCA). Despite increasing numbers of publicly accessible automated external defibrillators (AED) and interventions to increase public awareness for basic life support (BLS), the number of their use in real-life emergency situations remains low. METHODS: In this prospective population-based cross-sectional study, a total of 501 registered inhabitants of Vienna (Austria) were randomly approached via telephone calls between 08/2014 and 09/2014 and invited to answer a standardized questionnaire in order to identify public knowledge and awareness of BLS and AED-use. RESULTS: We found that more than 52 percent of participants would presume OHCA correctly and would properly initiate BLS attempts. Of alarming importance, only 33 percent reported that they would be willing to perform CPR and 50 percent would use an AED device. There was a significantly lower willingness to initiate BLS attempts (male: 40% vs. female: 25%; OR: 2.03 [95%CI: 1.39-2.98]; p<0.001) and to use an AED device (male: 58% vs. female: 44%; OR: 1.76 [95%CI: 1.26-2.53]; p = 0.002) in questioned female individuals compared to their male counterparts. Interestingly, we observed a strongly decreasing level of knowledge and willingness for BLS attempts (-14%; OR: 0.72 [95%CI: 0.57-0.92]; p = 0.027) and AED-use (-19%; OR: 0.68 [95%CI: 0.54-0.85]; p = 0.001) with increasing age. CONCLUSION: We found an overall poor knowledge and awareness concerning BLS and the use of AEDs among the Viennese population. Both female and elderly participants reported the lowest willingness to perform BLS and use an AED in case of OHCA. Specially tailored programs to increase awareness and willingness among both the female and elderly community need to be considered for future educational interventions.


Assuntos
Reanimação Cardiopulmonar/métodos , Conhecimentos, Atitudes e Prática em Saúde , Parada Cardíaca/prevenção & controle , Cuidados para Prolongar a Vida/normas , Parada Cardíaca Extra-Hospitalar/prevenção & controle , Idoso , Reanimação Cardiopulmonar/educação , Estudos Transversais , Feminino , Parada Cardíaca/epidemiologia , Comportamento de Ajuda , Humanos , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/epidemiologia , Estudos Prospectivos
14.
J Palliat Med ; 21(7): 978-986, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29624461

RESUMO

BACKGROUND: The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm is used across the country to document the treatment preferences of seriously ill or frail patients as medical orders. The National POLST Paradigm Task Force maintains consensus-based standards for POLST programs and uses these to determine whether a state POLST program is developing, endorsed, or mature. OBJECTIVES: To evaluate state program form adherence to national standards. DESIGN: Document review. MEASUREMENTS: Forms from endorsed/mature (n = 21) and developing (n = 23) states were compared with national standards to assess adherence to required and optional form elements. RESULTS: Required elements were present on 84% of endorsed/mature state POLST forms and 73% of the developing state POLST forms. Compliance with required elements in endorsed states ranged from 50% to 100%. Three endorsed/mature states (14%) had forms that met all of the required elements fully and 14 (67%) had forms that met the all of the elements fully or partially. CONCLUSIONS: There is variability in adherence to required and optional standards as well as challenges in interpreting and applying existing standards. Although there may be legal and logistical barriers to the existence of a national POLST form, standardization remains an important goal to support patient-centered care.


Assuntos
Planejamento Antecipado de Cuidados/normas , Adesão a Diretivas Antecipadas/normas , Governo Federal , Cuidados para Prolongar a Vida/normas , Ordens quanto à Conduta (Ética Médica)/legislação & jurisprudência , Governo Estadual , Assistência Terminal/normas , Planejamento Antecipado de Cuidados/estatística & dados numéricos , Adesão a Diretivas Antecipadas/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Estados Unidos
15.
J Fam Pract ; 67(4): 249-251, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29614148

RESUMO

Quite well, for cardiopulmonary resuscitation (CPR). Most patients (91%-100%) who select "do not resuscitate" (DNR) on their physician's orders for life-sustaining treatment (POLST) forms are allowed a natural death without attempted CPR across a variety of settings (community, skilled nursing facilities, emergency medical services, and hospice). Few patients (6%) who select "comfort measures only" die in the hospital, whereas more (22%) who choose "limited interventions," and still more (34%) without a POLST form, die in the hospital (strength of recommendation [SOR]: B, large, consistent cross-sectional and cohort studies).


Assuntos
Planejamento Antecipado de Cuidados/normas , Diretivas Antecipadas/estatística & dados numéricos , Assistência à Saúde/normas , Fidelidade a Diretrizes/normas , Cuidados para Prolongar a Vida/normas , Assistência Terminal/normas , Planejamento Antecipado de Cuidados/estatística & dados numéricos , Idoso , Estudos de Coortes , Estudos Transversais , Assistência à Saúde/estatística & dados numéricos , Feminino , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Masculino , Assistência Terminal/estatística & dados numéricos , Estados Unidos
16.
Rev Esp Geriatr Gerontol ; 53(4): 217-222, 2018.
Artigo em Espanhol | MEDLINE | ID: mdl-29475629

RESUMO

The identification of patients with advanced and complex chronic diseases, and the fragmentation of care towards the end of life, requires the drawing up a long-term therapeutic plan. This should take into account the values and preferences of the patients, as well as the vital and functional prognosis. Having an adjustment tool for determining the diagnostic and therapeutic effort is helpful in the continuity of care, as well as in decision-making in the transitions and dynamic changes of patients as they approach the end of life process.


Assuntos
Planejamento Antecipado de Cuidados/normas , Assistência Terminal/normas , Conferências de Consenso como Assunto , Humanos , Cuidados para Prolongar a Vida/normas , Espanha , Saúde da População Urbana
17.
Artif Organs ; 42(4): 394-400, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29423912

RESUMO

Extracorporeal life support (ECLS) weaning is a complex interdisciplinary process with no clear guidelines. To assess ventricular and pulmonary function as well as hemodynamics including end-organ recovery during ECLS weaning, we developed a standardized weaning protocol. We reviewed our experience 2 years later to assess its feasibility and efficacy. In 2015 we established an inter-professional, standardized, stepwise protocol for weaning from ECLS. If the patient did not require further surgery, weaning was conducted bedside in the intensive care unit (ICU). Most of the weaning procedures are guided via echocardiography. Data acquisition began at baseline level, followed by four-step course (each step lasting 10 min), entailing flow-reduction and ending 30 min after decannulation. Moreover, data from the preprotocol era are presented. Between May 2015 and 2017, 26 consecutive patients (18 male), median age 177 days (2 days-20 years) required ECLS with median support of 4 (2-11) days. Excluding eight not weanable patients, 21 standardized weaning procedures were protocolled in the remaining 18 children. Our generally successful protocol-guided weaning rate (with at least 24-h survival) was 89%, with a discharge home rate of 58%. Practical application of the novel standard protocol seems to facilitate ECLS weaning and to improve its success rate. The protocol can be administered as part of standard bedside ICU assessment.


Assuntos
Oxigenação por Membrana Extracorpórea/normas , Cuidados para Prolongar a Vida/normas , Choque Cardiogênico/terapia , Adolescente , Adulto , Criança , Pré-Escolar , Protocolos Clínicos , Ecocardiografia , Oxigenação por Membrana Extracorpórea/instrumentação , Oxigenação por Membrana Extracorpórea/métodos , Estudos de Viabilidade , Feminino , Humanos , Lactente , Recém-Nascido , Cuidados para Prolongar a Vida/instrumentação , Cuidados para Prolongar a Vida/métodos , Masculino , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Choque Cardiogênico/diagnóstico por imagem , Choque Cardiogênico/mortalidade , Taxa de Sobrevida , Resultado do Tratamento , Adulto Jovem
18.
J Palliat Med ; 21(6): 815-819, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29431571

RESUMO

BACKGROUND: The Physician Orders for Life-Sustaining Treatment (POLST) paradigm is considered one of the most important strategies to respect patients' values at the end of life in the United States. The cross-cultural adaptation of POLST entailed several methodological considerations, which may be informative for international researchers who may also consider bringing POLST to their countries as a means to promote care at the end of life that is consistent with patients' preferences. OBJECTIVE: To report the methods and outcome of the cross-cultural adaptation of the POLST form to Brazil. DESIGN: Cross-cultural adaptation study. SETTING/SUBJECTS: Twenty physicians and 10 patients at a university hospital participated in the pilot tests. RESULTS: The cross-cultural adaptation process included choosing which existing POLST form(s) to use as a source, deciding the intended reading level, which healthcare professionals should be allowed to sign the form, and consultation with attorneys, bioethicists, and members of the National POLST Paradigm Task Force. Pilot tests occurred in two stages using different approaches. First, 20 physicians were trained about POLST and asked for any unclear aspects related to the form. Second, trained investigators completed POLST forms after engaging in advance care planning conversations with 10 hospitalized patients or patients' surrogates. CONCLUSIONS: This report provides a basis for future cross-cultural adaptations of POLST to other countries. The authors hope such new adaptations will broaden the possibilities of research using POLST and also may promote wider provision of care at the end of life that is consistent with patients' preferences.


Assuntos
Planejamento Antecipado de Cuidados/normas , Comparação Transcultural , Cuidados para Prolongar a Vida/normas , Cuidados Paliativos/normas , Guias de Prática Clínica como Assunto , Traduções , Adulto , Idoso , Idoso de 80 Anos ou mais , Brasil , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estados Unidos
19.
Minerva Anestesiol ; 84(6): 756-765, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29343041

RESUMO

In the last decades, mortality from severe acute illnesses has considerably declined thanks to the advances in intensive care medicine. Meanwhile, critical care physicians realized that life-sustaining treatments (LST) may not be appropriate for every patient, and end-of-life care in the Intensive Care Unit (ICU) started to receive growing attention. Most deaths occurring in the ICU now follow a decision to forgo life-sustaining treatments (DFLST), which can be implemented either by withdrawing (WDLST) or withholding (WHLST) life-sustaining treatments. Despite the broad consensus about the equivalence of the two practices from an ethical point of view, the issue of the best option between WDLST and WHLST constantly gives rise to controversies in clinical practice. This review is not intended to take a stand for or against WDLST or WHLST. Based on available evidence, the definitions of the two practices are first presented. Secondly, the preferences of ICU physicians towards WDLST and WHLST are examined. Finally, some arguments are offered outlining pros and cons of WDLST and WHLST, stressing that the clinician's attention should focus on an early and thorough recognition of patients in need of a DFLST, rather than on the theoretical strength and weakness of the two practices. This approach will enable physicians to make informed decisions on how to implement the limitation of LSTs, considering the patients' clinical conditions and preferences, the circumstances and needs of their families.


Assuntos
Unidades de Terapia Intensiva , Cuidados para Prolongar a Vida , Suspensão de Tratamento , Tomada de Decisão Clínica , Humanos , Cuidados para Prolongar a Vida/normas , Terminologia como Assunto
20.
J Med Ethics ; 44(5): 336-342, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-28912289

RESUMO

Current management of people with prolonged disorders of consciousness is failing patients, families and society. The causes include a general lack of concern, knowledge and expertise; a legal and professional framework which impedes timely and appropriate decision-making and/or enactment of the decision; and the exclusive focus on the patient, with no legitimate means to consider the broader consequences of healthcare decisions. This article argues that a clinical pathway based on the principles of (a) the English Mental Capacity Act 2005 and (b) using time-limited treatment trials could greatly improve patient management and reduce stress on families. There needs to be early and continuing use of formal best interests meetings, starting between 7 and 21 days after onset of unconsciousness (from any cause, including progressive disorders). The treatment options need to evolve as the clinical state and prognosis becomes more certain. A formal discussion of treatment withdrawal should occur when the upper bound of predicted recovery falls below a level the patient would have considered acceptable, and it should always be discussed when the condition is considered permanent. Any decision to stop treatment should be contingent on a formal second opinion from an independent expert who should review the clinical situation and expected prognosis, but not the best interests decision. The article also asks how, if at all, the adverse effects on the family and the resource implications of long-term care of people left in a prolonged state of unconsciousness should be incorporated in the process.


Assuntos
Procedimentos Clínicos/ética , Inconsciência/terapia , Doença Crônica , Tomada de Decisão Clínica/ética , Ética Clínica , Humanos , Cuidados para Prolongar a Vida/ética , Cuidados para Prolongar a Vida/normas , Competência Mental , Assistência Centrada no Paciente/ética , Assistência Centrada no Paciente/normas , Relações Profissional-Família/ética , Padrão de Cuidado/ética , Suspensão de Tratamento/ética , Suspensão de Tratamento/normas
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