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ORIGINAL ARTICLE



Rachel Duarte Moritz1, Alberto
Deicas2, Juan Pablo Rossini3, Nilton
                                           Perceptions about end of life treatment in
Brandão da Silva1, Patrícia Miranda        Argentina, Brazil and Uruguay intensive care units
do Lago1, Fernando Osni Machado1
                                           Percepção dos profissionais sobre o tratamento no fim da vida, nas
                                           unidades de terapia intensiva da Argentina, Brasil e Uruguai




1. Intense Care Physicians, Brazilian         ABSTRACT                                  peutic futility. In the three countries,
Society of Intensive Care - AMIB -                                                      more than 90% of the completers had
Brazil.                                        Objective: To evaluate end-of-life       already made LTE decisions. Cardiopul-
2. Intensive Care Physicians, Uruguayan    procedures in intensive care units.          monary resuscitation, vasoactive drugs
Society of Intensive Care - SUMI –             Methods: A questionnaire was             administration, dialysis and parenteral
Uruguay.                                   prepared by the End-of-Life Study            nutrition were the most suspended/re-
3. Intensive Care Physician, Argentinean   Group of the Argentinean, Brazilian          fused therapies in the three countries.
Society of Intensive Care – SATI –         and Uruguayan Intensive Care societ-         Suspension of mechanic ventilation was
Argentina.                                 ies, collecting data on the participants’    more frequent in Argentina, followed by
                                           demographics, institutions and limit         Uruguay. Sedation and analgesia were
                                           therapeutic effort (LTE) decision mak-       the less suspended therapies in the three
                                           ing process. During this cross sectional     countries. Legal definement and ethical
                                           study, the societies’ multidisciplinary      issues were mentioned as the main barri-
                                           teams members completed the ques-            ers for the LTE decision making process.
                                           tionnaire either during scientific meet-         Conclusion: LTE decisions are fre-
                                           ings or online. The variables were ana-      quent among the professionals working
                                           lyzed with the Chi-square test, with a       in the three countries’ intensive care
                                           p<0.05 significance level.                   units. We found a more proactive LTE
                                               Results: 420 professionals complet-      decision making trend In Argentina,
                                           ed the questionnaire. The Brazilian units    and more equity for decisions distri-
                                           had more beds, unrestricted visit was less   bution in Uruguay. This difference ap-
                                           frequent, their professionals were young-    pears to be related to the participants’
Received from: Southern Cone End-          er and worked more recently in intensive     different ages, experiences, professional
of-Life Care Workgroup – a partnership     care units, and more non-medical pro-        types and genders.
between Brazilian Society of Intensive     fessionals completed the questionnaire.
Care Medicine – AMIB, Brazil;              Three visits daily was the more usual            Keywords: Terminal care; Termi-
Argentinean Society of Intensive Care      number of visits for the three countries.    nally ill; Treatment refusal;   Withhold-
Medicine – SATI – Argentina and            The most influencing LTE factors were        ing treatment; Medical futility;  Ques-
Uruguayan Socity of Intensive Care         prognosis, co-morbidities, and thera-        tionnaires
Medicine – SUMI – Uruguay.

Submitted on May 8, 2010
Accepted on June 14, 2010                     INTRODUCTION

Author for correspondence:                    Saying that one of the medical roles is “to refuse treating those who
Rachel Duarte Moritz                       were beaten by disease, understanding that medicine is impotent for
Rua João Paulo 1929 - Bairro João          these cases” (1), Hippocrates was the first to describe the limit of ther-
Paulo
                                           apeutic effort (LTE). However, during the current century, given the
Zip Code: 88030-300 – Florianópolis
                                           population ageing and the control of chronic-degenerative diseases add-
(SC), Brazil.
E-mail: rachel@hu.ufsc.br
                                           ed to technological improvements has progressively allowed to delay dy-
                                           ing, thus generating the need to broaden debate on medical procedures



                                                                                            Rev Bras Ter Intensiva. 2010; 22(2):125-132
126                                                                                              Moritz RD, Deicas A, Rossini JP,
                                                                                                Silva NB, Lago PM, Machado FO



for end-of-life patients.                                         - Decision responsibility for the therapy refusal/
    Although there is a general idea that dying at home       withdrawal in end-of-life critical patients (patient,
may be less painful, seven in 10 deaths occur in hos-         family members, ICU medical head, doctor on duty,
pitals, and more specifically in intensive care units         treatment doctor, medical or multiprofessional team
(ICUs).(2) Thus, the intensive care professional needs        consensus, ethics/bioethics committee, team and fam-
to be prepared to accept his (her) limitation as healer       ily members consensus);
in order to be ready to take care of the end-of-life              - Therapies judged as potentially futile, which
patient. The intensive care professional faces LTE pro-       could be refused/withdrawn in the ICU (mechanic
cedures daily, making the debate on ethic and legal           ventilation, sedation, analgesia, dialysis methods, va-
matters related to this issue a priority. (3-11) There have   soactive drugs, antibiotics, enteral nutrition, paren-
been changes in the above mentioned Hippocrates               teral nutrition, venous hydration, cardiopulmonary
thoughts. The current perspective is that the physi-          resuscitation).
cian and the multiprofessional team should offer pal-             - Who should be communicated in case of refusal/
liative care to end-of-life patients, minimizing the suf-     withdrawal of futile therapy (patient, family mem-
fering involved in the dying process.(11-13)                  bers, multiprofessional team, ethics committee).
    However, to change the ICUs’ therapeutic focus,               - Which palliative procedures would be used for
this department’s professionals must reset their proce-       an end-of-life patient (discharge from ICU, increase
dures. Improved understanding of these new situation          visits, refusal/withdrawal of futile therapies, sedation-
is the first step for effective change. Based on this, we     analgesia adjustment, ventilation change).
aimed to diagnose and compare the end-of-life pro-                - Which are the main barriers for therapy refusal/
cedures in the Southern Cone ICUs (from Brazil, Ar-           withdrawal decisions (religious, legal, ethical, lack of
gentina and Uruguay).                                         training, interpersonal conflicts).
                                                                  - Which actions should be implemented for end-
      METHODS                                                 of-life critical patient adjustment (palliative care for
                                                              end-of-life patients information leaflets, graduation
    This was a cross-sectional study conducted by the         and post-graduation training, class associations regu-
Brazilian Society of Intensive Care Medicine (AMIB),          lations on the subject, legal regulation, decisions doc-
the Argentinean Society of Intensive Care Medicine            umentation in the medical chart).
(SATI) and the Uruguayan Society of Intensive Care                The questionnaire was completed during intensive
Medicine (SUMI). The members of these societies’              care scientific meetings of the three countries (regional
End-of-Life Care Workgroup met personally to pre-             and/or national congresses) and also online, in the so-
pare a questionnaire based on the participants experi-        cieties’ sites, for a pre-established time. Members of the
ence and literature review. This questionnaire aimed          involved societies and part of multiprofessional teams
the diagnosis of the procedures for the dying patient         took part in the study. The responses of the three coun-
in the three countries ICUs. The questionnaire had            tries respondents were compared and the variables ana-
two parts. The first collected the respondents’ demo-         lyzed using the Chi-square (χ2) test. A p<0.05 value was
graphic data and information on their institutions            considered for statistical signification.
(i.e. age, professional background, affiliations, dura-
tion of the ICU work, religious beliefs, category of             RESULTS
hospital, ICU site and number of beds). In the sec-
ond part were asked questions regarding LTE. In this             Four hundred and twenty professionals participat-
structured questionnaire, depending on the questions,         ed in the study, 217 from Brazil, 141 from Argentina
objective responses should be marked by either yes,           and 62 from Uruguay. The ICUs where these profes-
no, always, almost always or never. In this phase were        sionals worked characteristics are shown on Table 1.
included the following questions:                             Table 2 shows the study participants characteristics.
    - Aspects considered for LTE decision making (age,           The inter-groups comparison using the χ2 test
co-morbidities, previous and “post-ICU” patient’s             showed a larger number of ICUs with more than 20
quality of life, patients and/or family wishes, severity      beds in Brazil. Additionally, fewer visits to critical pa-
scores, ICU time of stay, diagnosis, prognosis, thera-        tients are allowed in Brazil. Regarding the partici-
peutic futility, legal aspects);                              pants’ demographics, the Brazilians are younger and



                                                                                         Rev Bras Ter Intensiva. 2010; 22(2):125-132
Professional perceptions on end-of-life care                                                                                            127




Table 1 – Intensive care units characteristics in the different Southern-Cone countries
Characteristics                                Brazil               Argentina                  Uruguay                    P value
                                              N=217                   N=141                     N=62
Site
  North/Northeast                             31 (14.3)               66 (46.8)               11 (17.7)                      –
  Center/West                                 10 (4.6)                37 (26.2)                3 (4.8)                     <0.001
  South/Southeast                           176 (81.1)                37 (26.2)               38 (61.3)                      –
Category of hospital
  Teaching                                    92 (42.4)               87 (61.7)               36 (58.1)                      –
  Others                                    125 (57.6)                54 (38.2)               26 (41.9)                    <0.001
Type of ICU
  General/Mixed                             191 (88.0)              132 (93.6)                54 (87.1)                      0.3
  Other                                       26 (11.9)                9 (6.3)                 8 (12.9)                       –
Number of ICU beds
  <10                                         81 (37.3)               68 (48.2)               31 (50.0)                      –
  10-20                                      76 (35.0)                61 (43.2)               19 (30.6)                    <0.001
  > 20                                        60 (27.7)               12 (8.5)                 9 (14.5)                      –
Number of visits allowed
  Once daily                                  63 (29.0)              22 (15.6)                10 (16.1)                       –
  Up to 3 times daily                       137 (63.2)              103 (73.1)                43 (79.3)                     0.01
  Unrestricted                                17 (7.8)               18 (12.7)                 8 (12.9)                       –
ICU – intensive care unit. Results expressed as number (%), Chi-square

Table 2 – Characteristics of the participants in the different southern-cone countries
 Participants Characteristics                  Brazil               Argentina                  Uruguay                    P value
                                              N=217                  N=141                      N=62
 Age
   <35 years                                117 (53.9)               24 (17.1)                 14 (22.5)                     –
   35 to 50 years                             78 (35.9)              88 (62.4)                 41 (66.1)                   <0.001
   >50 years                                  22 (10.1)              29 (20.5)                  7 (11.2)                     –
 Gender
   Female                                   109 (50.2)               82 (58.1)                 20 (32.2)                     –
   Male                                     108 (49.8)               59 (41.8)                 37 (59.7)                   <0.001
 Religious belief
   Atheist/Agnostic                           65 (29.9)              40 (28.3)                 25 (40.3)                      –
   Believes in god                          152 (70.0)              101 (71.6)                 45 (72.5)                     0.5
 Profession
   Physician                                143 (65.9)              134 (95.0)                 52 (83.8)                   <0.001
   Other                                      74 (34.1)               7 (4.9)                  10 (16.1)                     –
 Board certificated                         135 (62.2)                   –                     47 (75.8)                    0.047
 Time working in ICU
   Up to 5 years                              94 (43.3)               0 (0)                    15 (24.1)                     –
   5 to 15 years                             75 (34.6)               81 (57.4)                 26 (41.9)                   <0.001
   15 to 30 years                             45 (20.8)              49 (34.7)                 18 (29.0)                     –
   More than 30 years                          3 (1.4)               11 (7.8)                   0 (0)                        –
ICU – intensive care unit. Results expressed as number (%), Chi-square.


more non-medical professionals completed the ques-                           Table 3 shows the factors influencing LTE deci-
tionnaire. More male participants were seen in Uru-                       sion making. The most frequent influencing factors
guay, and the Argentinean professionals were older.                       were the disease’s prognosis, its co-morbidities and
These findings were significant.                                          therapeutic futility. A significant inter-countries dif-



                                                                                                  Rev Bras Ter Intensiva. 2010; 22(2):125-132
128                                                                                                          Moritz RD, Deicas A, Rossini JP,
                                                                                                            Silva NB, Lago PM, Machado FO



ference was identified, with Argentinean profession-                            Regarding the therapeutic limit, cardiorespiratory
als trending to decide more frequently for LTE. The                         resuscitation, vasoactive drugs administration, dialy-
medical team was identified as the main responsible                         sis methods, and parenteral nutrition were the most
for LTE decision, particularly in Brazil and Argentina                      frequently withdrawn or refused therapies in the three
(Table 4), and in Brazil other stakeholders had a larger                    countries, with small differences.
participation. It was also found that in all countries                          A significant difference was found for mechanic
more than 90% of the respondents had ever decided                           ventilation withdrawal, more frequent in Argentina,
for LTE (Figure 1).                                                         followed by Uruguay (Table 5). In Table 6 are shown



Table 3 – Factors influencing the limit of therapeutic effort decision making
 Factors influencing limit decision making (al-       Brazil             Argentina                 Uruguay                  P value
 most always)                                      Total = 217          Total = 141               Total = 62
 Patient’s age                                     132 (60.8)             83 (58.9)               32 (51.6)                  NS
 Co-morbidities                                    181 (83.4)           124 (87.9)                41 (66.1)                 <0.001
 Severity scores                                   130 (59.9)             70 (49.6)               18 (29.0)                 <0.001
 Time in the ICU                                   114 (52.5)             63 (44.6)               18 (29.0)                 <0.001
 Diagnosis                                         158 (72.8)           112 (79.4)                33 (53.2)                 <0.001
 Prognosis                                         190 (87.6)           132 (93.6)                42 (67.7)                 <0.001
 Therapeutic futility                              176 (81.1)           128 (90.7)                40 (64.5)                 <0.001
 Previous quality of life                          176 (81.1)                –                    39 (62.9)                  0.003
 Post-ICU quality of life                          160 (73.7)                –                    29 (47.6)                 <0.001
 Legal aspects                                     154 (70.9)             85 (60.2)               23 (37.1)                 <0.001
 Patients/Family wishes                            164 (75.6)           106 (75.1)                28 (45.1)                 <0.001
ICU – intensive care unit.; NS – not significant. Results expressed as number (%), Chi-square.

Table 4 – Responsibility for limit of therapeutic effort decisions
 Almost always responsible for LTE decisions          Brazil                      Argentina        Uruguay                  P value
                                                     (N=217)                      (N=141)          (N=62)
 Medical team                                       176 (81.1)                    117 (82.9)       34 (54.8)                <0.001
 Multiprofessional team                             111 (51.2)                     52 (36.9)       13 (20.9)                <0.001
 Ethics committee                                    45 (20.7)                     13 (9.2)         0 (0)                   <0.001
 Family members                                     105 (48.4)                     56 (39.7)       20 (32.2)                <0.001
 The patient                                         44 (20.3)                     13 (9.2)         2 (3.2)                 <0.001
LTE – limit of therapeutic effort. Results expressed as number (%). Chi-square.

Table 5 – Almost always used therapeutic limits
 Limit of therapeutic effort used almost always             Brazil                Argentina        Uruguay                  P value
                                                           N=217                   N=141            N=62
Cardiorespiratory resuscitation                           141 (65.0)              121 (85.8)       33 (53.2)                <0.001
Vasoactive drugs                                          119 (54.8)              104 (73.8)       35 (56.5)                 0.001
Dialysis methods                                          125 (57.6)               98 (69.5)       32 (51.6)                 0.022
Parenteral nutrition                                      111 (51.2)               94 (66.6)       37 (59.6)                 0.014
Antibiotics                                               100 (46.1)               51 (36.1)       33 (53.2)                 0.049
Enteral nutrition                                         109 (50.2)               22 (15.6)       30 (48.0)                <0.001
Mechanic ventilation                                       41 (18.9)               68 (48.2)       16 (25.8)                <0.001
Hydration                                                  37 (17.1)               23 (16.3)        1 (1.6)                  0.007
Sedation                                                   24 (11.1)                4 (2.8)         1 (1.6)                  0.002
Analgesia                                                  11 (5.1)                 2 (1.4)         1 (1.6)                  0.122
Results expressed as number (%). Chi-square.




                                                                                                     Rev Bras Ter Intensiva. 2010; 22(2):125-132
Professional perceptions on end-of-life care                                                                                          129




Table 6 – Maintained therapies or therapeutic limits never used
 Therapies maintained or therapeutic limits never used    Brazil                  Argentina        Uruguay                 P value
                                                         N=217                     N=141            N=62
 Analgesia                                             171 (78.8)                 124 (87.9)       29 (46.7)               <0.001
 Sedation                                              131 (60.4)                 105 (74.5)       27 (43.5)               <0.001
 Hydration                                              91 (41.9)                     –            23 (37.1)                0.494
 Mechanic ventilation                                  107 (49.3)                  21 (14.8)       11 (17.7)               <0.001
 Enteral nutrition                                       39 (18.0)                  8 (5.6)         4 (6.4)                 0.001
 Antibiotics                                             43 (19.8)                 43 (30.4)        2 (3.2)                <0.001
 Parenteral nutrition                                    43 (19.8)                 20 (14.2)        2 (3.2)                 0.005
 Dialysis methods                                        42 (19.4)                  6 (4.2)         1 (1.6)                <0.001
 Vasoactive drugs                                        41 (18.9)                  6 (4.2)         2 (3.2)                <0.001
 Cardiorespiratory resuscitation                         46 (21.3)                  8 (5.6)         2 (3.2)                <0.001
Results expressed as number (%). Chi-square.

Table 7– Measures following end-of-life diagnosis
 Measures following end-of-life diagnosis (almost always)          Brazil         Argentina        Uruguay                 P value
                                                                  N=217            N=141            N=62
 Sedation-Analgesia changes                                      194 (89.4)       137 (97.2)       41 (66.1)               <0.001
 Limit of therapeutic effort                                     169 (77.9)       115 (81.5)       28 (45.2)               <0.001
 Mechanic ventilation change                                     106 (48.8)        80 (56.4)       33 (53.2)                0.339
 Unrestricted visits                                             172 (79.3)       121 (85.8)       39 (62.9)                0.001
 Discharge from ICU                                              102 (47.0)        86 (61.0)       20 (32.3)               <0.001
ICU – intensive care unit. Results expressed as number (%), Chi-square.

the never withdrawn or refused therapies. Analgesia
and sedation were the less withdrawn therapies in the
three countries, and in Brazil mechanic ventilation is
less frequently withdrawn versus the other countries.
    The intensive care professionals’ attitudes follow-
ing end-of-life diagnosis can be seen on Table 7. Fig-
ure 2 shows that the professionals overall considered
lack of legal definitions as the main barrier for the
LTE decision process, followed by lack of ethical clar-
ity and training of the involved personnel.                            Figure 2 – Main barriers for therapeutic limit decision
                                                                       making.

                                                                              DISCUSSION

                                                                           This study, with more than 81% of the participants
                                                                       being intensive care physicians from Brazil, Argentina
                                                                       and Uruguay, made clear the need of broader debate,
                                                                       leading to a widened understanding of the new inten-
                                                                       sive care paradigms.
                                                                           It was identified that in Brazil, as compared to the
                                                                       other countries, the population evaluated was young-
                                                                       er, and consequently had a shorter ICU experience,
LTE – limit of therapeutic effort. Results expressed as number (%).
Chi-square                                                             as well as had a larger number of non-medical profes-
Figure 1 – Limit of therapeutic effort frequency in the three          sionals. It is interesting that, nevertheless the Catholic
countries.                                                             religion predominance in the studied countries, 30%



                                                                                                Rev Bras Ter Intensiva. 2010; 22(2):125-132
130                                                                                                Moritz RD, Deicas A, Rossini JP,
                                                                                                  Silva NB, Lago PM, Machado FO



of the professionals declared to be atheist or agnostic,       as a palliative ICU measures is growing.(9,24) Also is
suggesting ICUs workers skepticism.                            currently discussed the relevance of appropriate inten-
    The characteristics of the ICUs where the com-             sive care professionals’ training in end-of-life patients
pleters worked had differences related to each coun-           management competencies. Proactive measures al-
try’s specificities. In Brazil, less flexibility regarding     lowing the patient a painless and less discomfort death
visits to critically ill patients was identified.              is mandatory, as well as appropriate support for the
    The analysis regarding the LTE decision making             family members.(12,13,25,26)
allowed concluding that the disease’s prognosis, the               In this study, the most commonly refused or with-
patients’ co-morbidities, and the therapeutic futility         drawn therapies, in the three countries, were cardiore-
were the main contributing factors for therapies re-           spiratory resuscitation, vasoactive drugs administration
fusal or withdrawal in the three countries. It is inter-       and dialysis methods. Analgesia, sedation and venous hy-
esting to add that legal definition, although pointed as       dration are the most frequently maintained therapies. A
the main barrier for LTE decision making, was ranked           difference was identified regarding mechanic ventilation
six by the Brazilian and Argentinean professionals,            withdrawal, done almost always by 48.2% of the Ar-
and seven by the Uruguayans.                                   gentinean professionals, 25.8% of the Uruguayans and
    The physician is ethically and technically trained         18.9% of the Brazilians. Regarding the measures adopt-
to provide the best possible care. In this study, the          ed following the end-of-life condition diagnosis, change
professional more frequently mentioned as respon-              in sedation-analgesia was the most prevalent measure in
sible for LTE decisions was the physician. According           the three countries. The results appear to indicate that
to Nunes (13) actions’ ethics is not determined by the         the Argentinean professionals feel more comfortable to
external behavior, but by the inner component – and            act proactively for the end-of-life critical patient care.
this means that the action results from targets the                Regarding the barriers limiting LTE mentioned by
person has establishes for him/herself, thus involving         the respondents, the lack of legal definition was the main
freedom of action. So, the main determinant is the             aspect, followed by the need of ethical definition and
intention, which moves forward to deliberation and             professionals training. For appropriate care of the end-
decision making. It could be inferred that nevertheless        of-life patient, several aspects are involved. The social ac-
the physician respects legal rules, the decision making        ceptance of death and the lack of accurate death predic-
is mainly based on the patient’s clinical aspects.             tion methods make difficult the decision making. Lack
    In this study we could identify that, although no          of palliative care training, and the difficulty for commu-
specific legal rules are established for LTE, most of          nicating “bad news” are barriers to overcome.(26,27)
the respondents (more than 90%) had already decided                As this study main fault, the demographic differ-
for limiting therapy during their professional lives.          ences (age, profession, gender, experience) between
Brazilian studies confirm this. (2,14,15) It is important      the participants may have influenced the results. Ad-
to emphasize the existence legal support for refus-            ditionally, those completing the questionnaire were
ing artificial resources. It is not considered a crime         taking part in events or visiting their societies’ sites,
refusing therapies not effectively beneficial to the pa-       and this may represent a bias for the results’ analy-
tient, which are exclusively therapeutic obstinacy. The        sis. The decision of categorizing the variables in three
procedure indication or contraindication is matter of          groups made an appropriate statistical analysis com-
medical decision, and should be discussed with the             plex. This is another limiting factor to be stressed.
patient, when possible, and family members, in order               Even though the pointed methodological faults,
to assure dignity for the end-of-life process.(16)             the authors take the liberty of suggesting that, given
    Much has been written in the last two decades              the relevant number of limit of therapeutic effort de-
regarding intensive care therapy withdrawal; better            cisions in ICUs, plans for end-of-life patients’ pallia-
understanding on LTE and palliative care has been              tive care should be implemented.
gained with the years. However, there are still cul-
tural and legal barriers making difficult the end-of-             CONCLUSIONS
life patient management. Classically, the therapies
most acknowledged as futile or useless are vasoactive              This study results allow concluding that, neverthe-
drugs and dialysis methods. (14,15,17-23) In the last years,   less regional and cultural differences, the end-of-life
the acceptance of withdrawing mechanic ventilation             limitation of therapeutic effort measures are frequent-



                                                                                           Rev Bras Ter Intensiva. 2010; 22(2):125-132
Professional perceptions on end-of-life care                                                                                              131




ly used by the ICU professionals in the three coun-                   variáveis foram analisadas através do teste qui-quadrado sendo
tries. The study shows a trend to more proactive LTE                  considerado significativa p<0,05.
measures in Argentinean ICUs, and more equity in                           Resultados: Participaram do estudo 420 profissionais. No
the decisions distribution in Uruguay. Although fur-                  Brasil as UTI tinham mais leitos, foi mais rara a permissão irres-
ther evidence is needed, this difference may be related               trita de visitas, os profissionais eram mais jovens, trabalhavam a
                                                                      menos tempo na UTI e houve maior participação de não médi-
to the differences regarding age, experience, type of
                                                                      cos. Três visitas/dia foi o número mais frequente nos três países.
professional and gender.                                              Os fatores que mais influíram nas decisões de LET foram prog-
                                                                      nóstico da doença, co-morbidades e futilidade terapêutica. Nos
    Acknowledgements: The authors acknowledge the                     três países mais de 90% dos participantes já havia decidido por
Southern Cone End-of-Life Workgroup: Francisco Al-                    LET. Reanimação cardiorrespiratória, administração de drogas
bano de Meneses, Jairo Constante Bitencourt Othero,                   vaso-ativas, métodos dialíticos e nutrição parenteral foram as te-
Jefferson Pedro Piva, Márcio Soares, Nara Azeredo,                    rapias mais suspensas/recusadas nos três países. Houve diferença
Raquel Pusch de Souza and Renato Terzi.                               significativa quanto à suspensão da ventilação mecânica, mais
                                                                      frequente na Argentina, seguida do Uruguai. Analgesia e seda-
                                                                      ção foram as terapias menos suspensas nos três países. Defini-
      RESUMO                                                          ções legais e éticas foram apontadas como as principais barreiras
                                                                      para a tomada de decisão.
    Objetivo: Avaliar as condutas tomadas nas Unidades de Te-              Conclusão: Decisões de LET são frequentemente utilizados
rapia Intensiva (UTI) com os pacientes críticos terminais.            entre os profissionais que atuam nas UTI dos três países. Exis-
    Métodos: Os membros do grupo de estudo do final da vida           te uma tendência da ação de LET mais pró-ativa na Argentina,
das sociedades Argentina, Brasileira e Uruguaia de Terapia In-        e uma maior equidade na distribuição das decisões no Uruguai.
tensiva elaboraram um questionário no qual constavam avalia-          Essa diferença parece estar relacionada às diferenças de idade, tem-
ções demográficas sobre os participantes, sobre as instituições       po de experiência, tipo de profissional e gênero dos participantes.
em que os mesmos trabalhavam e decisões sobre limite de es-
forço terapêutico (LET). Neste estudo de corte transversal os            Descritores: Assistência terminal; Doente terminal; Recusa
membros da equipe multiprofissional das sociedades responde-          do paciente ao tratamento; Suspensão de tratamento; Futilidade
ram o questionário durante eventos científicos e, via on line. As     médica; Questionários



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                                                                                                    Rev Bras Ter Intensiva. 2010; 22(2):125-132

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Argentina and brazil icu beds (table)

  • 1. ORIGINAL ARTICLE Rachel Duarte Moritz1, Alberto Deicas2, Juan Pablo Rossini3, Nilton Perceptions about end of life treatment in Brandão da Silva1, Patrícia Miranda Argentina, Brazil and Uruguay intensive care units do Lago1, Fernando Osni Machado1 Percepção dos profissionais sobre o tratamento no fim da vida, nas unidades de terapia intensiva da Argentina, Brasil e Uruguai 1. Intense Care Physicians, Brazilian ABSTRACT peutic futility. In the three countries, Society of Intensive Care - AMIB - more than 90% of the completers had Brazil. Objective: To evaluate end-of-life already made LTE decisions. Cardiopul- 2. Intensive Care Physicians, Uruguayan procedures in intensive care units. monary resuscitation, vasoactive drugs Society of Intensive Care - SUMI – Methods: A questionnaire was administration, dialysis and parenteral Uruguay. prepared by the End-of-Life Study nutrition were the most suspended/re- 3. Intensive Care Physician, Argentinean Group of the Argentinean, Brazilian fused therapies in the three countries. Society of Intensive Care – SATI – and Uruguayan Intensive Care societ- Suspension of mechanic ventilation was Argentina. ies, collecting data on the participants’ more frequent in Argentina, followed by demographics, institutions and limit Uruguay. Sedation and analgesia were therapeutic effort (LTE) decision mak- the less suspended therapies in the three ing process. During this cross sectional countries. Legal definement and ethical study, the societies’ multidisciplinary issues were mentioned as the main barri- teams members completed the ques- ers for the LTE decision making process. tionnaire either during scientific meet- Conclusion: LTE decisions are fre- ings or online. The variables were ana- quent among the professionals working lyzed with the Chi-square test, with a in the three countries’ intensive care p<0.05 significance level. units. We found a more proactive LTE Results: 420 professionals complet- decision making trend In Argentina, ed the questionnaire. The Brazilian units and more equity for decisions distri- had more beds, unrestricted visit was less bution in Uruguay. This difference ap- frequent, their professionals were young- pears to be related to the participants’ Received from: Southern Cone End- er and worked more recently in intensive different ages, experiences, professional of-Life Care Workgroup – a partnership care units, and more non-medical pro- types and genders. between Brazilian Society of Intensive fessionals completed the questionnaire. Care Medicine – AMIB, Brazil; Three visits daily was the more usual Keywords: Terminal care; Termi- Argentinean Society of Intensive Care number of visits for the three countries. nally ill; Treatment refusal;   Withhold- Medicine – SATI – Argentina and The most influencing LTE factors were ing treatment; Medical futility;  Ques- Uruguayan Socity of Intensive Care prognosis, co-morbidities, and thera- tionnaires Medicine – SUMI – Uruguay. Submitted on May 8, 2010 Accepted on June 14, 2010 INTRODUCTION Author for correspondence: Saying that one of the medical roles is “to refuse treating those who Rachel Duarte Moritz were beaten by disease, understanding that medicine is impotent for Rua João Paulo 1929 - Bairro João these cases” (1), Hippocrates was the first to describe the limit of ther- Paulo apeutic effort (LTE). However, during the current century, given the Zip Code: 88030-300 – Florianópolis population ageing and the control of chronic-degenerative diseases add- (SC), Brazil. E-mail: rachel@hu.ufsc.br ed to technological improvements has progressively allowed to delay dy- ing, thus generating the need to broaden debate on medical procedures Rev Bras Ter Intensiva. 2010; 22(2):125-132
  • 2. 126 Moritz RD, Deicas A, Rossini JP, Silva NB, Lago PM, Machado FO for end-of-life patients. - Decision responsibility for the therapy refusal/ Although there is a general idea that dying at home withdrawal in end-of-life critical patients (patient, may be less painful, seven in 10 deaths occur in hos- family members, ICU medical head, doctor on duty, pitals, and more specifically in intensive care units treatment doctor, medical or multiprofessional team (ICUs).(2) Thus, the intensive care professional needs consensus, ethics/bioethics committee, team and fam- to be prepared to accept his (her) limitation as healer ily members consensus); in order to be ready to take care of the end-of-life - Therapies judged as potentially futile, which patient. The intensive care professional faces LTE pro- could be refused/withdrawn in the ICU (mechanic cedures daily, making the debate on ethic and legal ventilation, sedation, analgesia, dialysis methods, va- matters related to this issue a priority. (3-11) There have soactive drugs, antibiotics, enteral nutrition, paren- been changes in the above mentioned Hippocrates teral nutrition, venous hydration, cardiopulmonary thoughts. The current perspective is that the physi- resuscitation). cian and the multiprofessional team should offer pal- - Who should be communicated in case of refusal/ liative care to end-of-life patients, minimizing the suf- withdrawal of futile therapy (patient, family mem- fering involved in the dying process.(11-13) bers, multiprofessional team, ethics committee). However, to change the ICUs’ therapeutic focus, - Which palliative procedures would be used for this department’s professionals must reset their proce- an end-of-life patient (discharge from ICU, increase dures. Improved understanding of these new situation visits, refusal/withdrawal of futile therapies, sedation- is the first step for effective change. Based on this, we analgesia adjustment, ventilation change). aimed to diagnose and compare the end-of-life pro- - Which are the main barriers for therapy refusal/ cedures in the Southern Cone ICUs (from Brazil, Ar- withdrawal decisions (religious, legal, ethical, lack of gentina and Uruguay). training, interpersonal conflicts). - Which actions should be implemented for end- METHODS of-life critical patient adjustment (palliative care for end-of-life patients information leaflets, graduation This was a cross-sectional study conducted by the and post-graduation training, class associations regu- Brazilian Society of Intensive Care Medicine (AMIB), lations on the subject, legal regulation, decisions doc- the Argentinean Society of Intensive Care Medicine umentation in the medical chart). (SATI) and the Uruguayan Society of Intensive Care The questionnaire was completed during intensive Medicine (SUMI). The members of these societies’ care scientific meetings of the three countries (regional End-of-Life Care Workgroup met personally to pre- and/or national congresses) and also online, in the so- pare a questionnaire based on the participants experi- cieties’ sites, for a pre-established time. Members of the ence and literature review. This questionnaire aimed involved societies and part of multiprofessional teams the diagnosis of the procedures for the dying patient took part in the study. The responses of the three coun- in the three countries ICUs. The questionnaire had tries respondents were compared and the variables ana- two parts. The first collected the respondents’ demo- lyzed using the Chi-square (χ2) test. A p<0.05 value was graphic data and information on their institutions considered for statistical signification. (i.e. age, professional background, affiliations, dura- tion of the ICU work, religious beliefs, category of RESULTS hospital, ICU site and number of beds). In the sec- ond part were asked questions regarding LTE. In this Four hundred and twenty professionals participat- structured questionnaire, depending on the questions, ed in the study, 217 from Brazil, 141 from Argentina objective responses should be marked by either yes, and 62 from Uruguay. The ICUs where these profes- no, always, almost always or never. In this phase were sionals worked characteristics are shown on Table 1. included the following questions: Table 2 shows the study participants characteristics. - Aspects considered for LTE decision making (age, The inter-groups comparison using the χ2 test co-morbidities, previous and “post-ICU” patient’s showed a larger number of ICUs with more than 20 quality of life, patients and/or family wishes, severity beds in Brazil. Additionally, fewer visits to critical pa- scores, ICU time of stay, diagnosis, prognosis, thera- tients are allowed in Brazil. Regarding the partici- peutic futility, legal aspects); pants’ demographics, the Brazilians are younger and Rev Bras Ter Intensiva. 2010; 22(2):125-132
  • 3. Professional perceptions on end-of-life care 127 Table 1 – Intensive care units characteristics in the different Southern-Cone countries Characteristics Brazil Argentina Uruguay P value N=217 N=141 N=62 Site North/Northeast 31 (14.3) 66 (46.8) 11 (17.7) – Center/West 10 (4.6) 37 (26.2) 3 (4.8) <0.001 South/Southeast 176 (81.1) 37 (26.2) 38 (61.3) – Category of hospital Teaching 92 (42.4) 87 (61.7) 36 (58.1) – Others 125 (57.6) 54 (38.2) 26 (41.9) <0.001 Type of ICU General/Mixed 191 (88.0) 132 (93.6) 54 (87.1) 0.3 Other 26 (11.9) 9 (6.3) 8 (12.9) – Number of ICU beds <10 81 (37.3) 68 (48.2) 31 (50.0) – 10-20 76 (35.0) 61 (43.2) 19 (30.6) <0.001 > 20 60 (27.7) 12 (8.5) 9 (14.5) – Number of visits allowed Once daily 63 (29.0) 22 (15.6) 10 (16.1) – Up to 3 times daily 137 (63.2) 103 (73.1) 43 (79.3) 0.01 Unrestricted 17 (7.8) 18 (12.7) 8 (12.9) – ICU – intensive care unit. Results expressed as number (%), Chi-square Table 2 – Characteristics of the participants in the different southern-cone countries Participants Characteristics Brazil Argentina Uruguay P value N=217 N=141 N=62 Age <35 years 117 (53.9) 24 (17.1) 14 (22.5) – 35 to 50 years 78 (35.9) 88 (62.4) 41 (66.1) <0.001 >50 years 22 (10.1) 29 (20.5) 7 (11.2) – Gender Female 109 (50.2) 82 (58.1) 20 (32.2) – Male 108 (49.8) 59 (41.8) 37 (59.7) <0.001 Religious belief Atheist/Agnostic 65 (29.9) 40 (28.3) 25 (40.3) – Believes in god 152 (70.0) 101 (71.6) 45 (72.5) 0.5 Profession Physician 143 (65.9) 134 (95.0) 52 (83.8) <0.001 Other 74 (34.1) 7 (4.9) 10 (16.1) – Board certificated 135 (62.2) – 47 (75.8) 0.047 Time working in ICU Up to 5 years 94 (43.3) 0 (0) 15 (24.1) – 5 to 15 years 75 (34.6) 81 (57.4) 26 (41.9) <0.001 15 to 30 years 45 (20.8) 49 (34.7) 18 (29.0) – More than 30 years 3 (1.4) 11 (7.8) 0 (0) – ICU – intensive care unit. Results expressed as number (%), Chi-square. more non-medical professionals completed the ques- Table 3 shows the factors influencing LTE deci- tionnaire. More male participants were seen in Uru- sion making. The most frequent influencing factors guay, and the Argentinean professionals were older. were the disease’s prognosis, its co-morbidities and These findings were significant. therapeutic futility. A significant inter-countries dif- Rev Bras Ter Intensiva. 2010; 22(2):125-132
  • 4. 128 Moritz RD, Deicas A, Rossini JP, Silva NB, Lago PM, Machado FO ference was identified, with Argentinean profession- Regarding the therapeutic limit, cardiorespiratory als trending to decide more frequently for LTE. The resuscitation, vasoactive drugs administration, dialy- medical team was identified as the main responsible sis methods, and parenteral nutrition were the most for LTE decision, particularly in Brazil and Argentina frequently withdrawn or refused therapies in the three (Table 4), and in Brazil other stakeholders had a larger countries, with small differences. participation. It was also found that in all countries A significant difference was found for mechanic more than 90% of the respondents had ever decided ventilation withdrawal, more frequent in Argentina, for LTE (Figure 1). followed by Uruguay (Table 5). In Table 6 are shown Table 3 – Factors influencing the limit of therapeutic effort decision making Factors influencing limit decision making (al- Brazil Argentina Uruguay P value most always) Total = 217 Total = 141 Total = 62 Patient’s age 132 (60.8) 83 (58.9) 32 (51.6) NS Co-morbidities 181 (83.4) 124 (87.9) 41 (66.1) <0.001 Severity scores 130 (59.9) 70 (49.6) 18 (29.0) <0.001 Time in the ICU 114 (52.5) 63 (44.6) 18 (29.0) <0.001 Diagnosis 158 (72.8) 112 (79.4) 33 (53.2) <0.001 Prognosis 190 (87.6) 132 (93.6) 42 (67.7) <0.001 Therapeutic futility 176 (81.1) 128 (90.7) 40 (64.5) <0.001 Previous quality of life 176 (81.1) – 39 (62.9) 0.003 Post-ICU quality of life 160 (73.7) – 29 (47.6) <0.001 Legal aspects 154 (70.9) 85 (60.2) 23 (37.1) <0.001 Patients/Family wishes 164 (75.6) 106 (75.1) 28 (45.1) <0.001 ICU – intensive care unit.; NS – not significant. Results expressed as number (%), Chi-square. Table 4 – Responsibility for limit of therapeutic effort decisions Almost always responsible for LTE decisions Brazil Argentina Uruguay P value (N=217) (N=141) (N=62) Medical team 176 (81.1) 117 (82.9) 34 (54.8) <0.001 Multiprofessional team 111 (51.2) 52 (36.9) 13 (20.9) <0.001 Ethics committee 45 (20.7) 13 (9.2) 0 (0) <0.001 Family members 105 (48.4) 56 (39.7) 20 (32.2) <0.001 The patient 44 (20.3) 13 (9.2) 2 (3.2) <0.001 LTE – limit of therapeutic effort. Results expressed as number (%). Chi-square. Table 5 – Almost always used therapeutic limits Limit of therapeutic effort used almost always Brazil Argentina Uruguay P value N=217 N=141 N=62 Cardiorespiratory resuscitation 141 (65.0) 121 (85.8) 33 (53.2) <0.001 Vasoactive drugs 119 (54.8) 104 (73.8) 35 (56.5) 0.001 Dialysis methods 125 (57.6) 98 (69.5) 32 (51.6) 0.022 Parenteral nutrition 111 (51.2) 94 (66.6) 37 (59.6) 0.014 Antibiotics 100 (46.1) 51 (36.1) 33 (53.2) 0.049 Enteral nutrition 109 (50.2) 22 (15.6) 30 (48.0) <0.001 Mechanic ventilation 41 (18.9) 68 (48.2) 16 (25.8) <0.001 Hydration 37 (17.1) 23 (16.3) 1 (1.6) 0.007 Sedation 24 (11.1) 4 (2.8) 1 (1.6) 0.002 Analgesia 11 (5.1) 2 (1.4) 1 (1.6) 0.122 Results expressed as number (%). Chi-square. Rev Bras Ter Intensiva. 2010; 22(2):125-132
  • 5. Professional perceptions on end-of-life care 129 Table 6 – Maintained therapies or therapeutic limits never used Therapies maintained or therapeutic limits never used Brazil Argentina Uruguay P value N=217 N=141 N=62 Analgesia 171 (78.8) 124 (87.9) 29 (46.7) <0.001 Sedation 131 (60.4) 105 (74.5) 27 (43.5) <0.001 Hydration 91 (41.9) – 23 (37.1) 0.494 Mechanic ventilation 107 (49.3) 21 (14.8) 11 (17.7) <0.001 Enteral nutrition 39 (18.0) 8 (5.6) 4 (6.4) 0.001 Antibiotics 43 (19.8) 43 (30.4) 2 (3.2) <0.001 Parenteral nutrition 43 (19.8) 20 (14.2) 2 (3.2) 0.005 Dialysis methods 42 (19.4) 6 (4.2) 1 (1.6) <0.001 Vasoactive drugs 41 (18.9) 6 (4.2) 2 (3.2) <0.001 Cardiorespiratory resuscitation 46 (21.3) 8 (5.6) 2 (3.2) <0.001 Results expressed as number (%). Chi-square. Table 7– Measures following end-of-life diagnosis Measures following end-of-life diagnosis (almost always) Brazil Argentina Uruguay P value N=217 N=141 N=62 Sedation-Analgesia changes 194 (89.4) 137 (97.2) 41 (66.1) <0.001 Limit of therapeutic effort 169 (77.9) 115 (81.5) 28 (45.2) <0.001 Mechanic ventilation change 106 (48.8) 80 (56.4) 33 (53.2) 0.339 Unrestricted visits 172 (79.3) 121 (85.8) 39 (62.9) 0.001 Discharge from ICU 102 (47.0) 86 (61.0) 20 (32.3) <0.001 ICU – intensive care unit. Results expressed as number (%), Chi-square. the never withdrawn or refused therapies. Analgesia and sedation were the less withdrawn therapies in the three countries, and in Brazil mechanic ventilation is less frequently withdrawn versus the other countries. The intensive care professionals’ attitudes follow- ing end-of-life diagnosis can be seen on Table 7. Fig- ure 2 shows that the professionals overall considered lack of legal definitions as the main barrier for the LTE decision process, followed by lack of ethical clar- ity and training of the involved personnel. Figure 2 – Main barriers for therapeutic limit decision making. DISCUSSION This study, with more than 81% of the participants being intensive care physicians from Brazil, Argentina and Uruguay, made clear the need of broader debate, leading to a widened understanding of the new inten- sive care paradigms. It was identified that in Brazil, as compared to the other countries, the population evaluated was young- er, and consequently had a shorter ICU experience, LTE – limit of therapeutic effort. Results expressed as number (%). Chi-square as well as had a larger number of non-medical profes- Figure 1 – Limit of therapeutic effort frequency in the three sionals. It is interesting that, nevertheless the Catholic countries. religion predominance in the studied countries, 30% Rev Bras Ter Intensiva. 2010; 22(2):125-132
  • 6. 130 Moritz RD, Deicas A, Rossini JP, Silva NB, Lago PM, Machado FO of the professionals declared to be atheist or agnostic, as a palliative ICU measures is growing.(9,24) Also is suggesting ICUs workers skepticism. currently discussed the relevance of appropriate inten- The characteristics of the ICUs where the com- sive care professionals’ training in end-of-life patients pleters worked had differences related to each coun- management competencies. Proactive measures al- try’s specificities. In Brazil, less flexibility regarding lowing the patient a painless and less discomfort death visits to critically ill patients was identified. is mandatory, as well as appropriate support for the The analysis regarding the LTE decision making family members.(12,13,25,26) allowed concluding that the disease’s prognosis, the In this study, the most commonly refused or with- patients’ co-morbidities, and the therapeutic futility drawn therapies, in the three countries, were cardiore- were the main contributing factors for therapies re- spiratory resuscitation, vasoactive drugs administration fusal or withdrawal in the three countries. It is inter- and dialysis methods. Analgesia, sedation and venous hy- esting to add that legal definition, although pointed as dration are the most frequently maintained therapies. A the main barrier for LTE decision making, was ranked difference was identified regarding mechanic ventilation six by the Brazilian and Argentinean professionals, withdrawal, done almost always by 48.2% of the Ar- and seven by the Uruguayans. gentinean professionals, 25.8% of the Uruguayans and The physician is ethically and technically trained 18.9% of the Brazilians. Regarding the measures adopt- to provide the best possible care. In this study, the ed following the end-of-life condition diagnosis, change professional more frequently mentioned as respon- in sedation-analgesia was the most prevalent measure in sible for LTE decisions was the physician. According the three countries. The results appear to indicate that to Nunes (13) actions’ ethics is not determined by the the Argentinean professionals feel more comfortable to external behavior, but by the inner component – and act proactively for the end-of-life critical patient care. this means that the action results from targets the Regarding the barriers limiting LTE mentioned by person has establishes for him/herself, thus involving the respondents, the lack of legal definition was the main freedom of action. So, the main determinant is the aspect, followed by the need of ethical definition and intention, which moves forward to deliberation and professionals training. For appropriate care of the end- decision making. It could be inferred that nevertheless of-life patient, several aspects are involved. The social ac- the physician respects legal rules, the decision making ceptance of death and the lack of accurate death predic- is mainly based on the patient’s clinical aspects. tion methods make difficult the decision making. Lack In this study we could identify that, although no of palliative care training, and the difficulty for commu- specific legal rules are established for LTE, most of nicating “bad news” are barriers to overcome.(26,27) the respondents (more than 90%) had already decided As this study main fault, the demographic differ- for limiting therapy during their professional lives. ences (age, profession, gender, experience) between Brazilian studies confirm this. (2,14,15) It is important the participants may have influenced the results. Ad- to emphasize the existence legal support for refus- ditionally, those completing the questionnaire were ing artificial resources. It is not considered a crime taking part in events or visiting their societies’ sites, refusing therapies not effectively beneficial to the pa- and this may represent a bias for the results’ analy- tient, which are exclusively therapeutic obstinacy. The sis. The decision of categorizing the variables in three procedure indication or contraindication is matter of groups made an appropriate statistical analysis com- medical decision, and should be discussed with the plex. This is another limiting factor to be stressed. patient, when possible, and family members, in order Even though the pointed methodological faults, to assure dignity for the end-of-life process.(16) the authors take the liberty of suggesting that, given Much has been written in the last two decades the relevant number of limit of therapeutic effort de- regarding intensive care therapy withdrawal; better cisions in ICUs, plans for end-of-life patients’ pallia- understanding on LTE and palliative care has been tive care should be implemented. gained with the years. However, there are still cul- tural and legal barriers making difficult the end-of- CONCLUSIONS life patient management. Classically, the therapies most acknowledged as futile or useless are vasoactive This study results allow concluding that, neverthe- drugs and dialysis methods. (14,15,17-23) In the last years, less regional and cultural differences, the end-of-life the acceptance of withdrawing mechanic ventilation limitation of therapeutic effort measures are frequent- Rev Bras Ter Intensiva. 2010; 22(2):125-132
  • 7. Professional perceptions on end-of-life care 131 ly used by the ICU professionals in the three coun- variáveis foram analisadas através do teste qui-quadrado sendo tries. The study shows a trend to more proactive LTE considerado significativa p<0,05. measures in Argentinean ICUs, and more equity in Resultados: Participaram do estudo 420 profissionais. No the decisions distribution in Uruguay. Although fur- Brasil as UTI tinham mais leitos, foi mais rara a permissão irres- ther evidence is needed, this difference may be related trita de visitas, os profissionais eram mais jovens, trabalhavam a menos tempo na UTI e houve maior participação de não médi- to the differences regarding age, experience, type of cos. Três visitas/dia foi o número mais frequente nos três países. professional and gender. Os fatores que mais influíram nas decisões de LET foram prog- nóstico da doença, co-morbidades e futilidade terapêutica. Nos Acknowledgements: The authors acknowledge the três países mais de 90% dos participantes já havia decidido por Southern Cone End-of-Life Workgroup: Francisco Al- LET. Reanimação cardiorrespiratória, administração de drogas bano de Meneses, Jairo Constante Bitencourt Othero, vaso-ativas, métodos dialíticos e nutrição parenteral foram as te- Jefferson Pedro Piva, Márcio Soares, Nara Azeredo, rapias mais suspensas/recusadas nos três países. Houve diferença Raquel Pusch de Souza and Renato Terzi. significativa quanto à suspensão da ventilação mecânica, mais frequente na Argentina, seguida do Uruguai. Analgesia e seda- ção foram as terapias menos suspensas nos três países. Defini- RESUMO ções legais e éticas foram apontadas como as principais barreiras para a tomada de decisão. Objetivo: Avaliar as condutas tomadas nas Unidades de Te- Conclusão: Decisões de LET são frequentemente utilizados rapia Intensiva (UTI) com os pacientes críticos terminais. entre os profissionais que atuam nas UTI dos três países. Exis- Métodos: Os membros do grupo de estudo do final da vida te uma tendência da ação de LET mais pró-ativa na Argentina, das sociedades Argentina, Brasileira e Uruguaia de Terapia In- e uma maior equidade na distribuição das decisões no Uruguai. tensiva elaboraram um questionário no qual constavam avalia- Essa diferença parece estar relacionada às diferenças de idade, tem- ções demográficas sobre os participantes, sobre as instituições po de experiência, tipo de profissional e gênero dos participantes. em que os mesmos trabalhavam e decisões sobre limite de es- forço terapêutico (LET). Neste estudo de corte transversal os Descritores: Assistência terminal; Doente terminal; Recusa membros da equipe multiprofissional das sociedades responde- do paciente ao tratamento; Suspensão de tratamento; Futilidade ram o questionário durante eventos científicos e, via on line. As médica; Questionários REFERENCES 6. Consensus statement of the Society of Critical Care Medicine’s Ethics Committee regarding futile and other possibly inadvi- 1. Moritz RD. O efeito da informação sobre o comportamento sable treatments. Crit Care Med. 1997;25(5):887-91. dos profissionais da saúde diante da morte [tese]. Florianó- 7. Vincent JL. Forgoing life support in western European in- polis: Programa de Pós-Graduação em Engenharia de Pro- tensive care units: the results of an ethical questionnaire. dução da Universidade Federal de Santa Catarina; 2002.   Crit Care Med. 1999;27(8):1626-33. 2. Moritz RD, Machado FO, Heerdt M, Rosso B, Beduschi 8. 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