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Cuidados intensivos e a tomada de decisão ético-clínica no fim de vida
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INTRODUÇÃO A Unidade de Cuidados Intensivos (UCI) constitui um serviço de elevada complexidade. Certos doentes são admitidos por intercorrências agudas de patologias crónico-degenerativas, com pouca possibilidade de reabilitação. Eclodem dilemas éticos relacionados com a pessoa humana, a adequabilidade dos tratamentos e com a alocação de recursos. MÉTODOS Foi construído um questionário electrónico com 32 perguntas (demográficas–9, tomada de decisão–16 e paliação-7). As respostas online foram concedidas, anonimamente e de modo voluntário, por intensivistas portugueses. A lista de contactos das UCIs foi obtida junto do sítio da Soc. Port. Cuid. Intensivos. Ademais, solicitou-se o apoio da Soc. Port. Med. Interna para a distribuição dos questionários. As respostas foram colectadas virtualmente pela SurveyMonkey®. A análise descritiva dos dados e os testes estatísticos foram executados no programa IBM-SPSS® versão 20. RESULTADOS Participaram 72 médicos: mulheres–54%; <40 anos–60%; casado/união–61%; cristãos–75%; Internistas–85%; antiguidade <7anos–59%. As UCIs têm 3-10 camas–60%, taxas de ocupação >80%–68% e de mortalidade 20-30%–54%. Na tomada de decisão ético-clínica (TDEC) participam sobretudo os médicos. A TDEC é influenciada por: qualidade de vida (prévia e pós-hospitalar), probabilidade de não sobreviver ao evento e comorbilidades. As dificuldades da TDEC devem-se à falta de formação sobre dilemas bioéticos e cuidados paliativos (CPAL). Em 61% dos casos, a consultoria da Comissão de Ética é solicitada raramente ou nunca. Os conflitos numa TDEC devem-se à falta de consenso multidisciplinar e à deliberação sustentada na fisiopatologia e não no “todo” da pessoa humana. A assunção da irreversibilidade é declarada no processo clínico e ocorre se há inconsciência permanente ou sofrimento desproporcionado. Num doente “não salvável” existe abstenção terapêutica (ABST) e decisão para não reanimar. Esta é precedida frequentemente por uma suspensão terapêutica (SUSP). Na limitação do esforço terapêutico, a SUSP é preterida face à ABST. A limitação é influenciada: escassez de benefício e indignidade da vida. Numa SUSP/ABST são mais afectadas: diálise, ressuscitação cardio-respiratória e inotrópicos. Na SUSP, a hidratação e a oxigenação periférica não são tocadas. Estas tampouco são atingidas na ABST, assim como: glicémia capilar, pressão arterial, frequência cardíaca e débito urinário. Na comparação, uma SUSP afecta mais os exames de imagem e análises laboratoriais, a ABST envolve os curarizantes e ventilação mecânica. Para 55% dos médicos há obstinação terapêutica que se deve: falta de consenso multidisciplinar e deliberação suportada pela hegemonia da fisiopatologia. No último ano, 70% dos intensivistas teve admissões fúteis. O sofrimento dos doentes incuráveis deve-se: dor, perturbações do sono, aspiração de secreções e entubação orotraqueal. Nas últimas horas de vida não se introduzem medidas invasivas e privilegia-se o conforto. Durante o processo de morrer, as famílias podem ficar menos satisfeitas com a sua fraca intervenção nas decisões e o pouco apoio emocional sentido, pouca comunicação existente e a frugal informação clínica. Os CPAL iniciam-se na inevitabilidade da morte ou perante sintomas refractários. Os CPAL estão indicados se os riscos do tratamento superam os benefícios, nos doentes que não queiram prosseguir a terapia agressiva ou nas pessoas agónicas. As acções que podem facilitar a implementação de CPAL na UCI são: entendimento dos fármacos indispensáveis ao controlo sintomático, agendamento de conferências para os casos complexos e existência de reuniões multidisciplinares. CONCLUSÕES Na TDEC no fim de vida há uma tendência para atomizar os indivíduos, sendo atendidas as demandas fisiopatológicas e não as necessidades pessoais. Há doentes que recebem tratamentos medicamente inapropriados no seu processo de morrer, sendo a SUSP rara. O intensivista, além de curar, tem a responsabilidade de assumir a transição precoce para CPAL nas situações de vida não salvável. A formação em CPAL é vital. O reconhecimento da importância da qualidade do fim de vida numa UCI, através de mudanças estruturais e organizacionais, implicará uma melhoria dos cuidados de saúde.
INTRODUCTION The Intensive Care Unit (ICU) is a service of high complexity. Certain patients are admitted due to acute complications of chronic-degenerative diseases, with little chance of rehabilitation. Ethical dilemmas occur, mainly related to the nature of the human being, treatment appropriateness and allocation of resources. METHODS A questionnaire was put together with 32 questions (demographics-9, decision making-16 and palliation-7). Answers were provided online, anonymously and voluntary, by Portuguese intensivists. ICUs’ contact list was sought from the Portuguese Society of Intensive Care. Furthermore, the distribution of the questionnaires was facilitated by the Portuguese Society of Internal Medicine. Responses were collected by SurveyMonkey®. Descriptive analysis of data and the statistical tests were run on IBM-SPSS® version 20. RESULTS 72 intensivists participated: women–54%; <40 years old–60%; married/partners–61%; Christians–75%; Internal Medicine specialists–85%; working at ICU <7 years–59%. ICUs had 3-10 beds –60%, occupancy rates (>80%)–68% and mortality rates (20-30%)–54%. Ethical and clinical decision-making (ECDM) involve mainly doctors. The decision is influenced by: quality of life (pre and post-hospital), probability of not surviving the event and co-morbidities. ECDM difficulties are due to lack of training on bioethical dilemmas and palliative care (PALC). In 61% of cases, the Ethics Committee´s advice is seldom or never requested. ECDM conflicts are due to lacking of consensus and the deliberation process (based on pathophysiology and not on the human being wholeness). Assumption of irreversibility – which is declared in the clinical file – occurs if there is either permanent unconsciousness or disproportionate suffering. Upon a terminal patient there are decisions either of “treatment withholding” (WHOLD) or “do not resuscitate” orders. The latter is often preceded by a “treatment withdrawing” indication (WDRAW). WDRAW is deprecated in relation to WHOLD. The “therapeutic limits” are influenced by both lacking of benefit and dignity of life. Both WDRAW and WHOLD concern mostly dialysis, cardio-respiratory resuscitation and inotropic agents. Hydration and peripheral oxygenation are not to be touched in neither WDRAW nor WHOLD. As far as capillary blood glucose, blood pressure, heart rate and urine output, they are not implicated in WHOLD. As per comparison: WDRAW involve more image exams and laboratory tests; WHOLD involve more mechanical ventilation and neuromuscular blocking agents. Therapeutic obstinacy is reported by 55% of the doctors. This is due to both lacking of multidisciplinary consensus and decisions being supported by the hegemony of pathophysiology. During the last year, 70% of intensivists reported futile admissions into the ICU. Terminal patients suffering is caused by: pain, sleep disturbance, aspiration of secretions and orotracheal intubation. In the last hours of life invasive measures are not prescribed whereas comfort is emphasized. During the process of dying, families are said to be less satisfied with: their small participation in decision-making, little emotional support offered, weak communication and the frugality of the clinical information. PALC begins on the inevitability of death or the presence of refractory symptoms. It is indicated: if the risks of treatment outweigh the benefits; in patients who do not want to pursue aggressive therapy or in agonic people. The measures which facilitate the implementation of PALC in the ICU are: knowledge of drugs that are essential to symptom management, scheduling conferences for the complex cases and existence of multidisciplinary meetings. CONCLUSIONS At the end of life, as far as ECDM is concerned, there is a tendency to atomize the individuals responding mainly to their pathophysiological demands not to their personal needs. There are patients, living their process of dying, who are prescribed medically inappropriate treatments. WDRAW is rare. At the end of life, the intensivist, beyond cure, has a responsibility to provide an early transition to PALC, in which training is therefore vital. The recognition of the importance of end of life quality in ICU, through structural and organizational changes, will entail an improvement in health care.
INTRODUCTION The Intensive Care Unit (ICU) is a service of high complexity. Certain patients are admitted due to acute complications of chronic-degenerative diseases, with little chance of rehabilitation. Ethical dilemmas occur, mainly related to the nature of the human being, treatment appropriateness and allocation of resources. METHODS A questionnaire was put together with 32 questions (demographics-9, decision making-16 and palliation-7). Answers were provided online, anonymously and voluntary, by Portuguese intensivists. ICUs’ contact list was sought from the Portuguese Society of Intensive Care. Furthermore, the distribution of the questionnaires was facilitated by the Portuguese Society of Internal Medicine. Responses were collected by SurveyMonkey®. Descriptive analysis of data and the statistical tests were run on IBM-SPSS® version 20. RESULTS 72 intensivists participated: women–54%; <40 years old–60%; married/partners–61%; Christians–75%; Internal Medicine specialists–85%; working at ICU <7 years–59%. ICUs had 3-10 beds –60%, occupancy rates (>80%)–68% and mortality rates (20-30%)–54%. Ethical and clinical decision-making (ECDM) involve mainly doctors. The decision is influenced by: quality of life (pre and post-hospital), probability of not surviving the event and co-morbidities. ECDM difficulties are due to lack of training on bioethical dilemmas and palliative care (PALC). In 61% of cases, the Ethics Committee´s advice is seldom or never requested. ECDM conflicts are due to lacking of consensus and the deliberation process (based on pathophysiology and not on the human being wholeness). Assumption of irreversibility – which is declared in the clinical file – occurs if there is either permanent unconsciousness or disproportionate suffering. Upon a terminal patient there are decisions either of “treatment withholding” (WHOLD) or “do not resuscitate” orders. The latter is often preceded by a “treatment withdrawing” indication (WDRAW). WDRAW is deprecated in relation to WHOLD. The “therapeutic limits” are influenced by both lacking of benefit and dignity of life. Both WDRAW and WHOLD concern mostly dialysis, cardio-respiratory resuscitation and inotropic agents. Hydration and peripheral oxygenation are not to be touched in neither WDRAW nor WHOLD. As far as capillary blood glucose, blood pressure, heart rate and urine output, they are not implicated in WHOLD. As per comparison: WDRAW involve more image exams and laboratory tests; WHOLD involve more mechanical ventilation and neuromuscular blocking agents. Therapeutic obstinacy is reported by 55% of the doctors. This is due to both lacking of multidisciplinary consensus and decisions being supported by the hegemony of pathophysiology. During the last year, 70% of intensivists reported futile admissions into the ICU. Terminal patients suffering is caused by: pain, sleep disturbance, aspiration of secretions and orotracheal intubation. In the last hours of life invasive measures are not prescribed whereas comfort is emphasized. During the process of dying, families are said to be less satisfied with: their small participation in decision-making, little emotional support offered, weak communication and the frugality of the clinical information. PALC begins on the inevitability of death or the presence of refractory symptoms. It is indicated: if the risks of treatment outweigh the benefits; in patients who do not want to pursue aggressive therapy or in agonic people. The measures which facilitate the implementation of PALC in the ICU are: knowledge of drugs that are essential to symptom management, scheduling conferences for the complex cases and existence of multidisciplinary meetings. CONCLUSIONS At the end of life, as far as ECDM is concerned, there is a tendency to atomize the individuals responding mainly to their pathophysiological demands not to their personal needs. There are patients, living their process of dying, who are prescribed medically inappropriate treatments. WDRAW is rare. At the end of life, the intensivist, beyond cure, has a responsibility to provide an early transition to PALC, in which training is therefore vital. The recognition of the importance of end of life quality in ICU, through structural and organizational changes, will entail an improvement in health care.
Descrição
Tese de mestrado, Bioética, Universidade de Lisboa, Faculdade de Medicina, 2017
Palavras-chave
Unidade de cuidados intensivos Cuidados paliativos Tomada de decisão Bioética Fim de vida Futilidade terapêutica Suspensão terapêutica Abstenção terapêutica Teses de mestrado - 2017