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Advisor(s)
Abstract(s)
Introdução
Os doentes nas Unidades de Cuidados Intensivos que possam estar com o prognóstico vital
limitado ou inclusive fechado, conscientes ou não, podem ter a possibilidade de ver a sua
vida prolongada indefinidamente graças ao avanço da tecnologia no campo da medicina.
Com isto, surge o dilema: quando é que devemos adequar o esforço terapêutico e
diagnóstico?
Objetivo
Esta revisão sistemática procura:
? analisar e unificar os diferentes princípios e valores bioéticos e fatores que
influenciam a decisão de limitação dos esforços terapêuticos e diagnósticos nestas
unidades, independentemente da patologia e da idade do doente.
Metodologia
Revisão Sistemática e Integrativa da Literatura com síntese narrativa. As bases de dados
eletrónicas PubMed, Scielo, Journal of Medical Ethics, Critical Care Medicine LWW e Web
of Science foram utilizadas. Os domínios ethical decision making e intensive care foram os
selecionados, com os termos MeSH Decision making, Intensive care units OR Critical care,
Withholding treatment, Medical Futility e Ethics OR Bioethics e as keywords Decision
making, Intensive Care, Limitation of therapeutic ef ort, Futility e Ethics. Os termos MeSH
foram utilizados e combinados com outros termos e os seus sinónimos e os operadores
booleanos AND e OR foram utilizados. Os títulos e abstracts foram analisados pelos dois
revisores na plataforma Google Sheets. Os artigos incluídos anteriormente foram
comparados com os critérios de inclusão e exclusão. A qualidade dos artigos selecionados foi
testada utilizando as ferramentas de Hawker et al e a JBI Systematic Reviews Checklist para
os estudos de caso. A informação dos artigos foi extraída utilizando um formulário
desenvolvido para este propósito. A estratégia de pesquisa e de recolha de dados PRISMA e
PICO, respetivamente, foram escolhidas para a realização desta revisão.
Resultados
O total de 41 artigos foram incluídos nesta revisão sistemática. Foram artigos de diferentes
países e com tamanhos e características amostrais variados. O princípio da autonomia é o
mais abordado seguido da beneficência, não maleficência e, por último, da justiça. A
autonomia dos doentes tem sido cada vez mais respeitada apesar de ainda existirem alguns
conflitos e aspetos que necessitam de maior exploração. A tomada de decisão sobre limitar
terapêutica e diagnóstico permite e promove a beneficência e a não-maleficência dos
doentes. O princípio da justiça verificou-se num caso de alocação injusta de produtos
sanguíneos numa altura conhecida por haver maior necessidade dos mesmos. A maioria dos profissionais reconhece a dignidade inerente à vida do doente como um valor relevante,
preservando-se mesmo até à morte, sendo este o valor mais referido. O maior tempo de
internamento e a má qualidade de vida foram os fatores mais encontrados nesta pesquisa e
são promotores destas decisões, outros fatores dentro da mesma categoria são na sua
maioria diretamente relacionados com o doente, ou, com menos impacto, relacionados com
os profissionais, hospitais, regiões e outros. É de destacar o papel importante das
características dos profissionais de saúde em dificultar ou impedir a tomada destas decisões,
sendo que nesta categoria os fatores relacionados com o doente têm um menor peso.
Conclusão
Os resultados desta revisão sistemática foram obtidos através de uma adequada estratégia de
pesquisa, seleção de artigos e extração de dados. As barreiras encontradas poderão ter
afetado a seleção de artigos e a sistematização da colheita de dados. Contudo, os artigos
selecionados continham a informação necessária e a devida qualidade para responder às
questões colocadas sem comprometer a validade desta revisão.
A autonomia foi o princípio bioético mais referido, seguido da beneficência, não-maleficência
e, por fim, a justiça. A dignidade foi o valor mais abordado e é respeitado até ao momento da
morte do doente.
Relativamente aos fatores que afetam estas decisões, estão relacionados diretamente com o
doente ou não. Os fatores que promovem a adequação de esforços terapêuticos e
diagnósticos estão maioritariamente relacionados diretamente com o doente, não
exclusivamente à sua patologia, nomeadamente o maior tempo de internamento e a má
qualidade de vida expectável. Observa-se a situação contrária nos fatores que dificultam ou
impedem estas decisões, destacando o papel das características dos profissionais, em
particular a religiosidade e a falta de familiaridade nos cuidados de conforto.
É de destacar a grande necessidade de investir de forma significativa na educação dos
profissionais médicos e não médicos nesta temática.
Introduction The patients in the Intensive Care Unit that have limited or close prognosis, conscious or not, might have the possibility to see their lives prolonged indefinitely due to the advancements in technology in the field of medicine. With this, arises the dilemma: when should we adequate the therapeutic and diagnostic effort? Objective This systematic review will: ? analyze and unify the different bioethical principles and values and factors that influence the decision to limit therapeutic and diagnostic efforts in these units, independently of the pathology and age of the patient. Methodology Integrative and Systematic Review of Literature with narrative synthesis. The following electronic databases were used in this research: PubMed, Scielo, Journal of Medical Ethics, Critical Care Medicine LWW and Web of Science. The domains ethical decision making and intensive care were selected, with the MeSH terms Decision making, Intensive care units OR Critical care, Withholding treatment, Medical Futility and Ethics OR Bioethics and the keywords Decision making, Intensive Care, Limitation of therapeutic ef ort, Futility and Ethics. The MeSH terms were used and combined with other terms and their synonyms and the boolean operators AND and OR were used. The titles and abstracts were analyzed by the two reviewers in the Google Sheets platform. The selected articles from the precious phase were compared with the inclusion and exclusion criteria. The resulting articles were evaluated for their quality with Hawker et al tool and JBI Systematic Reviews Checklist for study cases. The articles’ information was extracted using a form developed for this purpose. The search strategy and the data collection followed the PRISMA and PICO approach, respectively, in this review. Results A total of 41 articles were included in this systematic review. They were articles from different countries with variable sample sizes and characteristics. The principle of autonomy is the most discussed principle, followed by beneficence, non-maleficence and, by last, justice. The patients’ autonomy has been more respected despite the fact that there are still some conflicts and aspects worthy of better exploration. The decision making about limiting therapeutic and diagnostic efforts allows and promotes beneficence and non-maleficence of the patients. The principle of justice was verified in a case of unfair allocation of blood products in a time known for its scarcity. The majority of the professionals recognize the dignity inherent to human life as a relevant value, preserving it even until death, being the most referred value. The longer hospital stay and worse quality of life were the most found factors in this research and they promote these decisions, other factors found in this category are mostly related directly to the patient or, with less impact, related to the professionals, hospitals, regions and others. It is noteworthy the important role of the health professionals’ characteristics in hampering or impeding the decision making, being that in this category the factors related to the patient have less impact. Conclusion The results of this systematic review were obtained with an adequate search strategy, articles selection and data extraction. The barriers found might have affected the articles selection process and the systematization of the data collection. Despite this, the selected articles had the necessary information and the proper quality to answer the questions of this review without compromising its validity. Autonomy was the most referred bioethical principle, followed by beneficence, non-maleficence and justice. Dignity was the most mentioned value and it is respected until the patient’s death. The factors that affect these decisions are related directly or indirectly to the patient. Factors that promote the adequation of therapeutic and diagnostic efforts are mostly related directly to the patients, not exclusively to their pathology, mainly the longer hospitalization time and the expected low quality of life. The contrary situation is verified in the factors that hamper or impede these decisions, emphasizing the role of the professionals’ characteristics, in particular the religiousness and the lack of familiarity in comfort care. It is noteworthy to mention the great necessity to invest significantly in the education of the medical and non-medical professionals in this area.
Introduction The patients in the Intensive Care Unit that have limited or close prognosis, conscious or not, might have the possibility to see their lives prolonged indefinitely due to the advancements in technology in the field of medicine. With this, arises the dilemma: when should we adequate the therapeutic and diagnostic effort? Objective This systematic review will: ? analyze and unify the different bioethical principles and values and factors that influence the decision to limit therapeutic and diagnostic efforts in these units, independently of the pathology and age of the patient. Methodology Integrative and Systematic Review of Literature with narrative synthesis. The following electronic databases were used in this research: PubMed, Scielo, Journal of Medical Ethics, Critical Care Medicine LWW and Web of Science. The domains ethical decision making and intensive care were selected, with the MeSH terms Decision making, Intensive care units OR Critical care, Withholding treatment, Medical Futility and Ethics OR Bioethics and the keywords Decision making, Intensive Care, Limitation of therapeutic ef ort, Futility and Ethics. The MeSH terms were used and combined with other terms and their synonyms and the boolean operators AND and OR were used. The titles and abstracts were analyzed by the two reviewers in the Google Sheets platform. The selected articles from the precious phase were compared with the inclusion and exclusion criteria. The resulting articles were evaluated for their quality with Hawker et al tool and JBI Systematic Reviews Checklist for study cases. The articles’ information was extracted using a form developed for this purpose. The search strategy and the data collection followed the PRISMA and PICO approach, respectively, in this review. Results A total of 41 articles were included in this systematic review. They were articles from different countries with variable sample sizes and characteristics. The principle of autonomy is the most discussed principle, followed by beneficence, non-maleficence and, by last, justice. The patients’ autonomy has been more respected despite the fact that there are still some conflicts and aspects worthy of better exploration. The decision making about limiting therapeutic and diagnostic efforts allows and promotes beneficence and non-maleficence of the patients. The principle of justice was verified in a case of unfair allocation of blood products in a time known for its scarcity. The majority of the professionals recognize the dignity inherent to human life as a relevant value, preserving it even until death, being the most referred value. The longer hospital stay and worse quality of life were the most found factors in this research and they promote these decisions, other factors found in this category are mostly related directly to the patient or, with less impact, related to the professionals, hospitals, regions and others. It is noteworthy the important role of the health professionals’ characteristics in hampering or impeding the decision making, being that in this category the factors related to the patient have less impact. Conclusion The results of this systematic review were obtained with an adequate search strategy, articles selection and data extraction. The barriers found might have affected the articles selection process and the systematization of the data collection. Despite this, the selected articles had the necessary information and the proper quality to answer the questions of this review without compromising its validity. Autonomy was the most referred bioethical principle, followed by beneficence, non-maleficence and justice. Dignity was the most mentioned value and it is respected until the patient’s death. The factors that affect these decisions are related directly or indirectly to the patient. Factors that promote the adequation of therapeutic and diagnostic efforts are mostly related directly to the patients, not exclusively to their pathology, mainly the longer hospitalization time and the expected low quality of life. The contrary situation is verified in the factors that hamper or impede these decisions, emphasizing the role of the professionals’ characteristics, in particular the religiousness and the lack of familiarity in comfort care. It is noteworthy to mention the great necessity to invest significantly in the education of the medical and non-medical professionals in this area.
Description
Keywords
Decision Making Ethics. Futility Intensive Care Limitation of Therapeutic Effort