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Abstract(s)
Introdução: Com o avanço tecnológico na área da saúde, há um risco crescente do uso de tratamentos fúteis em doentes terminais. Nestes casos pode-se balizar as intervenções a partir da limitação do esforço terapêutico, garantindo um processo de morte natural e digna. Esta decisão deve envolver o doente, a equipa de profissionais de saúde da Unidade de Cuidados Intensivos e a família, em prol do melhor interesse do doente. A partir das diretivas antecipadas de vontade é possível recolocar a autonomia do doente no centro do processo de decisão.
Objetivo: Identificar retrospetivamente numa amostra de doentes internados na Unidade de Cuidados Intensivos do Centro Hospitalar Cova da Beira, o número de casos onde se podem detetar decisões de limitação do esforço terapêutico e de ordem de não reanimar, caracterizar o respetivo processo de tomada decisão e o grau de explicitação com que este tenha sido documentado.
Métodos: Estudo retrospetivo, no qual se avaliaram diários clínicos do ano civil de 2015, na Unidade de Cuidados Intensivos do Centro Hospitalar Cova da Beira. As variáveis consideradas foram: as características demográficas; o número de limitações do esforço terapêutico realizadas; o número de doentes vivos ou mortos após a aplicação da limitação; onde foi expressa a limitação: diário médico e/ou diário de enfermagem; quem participou no processo de decisão; e o tipo de limitação que foi realizada.
Resultados: No período ocorreram 268 internamentos na Unidade de Cuidados Intensivos, dos quais 23 (8,58%) apresentaram algum tipo de limitação do esforço terapêutico. O processo de limitação foi documentado na maioria no diário clínico médico, 11 (47,83%). Sendo os restantes documentados com a mesma prevalência, 6 (26,09%), nos diários de enfermagem ou em ambos os diários. Dos doentes com limitação, as decisões foram tomadas: apenas pelo médico assistente, em 16 (69,57%) doentes; médico assistente e família, em 4 (17,39%) doentes; equipa médica, em 1 (4,35%) doente; equipa médica e família, em 1 (4,35%) doente; família, 1 (4,35%); enfermagem ou com base em diretivas antecipadas de vontade, em nenhum caso. Em relação ao tipo de limitações executadas, 5 (21,74%) foi por suspensão e 18 (78,26%) por abstenção (12 por ordem de não reanimar, 2 de tratamento cirúrgico e 4 de tratamento médico).
Conclusão: Parece ser necessário desenvolver o enquadramento ético – jurídico e a formação sobre limitações do esforço terapêutico; o estabelecimento de protocolos de auxílio a decisão e de impressos próprios para a sua documentação de forma obrigatória e sistemática; maior envolvimento dos doentes, enfermeiros, familiares e representantes legais no processo de decisão.
Introduction: Technological advances in the health sector have led to the increasing risk of futile treatments on terminally ill patients. In these cases, it is possible to define interventions based on the limitation of therapeutic effort, thus ensuring a process of natural and dignified death. This decision should involve the patient, the Intensive Care Unit professionals and the family, in favour of the patient’s best interest. From the advance directives, it is possible to relocate the patient’s autonomy to the centre of the decision-making process. Objective: To retrospectively identify, from a sample group of patients hospitalised in the Intensive Care Unit of the Hospital Centre of Cova da Beira, the number of cases where it is possible to identify decisions of limitation of therapeutic effort and of do-not-resuscitate order; the respective decision-making process and the degree of explicitness with which it was documented. Methods: A retrospective study, based on the clinical journals of the year 2015 of the Intensive Care Unit of the Hospital Centre of Cova da Beira. The considered variables were: demographic characteristics; the number of living or deceased patients after the limitation was put into practice; where the limitation was stated: medical and/or nursing journal; who took part in the decision-making process; and the type of limitation in use. Results: During this period, there were 268 hospitalisations in the Intensive Care Unit, 23 (8.58%) of which presented some type of limitation of therapeutic effort. The process of limitation was mainly documented in the clinical medical journal, 11 (47,83%). The remaining documented cases with the same prevalence, 6 (26,09%), in the nursing or in both journals. Of the patients with limitation, decisions were made: by the physician associate, in 16 (69,57%) patients; by the physician associate and the family, in 1 (4,35%) patient; by the medical team and the family, in 1 (4,35%) patient; by the family, in 1 (4,35%) patient; by nursing staff or based upon advance directives, no cases were verified. With regards to the type of limitations in place, 5 (21,74%) were due to suspension and 18 (78,26%) to abstention (12 by Do-Not-Resuscitate Orders, 2 by surgical treatment and 4 by medical treatment). Conclusion: it seems necessary to develop an ethical and legal framework and provide training on limitations of therapeutic effort; the establishment of protocols in aid of decision-making and appropriate forms for their compulsory and systematic documentation should also be developed; there should be a greater involvement of patients, nursing staff, family and legal representatives in the decision process.
Introduction: Technological advances in the health sector have led to the increasing risk of futile treatments on terminally ill patients. In these cases, it is possible to define interventions based on the limitation of therapeutic effort, thus ensuring a process of natural and dignified death. This decision should involve the patient, the Intensive Care Unit professionals and the family, in favour of the patient’s best interest. From the advance directives, it is possible to relocate the patient’s autonomy to the centre of the decision-making process. Objective: To retrospectively identify, from a sample group of patients hospitalised in the Intensive Care Unit of the Hospital Centre of Cova da Beira, the number of cases where it is possible to identify decisions of limitation of therapeutic effort and of do-not-resuscitate order; the respective decision-making process and the degree of explicitness with which it was documented. Methods: A retrospective study, based on the clinical journals of the year 2015 of the Intensive Care Unit of the Hospital Centre of Cova da Beira. The considered variables were: demographic characteristics; the number of living or deceased patients after the limitation was put into practice; where the limitation was stated: medical and/or nursing journal; who took part in the decision-making process; and the type of limitation in use. Results: During this period, there were 268 hospitalisations in the Intensive Care Unit, 23 (8.58%) of which presented some type of limitation of therapeutic effort. The process of limitation was mainly documented in the clinical medical journal, 11 (47,83%). The remaining documented cases with the same prevalence, 6 (26,09%), in the nursing or in both journals. Of the patients with limitation, decisions were made: by the physician associate, in 16 (69,57%) patients; by the physician associate and the family, in 1 (4,35%) patient; by the medical team and the family, in 1 (4,35%) patient; by the family, in 1 (4,35%) patient; by nursing staff or based upon advance directives, no cases were verified. With regards to the type of limitations in place, 5 (21,74%) were due to suspension and 18 (78,26%) to abstention (12 by Do-Not-Resuscitate Orders, 2 by surgical treatment and 4 by medical treatment). Conclusion: it seems necessary to develop an ethical and legal framework and provide training on limitations of therapeutic effort; the establishment of protocols in aid of decision-making and appropriate forms for their compulsory and systematic documentation should also be developed; there should be a greater involvement of patients, nursing staff, family and legal representatives in the decision process.
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Keywords
Diretivas Antecipadas de Vontade Limitação do Esforço Terapêutico Ordem de Não Reanimar Suspensão e Abstenção do Tratamento Unidade de Cuidados Intensivos