Limitación de tratamiento de soporte vital en una Unidad de Cuidado Intensivo pediátrica chilena: 2004-2014 / Limitation of Vital Support in a Chilean Pediatric Intensive Care Unit: 2004-2014

Resumen Objetivo: Describir las frecuencias y características del proceso de Limitación de Tratamiento de So porte Vital (LTSV) en pacientes de la Unidad de Cuidados Intensivos Pediátricos (UCI) entre 2004 2014. Pacientes y Método: Estudio retrospectivo, observacional descriptivo a partir de dos registros de la UCI del Hospital Roberto del Río: 1) ficha clínica individual de seguimiento y 2) ficha de registro de indicadores de calidad incluida LTSV, ambos actualizados diariamente al iniciar la visita clínica. Desde estos registros se analizaron los casos con dilemas bioéticos en los que se propuso LTSV du rante su hospitalización en UCI ("LTSV intra-UCI"). Se menciona la población rechazada de ingresar a UCI ("LTSV pre-UCI") y los fallecidos con LTSV en cama básica. Resultados: De 7.821 ingresos a UCI en el 1,51% (118 pacientes) se establece una LTSV: ONI (Orden de No Innovación) en 78,8% de los casos, retiro de medidas terapéuticas en 14,4% y suspensión de ventilación mecánica en 6,8%. En 23,7% el diagnóstico de base fue neurológico u oncológico, para cada uno. La condición fisiopatológica predominante para una LTSV fue neurológica (39%). El tiempo de estadía en UCI triplica el promedio de estada de los egresos totales de UCI, pero es de amplia variabilidad. Conclusiones: Es factible realizar una LTSV en UCI cuando el equipo incorpora esta perspectiva al trabajo diario junto a la familia. Hay una amplia variabilidad individual en las características del proceso de LTSV, propio del ámbito de la ética clínica.

Abstract Objective: Describe the frequency and characteristics of PICU patients who undergo a process of withholding or withdrawing life-sustaining treatment (LTSV), between 2004 y 2014. Patients and Method: A retrospective, observational descriptive study, using two documents for quality assessment in the PICU of Hospital Roberto del Río: 1) daily individual patient tracking log and 2) daily record of quality indicators, including LTSV, both updated daily at the morning visit. All PICU patients with an ethical dilemma during their PICU stay in which a LTSV was proposed were included. We men tion patients rejected for admission in the ICU and those who died in basic units of the hospital with LTSV. Results: In 118 patients of 7821 PICU admissions (1,5%) we determined a LTSV: ONR (Non Resuscitation Order) for all of them, ONI (Non Innovation Order) in 78,8%, withdrawal of some therapeutics in 14,4% and withdrawal of active mechanical ventilation in 6,8%. The basic diagnosis was 23,7% for each neurologic and oncologic diseases. The predominant pathophysiologic condition leading to a LTSV was severe chronic neurologic damage (39%). The length of stay was threefold the mean PICU stay, with a large variability due to expectable individual factors when ethic decisions are involved. Conclusion: LTSV is feasible when the team is involved and this perspective is part of daily clinical analysis. The wide individual variability in the LTSV process is expectable in ethical decisions.

Eutanasia en Chile: una discusión pendiente / Euthanasia in Chile

Euthanasia is a complex medical procedure. Even though end of life decisions are common situations in health practice, there is a lack of consensus about their terminology. In this manuscript, the main concepts about this issue are defined and delimited; including active and passive euthanasia and limitation of therapeutic effort. Then, a revision is made about the international experience on euthanasia, to then go through the Chile’s history in euthanasia and the population’s opinion. In Chile, euthanasia is an act that has been removed from the social dialogue and legislation. In order to have an open discussion in our population about the issue, the debate has to be opened to the citizens, accompanied by clear medical information about the procedure.

End-of-life decisions in perinatal care: A view from health-care providers in Mexico / Decisiones sobre el final de la vida en la atención perinatal: Una visión del equipo de salud en México

Objective. To examine the opinions of a perinatal health team regarding decisions related to late termination of pregnancy and severely ill newborns. Materials and Methods. An anonymous questionnaire was administered to physicians, social workers, and nurses in perinatal care. Differences were evaluated using the chi square and Student's t tests. Results. When considering severely ill fetuses and newborns, 82% and 93% of participants, respectively, opted for providing palliative care, whereas 18% considered feticide as an alternative. Those who opted for palliative care aimed to diminish suffering and those who opted for intensive care intended to protect life or sanctity of life. There was poor knowledge about the laws that regulate these decisions. Conclusions. Although there is no consensus on what decisions should be taken with severely ill fetuses or neonates, most participants considered palliative care as the first option, but feticide or induced neonatal death was not ruled out.

Objetivo. Explorar la opinión del equipo de salud sobre las decisiones relacionadas con la atención de fetos y neonatos gravemente enfermos. Material y métodos. Se aplicó un cuestionario anónimo a médicos, trabajadoras sociales y enfermeras perinatales. Las diferencias se evaluaron con las pruebas chi cuadrada y t de Student. Resultados. Al tratar fetos y neonatos gravemente enfermos, 82 y 93% de los participantes optaron, respectivamente, por atención paliativa. El 18% consideró el feticidio como alternativa. Quienes optaron por atención paliativa, lo hicieron para disminuir el sufrimiento, mientras que los que eligieron cuidados intensivos lo hicieron para proteger la vida o la sacralidad de la vida. Nuestro estudio mostró un pobre conocimiento de las leyes que regulan estas decisiones. Conclusiones. Aun cuando no existe un consenso sobre las decisiones que deben tomarse con fetos o neonatos gravemente enfermos, la mayoría consideró como primera opción los cuidados paliativos, aunque el feticidio y la muerte neonatal inducida no se descartaron.

Moral consensus theory: paradigm cases of abortion and orthothanasia in Brazil.

Bioethics is a relatively new way of thinking about relationships in medical practice. It enables reflection on ethical conflicts, and opens up management options without dictating rules. Despite this historical context, medical ethics has been sidelined in the course of the development of bioethics.

Termination of ventilatory support of a patient under compulsion, who is not yet brain dead

Clinicians are more comfortable psychologically in withholding a treatment than withdrawing it. Reasons for this are related to the fact that withholding is passive, whereas withdrawing is active and associated with a greater sense of moral responsibility. Withdrawing or terminating ventilation in Intensive Care Unit [ICU], even in a terminally sick patient, needs thoughtful review, particularly in those patients who are not yet brain dead. So many arguments may be offered against termination of ventilatory support. Ventilation is a part of palliative care which is always instituted to improve the quality of life and to relieve physical as well as psychosocial problems. Age is a very important factor as younger patients have a greater chance to improve than elderly, if the brain is not yet dead. Even during end of life care, not only ventilation is continued, but antibiotics, nutrition and care of bed-sores etc is also continued. As far as moral principles are concerned, termination of ventilation or withholding it, are equivalent in terms of medical ethics. Dignity of dying is as vital and important as dignity of living. One can always justify continuation of ventilation on ethical grounds. There is clinical precedence for this practice. In the opinion of the Supreme Court, withdrawing of life support should be considered synonymous as a kind of euthanasia. So, the termination of ventilation under compulsion would stand illegal and unlawful. Discontinuation of ventilation on economic reasons must be considered immoral and irrational. Sometimes the decision of terminating ventilatory support may be taken in the absence of interdisciplinary communication or that with the family of the patient. Many religious beliefs argue against the termination of ventilation. There are some religious groups who even challenge the existing brain death criteria. I would suggest that all these factors should be considered before taking the decision to terminate the ventilatory support under compulsion in a terminally sick patient, whose is not yet brain dead

Life-Sustaining Medical Treatment for Terminal Patients in Korea

No abstract available.

Euthanasia revisited: The aruna shanbaug verdict.

Euthanasia and its procedure have long history of locking horns as a vexed issue with laws of countries across the world. Every human being of adult years and sound mind has a right to determine what shall be done with his/her own body. It is unlawful to administer treatment to an adult who is conscious and of sound mind, without his consent. In patients with Permanently Vegetative State (PVS) and no hope of improvement, the distinction between refusing life saving medical treatment (passive euthanasia) and giving lethal medication is logical, rational, and well established. It is ultimately for the Court to decide, as parens patriae, as to what is in the best interest of the patient. An erroneous decision not to terminate results in maintenance of the status quo; the possibility of subsequent developments such as advancements in medical science, the discovery of new evidence regarding the patient’s intent, changes in the law, or simply the unexpected death of the patient despite the administration of life-sustaining treatment, at least create the potential that a wrong decision will eventually be corrected or its impact mitigated.

Euthanasia: a misunderstood term

Although the word 'euthanasia', a compound word of eu- (good, well) and thanatos (death) is widely known, it is greatly misunderstood. With regard to end-of-life medicine, several phrases, including death with dignity, passive euthanasia, and natural death also need to be clarified. A review of their meanings and connotations is provided along with a brief history of the discussion in Korea on forgoing life support. Korea has no law regarding the cessation of artificial ventilation, but several judgments of law courts provide us with a general principle that cessation could be applied if the patient is in an irreversible or dying condition medically, and has presented his or her intention with something like an advance directives, or is reasonably presumed to have such a will.

Demanda por eutanásia e condição de pessoa: reflexões em torno do estatuto das lágrimas / Demanda por eutanasia y condición de persona: reflexiones en torno al estatuto de las lágrimas / Euthanasia court claims and personhood: on the statute of tears

Este artigo enfoca a condição de pessoa contemporânea a partir do exame de notícias recentes sobre demandas por autorização legal de eutanásia. O caso de Christian Rossiter, tetraplégico após um atropelamento, é debatido. Em seu pedido - autorizado pela Suprema Corte do estado da Austrália Ocidental em agosto de 2009 - declarou que "não pode realizar suas funções humanas mais básicas, como secar as lágrimas do rosto". Tal solicitação se diferencia de outras, nas quais o argumento se centra na dor e no sofrimento físico, como ocorreu com Chantal Sébire. O caso aqui examinado evidencia tanto uma formulação da condição de pessoa quanto de gênero, na qual a esfera das emoções - e seu controle - é central. Este artigo discute o estatuto das lágrimas na sociedade ocidental contemporânea no que concerne a diferenças entre os gêneros e a situações radicais de vida/morte, quando é preciso definir os limites de existência da pessoa.

El presente artículo aborda la condición contemporánea de persona a partir del examen de noticias acerca de demandas de autorización legal de eutanasia. Se debate el caso de Christian Rossiter, tetraplégico a raíz de un accidente automovilístico, quien en su pedido -concedido por la Suprema Corte de Australia Occidental en agosto de 2009- declaró no poder "realizar sus funciones humanas más básicas, como secarse las lágrimas del rostro". Este reclamo se diferencia de otros cuyos argumentos se centran en el dolor y en el sufrimiento físico. El caso examinado explicita una formulación de la condición de persona en la cual la esfera de las emociones -y su control- es central. El artículo discute el estatuto de las lágrimas en la sociedad occidental contemporánea, enfocando diferencias de género y situaciones radicales de vida/muerte, en las se hace preciso definir límites de la existencia de la persona.

This article focuses on the contemporary notions of personhood, based on the examination of news articles on requests for legal authorization of euthanasia. The case of Christian Rossiter, left quadriplegic after being run over by a car, is discussed. On his claim - authorized by the Western Australia's Supreme Court in August 2009 - he stated that he was "unable to perform even the most basic human functions, such as wiping the tears from his face". Such request differs from others in which the argument focuses on pain and physical suffering, as with Chantal Sébire. The case examined in this study represents a formulation of personhood in which the sphere of emotions - and their control - is central. This article discusses the statute of tears in contemporary Western society, concerning gender differences,, and the extreme situations of life/death, when it is necessary to define the limits of a person's existence.

Matar, dejar morir y eutanasia en el proyecto de ley sobre derechos de las personas y en la doctrina chilena / To kill, let die and euthanasia in the bill of rights of patients and in the Chilean doctrine

The Bill of Rights for Patients provides the patient with autonomy for disposing of his life, enabling him to reject those treatments that unnecessarily prolong his life. However, the bill does not allow an artificial acceleration of death. Therefore, the bill does not permit euthanasia (at least, certain form of it) nor assisted-suicide. However, according to the practice of medicine and also Chilean doctrine, it is permitted to inject morphine to a patient to relieve his pain, even though that could hasten his death. In consequence, it is allowed for the patient to dispose of his life and also to inject in him morphine for pain relief, endangering his life, but neither euthanasia nor assisted-suicide is allowed. Is this coherent? According to Chilean doctrine, it could be coherent under the condition of accepting the distinction between killing and letting die and also the double effect doctrine. The problem is that there is abundant English literature in the realm of moral philosophy to disregard both conditions. Therefore, it is possible to claim that the Bill is not coherent and that the Chilean doctrine is based upon a distinction and a doctrine that are not acceptable.

Euthanasia in cancer patients, Islamic point of view

Euthanasia is an important subject that concerns law and medicine as well as morality and religion in the 21[St] century. Euthanasia has become a challengeable problem in scientific arena. In some countries, legal and medical practitioners are allowed to kill those cancer patients who suffer from excessive pain while incur enormous amount of expenses for their treatments. We used 3 main sources to find Islamic views on euthanasia: First, the Islamic primary source, the Holy Quran, which is the most important and reliable source for finding Islamic perspectives. Second, traditions [hadith] which include Prophet Mohammad's and his relatives's [Imams] advices. Third, religious opinions and decrees [Fatwas] from great Muslim scholars who are called Mofti Al-Aazam in Sunni tradition and Ayatollah Al-Ozma in Shiite tradition. Based on the reasons proposed in the references, it can be concluded that euthanasia is forbidden in Islamic theology; and no types of euthanasia are allowed or accepted in Islam; and any action whether voluntary or involuntary that results in euthanasia of cancer patients is considered suicide and is strongly forbidden in Islam. Euthanasia is purely illegal in Judaism, Christianity, and Islam. In this study, we introduced a religious law based on Islamic point of view and Emamyeh section in Islam. To investigate the sensitive issue of euthanasia in Islam, the Holy Quran as the fundamental reference of Islamic law and Sonnah as the reference of Hadith [Traditions] were studied

Reflexões legais e éticas sobre o final da vida: uma discussão sobre a ortotanásia / Legal and ethical reflections about end of life: a discussion about orthothanasia

O artigo apresenta as bases éticas e legais da ortotanásia. A busca de conhecimentos esteve baseada em dados disponíveis online e na literatura impressa, tendo como critério de inclusão a relevância dos artigos para a discussão da ortotanásia. Discute-se a ortotanásia tantono campo da medicina quanto no da bioética. São debatidas as leis, a ética e o critério da dignidade quanto à prática da ortotanásia. Reflete-se sobre a morte, os dilemas éticos e as ações dos profissionais em contextos de doentes terminais. O prolongamento da vida do paciente instaura situações muito complexas, mas o limite para investir deve ser definido pela concepção de morte digna, aliada à plena consciência da limitação das intervenções. A solução mais correta para cada situação está diretamente ligada à dignidade da pessoa que sofre o inevitável processoda morte, respeitando suas decisões.

Autonomia pessoal e morte / Personal autonomy and death

Este trabalho faz revisão bibliográfica sobre os temas autonomia, consentimento informado e morte, demonstrando como é polêmico discutir a morte no contexto social e profissional brasileiro. Argumenta que a compreensão do processo de morrer ajudará os profissionais a amparar os pacientes na sua morte e a respeitar sua dignidade. Aponta tambémque falar ou pensar sobre esse tema torna-se mais difícil quando não existe mais o que se fazer para aliviar o sofrimento frente à morte iminente. Conclui considerando que neste momento as pessoas deveriam ter o direito de escolher e decidir com dignidade o seu destino, prolongando sua agonia em leito hospitalar ou morrer na companhia de seus entes queridos.

Eutanasia, calidad de vida y retiro de soporte vital: estudio en 5 Centros de cuidados críticos / Euthanasia, quality of life and retirement of vital support: study in 5 Centers of cares critics

Objetivos. Evaluar opiniones y conductas acerca de métodos de abstención y/o retiro de soporte vital y de la eutanasia, en profesionales que trabajan usualmente en el ámbito de Servicios de Terapia Intensiva. Métodos. Diseño prospectivo, observacional, transversal, analítico. Se encuestaron 130 profesionales de 5 unidades de Terapia Intensiva. Encuesta abierta/cerrada. Estadística descriptiva, regresión lineal y logistica. Resultados. El 86.92% considera que la abstención (A) y/o retiro (R) de los métodos de soporte vital implica límites en la atención médica, el 63.07% piensa que A y R no son equivalentes. El 78.46% no consigna en las historias sus decisiones. El 36.92% no discute con el resto del equipo sus decisiones. Las variables más relacionadas con A y R son: irreversibilidad del cuadro agudo (80.76%) e ineficacia de medidas terapeúticas (70.00%). A es más frecuente que R (47.69% y 40.76%). El 24.61% consensúa con la familia. El 31.53% investiga preferencias previas del paciente. Los R más comunes son: suspensión de inótropicos (50.00%) y de la ventilación mecánica (36.92%). El 15.38% está a favor de la eutanasia. De las variables mencionadas, no se hallaron predictores a favor de la eutanasia en el modelo multivariado. No se hallaron diferencias a favor de eutanasia entre Centros, ni entre médicos versus enfermeros, ni entre médicos experimentados versus en formación (p 0.05 o más en todos los casos). La antiguedad en terapia intensiva no fue predictora de eutanasia en regresión lineal (p0.6110). Conclusiones. La mayoría de los profesionales considera que abstención o retiro del soporte vital implica limitar la atención, sin consignar tal conducta en la historia, y basándose en general en la irreversibilidad del cuadro agudo, la minoría ésta a favor de la eutanasia, sin diferencias según profesión o antigüedad profesional.

Difference between voluntary active and voluntary passive euthanasia: An ethico-legal perspective

Death and Dying are an important part of the development process and especially death is an event that occurs at the end of the dying process. But the management of death is a controversial topic because efforts to postpone or hasten death have medical, legal and ethical ramifications. Euthanasia, the act of painlessly ending the lives of individuals who are suffering from an incurable disease, has always been considered illegal and immoral act, however, voluntary passive euthanasia may be considered moral