Obstinación terapéutica y su límite con la ética: ¿cuándo detenerse? / Therapeutic effort limit, when do we stop?

Obstinacy or therapeutic cruelty is a medical practice based on the application of extraordinary and disproportionate methods of life support in terminally ill or irrecoverable patients. It is not without risks and can cause physical, psychological and social damage, which is why this practice is not ethically acceptable. It violates the four principles of bioethics: non-maleficence, beneficence, justice and autonomy. The reasons that lead to therapeutic obstinacy are: 1) lack of a definitive diagnosis; 2) false expectation of improvement of the patient; 3) disagreement (between doctors and family or between doctors themselves) with respect the patient's situation; 4) difficulty in communicating with the patient and his/her family; 5) compliance with unrealistic or futile treatments; 6) cultural or spiritual barriers and 7) medical-legal aspects. Limitation of therapeutic effort (LTE) is a deliberate or thoughtful decision about the non-implementation or withdrawal of therapeutic measures that will not provide significant benefit to the patient. But, refusing a treatment, must not imply the artificial acceleration of the death process. Chile does not contemplate euthanasia or assisted suicide in its legislation. Criteria used to justify the limitation of the therapeutic effort are: 1) futility of the treatment (futility); 2) declared wishes of the patient; 3) quality of life and 4) economic cost. The Healthcare Ethics Committee of the Hospital de Urgencia Asistencia Pública has prepared a LET Clinical Guide, proposing a decision-making flow chart that takes in account the autonomy of the patient, the opinion of the medical team, patient and family. In case of disagreement, the Healthcare Ethics Committee's may be requested to issue a pronouncement.

La obstinación o ensañamiento terapéutico es una práctica médica basada en la aplicación de métodos extraordinarios y desproporcionados de soporte vital en enfermos terminales o irrecuperables. No está exenta de riesgos y puede producir daño físico, psicológico y social, motivo por el cual no es aceptable desde el punto de vista ético. Viola los cuatro principios de la bioética: no maleficencia, beneficencia, justicia y autonomía. Las razones que conducen a la obstinación terapéutica son: 1) la falta de un diagnóstico definitivo; 2) la falsa expectativa en el mejoramiento del paciente; 3) el desacuerdo (entre médicos y familia o entre los médicos mismos) con la situación del paciente; 4) la dificultad para comunicarse con el paciente y con la familia; 5) la conformidad con tratamientos poco realistas o fútiles; 6) barreras culturales o espirituales y 7) aspectos médico legales. La limitación del esfuerzo terapéutico (LET) es una decisión deliberada o meditada sobre la no implementación o la retirada de medidas terapéuticas que no aportarán un beneficio significativo al paciente. Pero, rechazar un tratamiento no puede implicar la aceleración artificial del proceso de la muerte. Chile no contempla en su legislación la eutanasia ni el suicidio asistido. Criterios utilizados para justificar o no, la limitación del esfuerzo terapéutico: 1) la inutilidad del tratamiento (futilidad); 2) los deseos expresos del paciente; 3) la calidad de vida y 4) el costo económico. El Comité de Ética Asistencial del Hospital de Urgencia Asistencia Pública, ha elaborado una Guía Clínica de LET. Propone un flujograma de toma de decisiones que considera la autonomía del paciente, la postura tanto del equipo médico, del paciente y su familia y en caso de no acuerdo, del comité de Ética Asistencial.

Do-not-resuscitate order in COVID-19 times: bioethics and professional ethics / Orden de no re-animación en COVID-19: bioética y ética profesional / Ordem de não reanimação em tempos da COVID-19: bioética e ética profissional

ABSTRACT Objective: To reflect about the do-not-resuscitation order at COVID-19 in Brazil, under bioethical focus and medical and nursing professional ethics. Method: Reflection study based on the principlist bioethics of Beauchamps and Childress and in professional ethics, problematizing actions, and decisions of non-resuscitation in the pandemic. Results: It is important to consider the patient's clinic, appropriation of treatment goals for people with comorbidities, elderly people, with less chance of surviving to resuscitation, or less quality of life, with the palliative care team, to avoid dysthanasia, use of scarce resources and greater exposure of professionals to contamination. Conclusion: COVID-19 increased the vulnerabilities of professionals and patients, impacting professional decisions and conduct more widely than important values ​​such as the restriction of freedom. It propelled the population in general to rethink ethical and bioethical values ​​regarding life and death, interfering in decisions about them, supported by human dignity.

RESUMEN Objetivo: Reflexionar sobre el orden de no reanimación en COVID-19 en Brasil, bajo enfoque bioético y ética profesional médica y de enfermería. Método: Estudio de reflexión basado en la bioética principialista de Beauchamps y Childress y ética profesional, acciones problemáticas y decisiones de no reanimación en la pandemia. Resultados: Considerar la clínica del paciente, con un esquema apropiado de los objetivos del tratamiento, especialmente en los ancianos y las personas con comorbilidades y contar con el apoyo del equipo de cuidados paliativos, para evitar la distanasia, así como el mal uso de los recursos y la exposición de los profesionales a la contaminación. Conclusión: COVID-19 aumentó las vulnerabilidades de profesionales y pacientes, impactando decisiones profesionales y conductas más amplias que valores importantes como la restricción de la libertad, pero especialmente haciendo que la población en general reconsidere los valores éticos y bioéticos con respecto a la vida y la muerte, interferir en las decisiones sobre ellos apoyadas por la dignidad humana.

RESUMO Objetivo: Refletir sobre ordem de não reanimação na COVID-19 no Brasil, sob foco bioético e da ética profissional médica e de enfermagem. Método: Estudo de reflexão embasado na bioética principialista de Beauchamps e Childress e na ética profissional, problematizando ações e decisões de não reanimação na pandemia. Resultados: Importa considerar a clínica do paciente, apropriação das metas dos tratamentos de pessoas com comorbidades, idosas, com menores chances de sobreviver à reanimação, ou menor qualidade de vida, junto à equipe de cuidados paliativos, para evitar distanásia, uso dos recursos escassos e maior exposição dos profissionais à contaminação. Conclusão: A COVID-19 ampliou as vulnerabilidades de profissionais e pacientes, impactando nas decisões e condutas profissionais mais amplamente do que nos valores importantes como a restrição da liberdade. Impulsionou a população em geral a repensar valores éticos e bioéticos referentes à vida e à morte, interferindo nas decisões sobre elas, respaldas na dignidade humana.

Do not attempt resuscitation orders at the emergency department of a teaching hospital / Ordens de não ressuscitação no serviço de emergência de um hospital universitário

ABSTRACT Objective: To identify factors associated with not attempting resuscitation. Methods: A cross-sectional study conducted at the emergency department of a teaching hospital. The sample consisted of 285 patients; in that, 216 were submitted to cardiopulmonary resuscitation and 69 were not. The data were collected by means of the in-hospital Utstein Style. To compare resuscitation attempts with variables of interest we used the χ2 test, likelihood ratio, Fisher exact test, and analysis of variance (p<0.05). Results: No cardiopulmonary resuscitation was considered unjustifiable in 56.5% of cases; in that, 37.7% did not want resuscitation and 5.8% were found dead. Of all patients, 22.4% had suffered a previous cardiac arrest, 49.1% were independent for Activities of Daily Living, 89.8% had positive past medical/surgical history; 63.8% were conscious, 69.8% were breathing and 74.4% had a pulse upon admission. Most events (76.4%) happened at the hospital, the presumed cause was respiratory failure in 28.7% and, in 48.4%, electric activity without pulse was the initial rhythm. The most frequent cause of death was infection. The factors that influenced non-resuscitation were advanced age, history of neoplasm and the initial arrest rhythm was asystole. Conclusion: Advanced age, past history of neoplasia and asystole as initial rhythm were factors that significantly influenced the non-performance of resuscitation. Greater clarity when making the decision to resuscitate patients can positively affect the quality of life of survivors.

RESUMO Objetivo: Identificar fatores associados à não realização de ressuscitação. Métodos: Estudo transversal realizado no serviço de emergência de um hospital universitário. A amostra foi composta por 285 pacientes, dos quais 216 foram submetidos à ressuscitação cardiopulmonar, e 69 não tiveram esta conduta. Os dados foram coletados por meio do in-hospital Utstein Style. Para comparar as tentativas de ressuscitação e as variáveis de interesse, utilizaram-se o teste do χ2, a razão de verossimilhança, o teste exato de Fisher e a análise de variância (p<0,05). Resultados: A não ressuscitação foi considerada injustificável em 56,5% dos casos, sendo que 37,7% não queriam ressuscitação e 5,8% foram encontrados mortos. Do total de pacientes, 22,4% tiveram parada cardíaca prévia, 49,1% eram independentes para Atividades de Vida Diária, e 89,8% tinham alguma história pregressa; 63,8% estavam conscientes, 69,8% estavam respirando e 74,4% tinham pulso palpável à admissão. A maioria dos eventos (76,4%) ocorreu no hospital, e a causa presumida de parada foi insuficiência respiratória em 28,7% e, em 48,4%, o ritmo inicial foi atividade elétrica sem pulso. A causa mais frequente de morte foi infecção. Os fatores que influenciaram na não realização de ressuscitação foram idade avançada, história de neoplasia e assistolia como ritmo inicial de parada. Conclusão: Idade avançada, história de neoplasia e assistolia como ritmo inicial foram os fatores que influenciaram significativamente na não realização de ressuscitação. Maior clareza na decisão de reanimar pode afetar positivamente a qualidade de vida dos pacientes.

Orden de no reanimar: una oferta racional y ética / Do not resuscitate (DNR): a rational and ethic proposal

Razones técnico-profesionales, sociales y legales han convertido a la reanimación cardiopulmonar (RCP) en mandatoria frente al paro cardiorrespiratorio (pCR). Los resultados de la aplicación indiscriminada de RCP obligaron a cuestionar la conducta. Se propuso la "Orden de No Reanimar" (ONR), que consiste en evitar la RCP frente a eventual pCR, conforme a la oferta efectuada o consentida por los médicos y aceptada o solicitada por los pacientes o sus representantes. El comportamiento resulta dilemático. Se debate en países con experiencia al respecto y ha despertado escaso interés en Argentina. Objetivos - analizar la experiencia observada con la aplicación de ONR y discutir los fundamentos sociales, médicos, éticos y legales. Diseño. Observacional retrospectivo. Población. Pacientes fallecidos entre enero '99 y junio '03. Método. Revisión aleatoria de Historias Clínicas. Resultados. En el periodo estudiado egresaron 4792 pacientes. Se tomaron al azar 57 (48.7%) de las Historias Clínicas de los 117 fallecidos. Se tabularon edad, diagnóstico, registro de ONR y de RCP: 17 registraban ONR (29.8%) y no fueron reanimados, 17 tampoco recibieron RCP porque presentaban signos d e muerte cuando se consultó. El resto fue reanimado. La oferta de ONR se fundó en la futilidad cuali-cuantitativa de pronóstico y resultados. Las familias aceptaron las propuestas según criterios de afecto, piedad o compasión. La oferta respeta la autonomía, beneficia al no prolongar padecimientos, evita la maleficente supervivencia sin calidad y la injusta mortificación física y moral carente de futuro. Subsumida en la doctrina de consentimiento informado, goza de aprobación ética y legal. No corresponde si desestima valores de pacientes o familias. Conclusiones. La ONR constituye un cambio con justificación plena. Su oferta ponderada favorece la veracidad, personaliza las decisiones y permite actuar de acuerdo con valores, preferencias y circunstancias individuales. Concertada, expresa un pacto de voluntades, abona la mejor relación paciente - médico y honra la función médica de cuidar hasta el fin de la vida. Satisface los postulados de la ética dialógica y su justificación ética se subsume en la doctrina de consentimiento informado. No desacata obligaciones legales. Es improcedente la ONR que excluye o desacata la opinión de pacientes o familiares, tanto derivada de la decisión médica exclusiva, cuanto exigida a los profesionales por normativas institucionales: quebranta compromisos terapéuticos, desobedece normas éticas, infringe derechos básicos y contraviene preceptos legales

Technical and professional motives, social arguments and legal reasons have made of cardiopulmonary reanimation (CPR) a mandatory response to cardiorrespiratory arrest (cra). In spite of its invasivity, CPR does not requires previous consent, giving it a special category among therapeutic media. Outcomes obtained after indiscriminate CPR application questioned the conduct and gave birth to Do Not Resuscitate (DNR) concept. The procedure offers to obviate CPR according to an offer made or consented by medical doctors and accepted or asked for by patients or their families. The proposal remains a dilemma and is yet in discussion in countries with experience on the matter and has received scarce attention in Argentina. Objectives. To analyse experience in application of DNR and to discuss its social, medical, ethic and legal foundations. Design. Observational retrospective. Methods. Alleatory revision of Clinical Histories of deceased patients between january 1999 and june 2003. Results. Over 4792 patients under care, 117 died. Age, diagnosis, DNR and CPR registration were collected from 57 histories randomly selected (48.7%): 17 of them (29.8%) registered DNR and were not reanimated, 13 were not reanimated because there were obvious signs of death in the moment of consultation. The rest of the population received CPR. Medical offer of DNR was founded in futility of prognoses and outcomes. Families accepted all DNR proposals for affection, pious or compassion criterions. The proposal respects autonomy, benefits as much as avoids inconducent suffering, withdraws maleficency of life without quality and the injustice of physical and moral pains without future. Subsumed in informed consent doctrine, it has ethic and legal approbation. It is not indicated if it underestimates patients and families values. Conclusions. DNR constitutes a fully justified change in medical assistance. It honours medical promise of care of patients up to the end of life. Its proper application favours veracity, takes care of personal values, preferences and circumstances and opens a place to personalized decisions. Once concerted, DNR expresses a pact and favours patient ­ professional relationship and honours medical function of caring for life up to the end. It satisfies dialogic ethics premises. Its ethical justification is subsumed informed consent doctrine. It respects legal obligations. If unconsulted with patients or families, as spontaneous medical decission or as a response to institutional policies, DNR contravenes therapeutical compromises, disobeys ethical principles and attempts against basical rights and enforced legal precepts

Orden de no reanimar, consideraciones sobre este problema / Don not resuscitate order: some considerations about this problem

El artículo define aspectos y significados clínicos y éticos sobre Paro Cardiorrespiratorio (PCR), Maniobras de Reanimación Cardiopulmonar y Orden de No resucitación Cardiopulmonar (No-RCP). Enfatiza la diferencia entre el cese de la función cardiorrespiratoria por muerte natural (p.ej. por enfermedad crónica irreversible), distinguiéndolo de el PCR súbito, reversible. Se examinan estas situaciones a la luz de los “Fines de la Medicina” (Hastings Center, 1996).Se analizan los principales problemas, comenzando por las dificultades según los diferentes escenarios (servicio de urgencia, pabellón de maternidad, sala de hospitalizados, unidad de intensivo, pabellones quirúrgicos); se analiza la incertidumbre sobre el pronóstico de cada pacientes y sobre quién(es) deben tomar las decisiones sobre el fin de la vida. Idealmente debe ser el paciente autónomo quien tome la decisión, pero en otros casos se requieren alternativas, una de ellas es la Orden Unilateral. Otros problemas son la Validez de las órdenes de no-RCP en los diferentes tiempos evolutivos, el problema de la Futilidad y la Validez de las “Directivas Anticipadas”, en este grupo resalta el enfoque POLST (Physician’s Order for Life Sustaining Treatment) como más comprehensivo; como complemento ha surgido también el concepto AND (Allow Natural Death), que podría estar destinado a remplazar la orden de no-RCP (DNR).

This article examines the ethical and clinical significance of Cardiopulmonary Arrest, Cardiopulmonary Resuscitation maneuvers and Do Not Resuscitate Order (DNR). It emphasizes Cardiopulmonary Arrest, Cardiopulmonary Resuscitation maneuvers and Do Not Resuscitate Order (DNR). It emphasizes the difference between the cessation of cardiorespiratory function by natural death (e.g. by chronic irreversible disease) as different from the sudden, reversible cardiopulmonary arrest. It considers these situations under the light of the “Goals of Medicine” (Hastings Center, 1996). We look through the main problems, in first place the specific difficulties according to different scenarios (emergency room, maternity ward, hospital room, intensive care unit, surgical blocks); second we analyzes the uncertainty about patients prognosis and third the controversial issue about who should take charge the end of life decisions. The autonomous patient should ideally be who takes the decisions. Other cases need alternatives ways, one of them is the “Unilateral Order”. Other problems are the validity of the DNR orders in different clinical times, the problem of futility and the value of Advance Directives; in this last point POLST (Physician’s Order for Life Sustaining Treatment) approach appears as more comprehensive; at last, the new concept AND (allow natural death) could be destined to replace the DNR order.

La reanimación cardiorrespiratoria y la orden de no reanimar / Cardiopulmonary resuscitation and do not resuscitate orders

In medical practice, the different scenarios in which cardio respiratory resuscitation (CPR) may be applied must be taken into account. CPR is crucial in subjects that arrive in emergency rooms or suffer a cardiac arrest in public places or at their homes. It is also critical in hospitalized patients with potentially reversible diseases, who suffer cardiac arrest as an unexpected event during their evolution. In intensive care units, the decision is particularly complex. The concepts of therapeutic proportionality, treatment futility and therapeutic tenacity can help physicians in their decision making about when CPR is technically and morally mandatory. The do not resuscitate (DNR) decision in taken when a patient is bearing an irreversible disease and his life is coming to an end. DNR decisions are clearly indicated in intensive care units to limit the therapeutic effort and in other hospital facilities, when death is foreseeable and therapeutic tenacity must be avoided. DNR orders must be renewed and reconsidered on a daily basis. It does not mean that other treatment should be discontinued and by no means should the patient be abandoned. DNR and previous directives, DNR and quality of life and DNR communication are also commented in the present article.