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SPCI - Sociedade Portuguesa de Cuidados Intensivos

Revista Brasileira de Terapia Intensiva

AMIB - Associação de Medicina Intensiva Brasileira


ISSN: 0103-507X
Online ISSN: 1982-4335

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Moritz RD, Deicas A, Capalbo M, Forte DN, Kretzer LP, Lago P, et al. II Forum of the "End of Life Study Group of the Southern Cone of America": palliative care definitions, recommendations and integrated actions for intensive care and pediatric intensive care units. Rev Bras Ter Intensiva. 2011;23(1):24-29



Special Article

II Forum of the "End of Life Study Group of the Southern Cone of America": palliative care definitions, recommendations and integrated actions for intensive care and pediatric intensive care units

Rachel Duarte MoritzI, Alberto DeicasII, Mônica CapalboIII, Daniel Neves ForteI, Lara Patrícia KretzerI, Patrícia LagoI, Raquel PuschI, Jairo OtheroI, Jefferson PivaI, Newton Brandão da SilvaI, Nara AzeredoI, Raphaella RopelatoI

IAssociação de Medicina Intensiva Brasileira - AMIB - Brazil
IISociedade Uruguaia de Medicina Intensiva - SUMI - Uruguay
IIISociedade Argentina de Terapia Intensiva - SATI - Argentina

Conflicts of interest: None.

Submitted on November 15, 2010
Accepted on December 16, 2010

Corresponding author:

Patricia Miranda Lago
Rua Furriel Luis Vargas 238/238
Zip Code: 90470-130 - Porto Alegre (RS), Brazil
E-mail: [email protected]



Palliative care is aimed to improvethe quality of life of both patients andtheir family members during the courseof life-threatening diseases throughthe prevention, early identificationand treatment of the symptoms ofphysical, psychological, spiritual andsocial suffering. Palliative care shouldbe provided to every critically illpatient; this requirement renders thetraining of intensive care practitionersand education initiatives fundamental.Continuing the Technical Councilon End of Life and Palliative Care ofthe Brazilian Association of IntensiveMedicine activities and consideringpreviously established concepts, the IIºForum of the End of Life Study Groupof the Southern Cone of Americawas conducted in October 2010. Theforum aimed to develop palliativecare recommendations for critically illpatients.

Keywords: Hospice care; Intensivecare units; Critical illness




Although intensive care units (ICUs) are intended to manage potentially recoverable clinically unstable patients, many ICU patients eventually die from multiple organ failure. In addition, some patients with chronic-degenerative diseases are admitted to ICU due to acute intercurrences of their underlying diseases. This raises ethical issues related to both the appropriate care of terminal critically ill patients and to resource allocation policies. In 2009, aiming to optimize the care of terminal critically ill patients, members of the Argentinean, Uruguayan and Brazilian Intensive Care Associations developed a algorithm (Figure 1).(1)

Although most patients and their family members say that interdisciplinary cooperation is essential for appropriate end-of-life care, treatment decisions are, mostly, made by physicians in a paternalist doctor-patient relationship model. Cultural aspects influence these decision-making processes.(2) However, more debate on this subject is being stimulated, with growing importance attributed to the patient's autonomy, from a legal (Brazilian Civil Code, article 15), ethical(3) or practical/cultural(4,5) point of view; pre-established concepts therefore become dynamic. This statement is corroborated by the recent Brazilian Medical Ethics Code changes.(3) Its last review states, as fundamental principle XXI, "For professional decision-making processes, respecting his/her own dictates of conscience and legal injunctions, the physician shall accept the patient's expressed diagnostic and therapeutic choices, since appropriate to the case and scientifically acknowledged," and principle XXII: "In irreversible and terminal circumstances, the doctor should refrain from conducting unnecessary diagnostic and therapeutic measures, and provide every appropriate palliative care to his/her patients." Additionally, in chapter V, with respect to the medical relationship with patients and family members, Article 41 says that a doctor should not "Abbreviate the patient's life, even if requested by the patient him/herself or his/her legal representative," adding, "In cases of incurable and terminal disease, the doctor should provide all available palliative care, and refrain from useless or obstinate diagnostic or therapeutic measures, always considering the expressed patient's will or, if incapable, his/her legal representative's."(3) Article 15 of the new Brazilian Civil Code states that "nobody can be constrained to undergo to life-threatening medical therapy or surgical intervention." As a consequence, it is clear that physicians must inform their patients of treatment risks and of their disease course and consequences. Therefore, the patient is entitled to refuse a treatment, choosing the risk of dying from the disease instead of the risk of dying from the therapy.

There is evidence that the way in which family members are given information about ICU end-of-life conditions influences decision-making, satisfaction, conflict resolution, and family members' health for up to 90 days after the patient's death.(6-8) For both ICS and non-ICU patients, communication about life-limiting diseases and therapy should not be associated with stress but with the reduction of the use of futile treatments and consequently improved quality of life and the conservation of health care resources.(9)

The World Health Organization describes palliative care as an approach aimed to improve the quality of life in patients with life-threatening conditions and for their family members through the early prevention and treatment of the symptoms of physical, psychological, spiritual and social suffering.(10) The main treatment focus is the patient's quality of life. During the 1990s, palliative care focused only on end-of-life care. However, since 2002, this definition was extended, and the current trend is that all patients with life-threatening diseases receive early and integrated curative and palliative care, with its intensity customized according to the patients and family members' needs and wishes (Figure 2).(11) These modalities of care are not incompatible and may complement the patient and family members' care in life-threatening situations. The main question for the assisting team, the patient and family members is not "if" the patient is a candidate for palliative care but the treatment priority, either cure or comfort and quality of life. For this, both biological (disease severity, prognosis and available therapies) and ethical (e.g., autonomy and beneficence balance) issues, in addition to personal or cultural aspects (e.g., death-related values and preferences or willingness to participate in the decision-making process). In the ICU, the importance of the integration of palliative and curative care, starting from admission, is increasingly emphasized, aiming to provide better quality care.(1,9-15) It should be emphasized that in outpatients, early palliative care integrated with disease-modifying therapies are associated both with better quality of life and higher survival rates.(16)

Progressively more targets are being identified to reduce the ethical tensions associated with terminal illnesses, with special emphasis on comfort-aimed therapy. Promotion of better communication and ICU palliative care knowledge may prevent conflicts and improve therapy for critically ill patients. The respect of the patients' and families' social-cultural values, the evaluation of the ethical and practical consequences of the refusal or suspension of futile therapies and the administration of sedation/analgesia and non-pharmacological therapies are advised to reduce the suffering of all parties.(9,10,14,17) The ability and the education and training of the ICU palliative care professionals to reduce the length of stay and improve the quality of provided care are not doubted.(9) Different models were proposed to improve ICU palliative care. Two of them should be emphasized: integrative, aimed to incorporate palliative care and interventions into the daily practice of intensive care practitioners, and consulting, involving consultations with palliative care teams and including these practices in regular ICU care.(15) Again, we emphasize that care should be provided to every single ICU patient and his/her family members.



Proceeding with the Technical Council of End of Life and Palliative Care of the Brazilian Association of Intensive Medicine (AMIB) plans and considering the previously established concepts and the need for the palliative care of all critically ill patients, the II Forum of the End of Life Study Group of the Southern Cone of America was conducted. This forum aimed to develop recommendations for palliative care for critically ill patients.

The Forum was held during the XV Brazilian Intensive Care Medicine Congress, on October 15, 2010, in Brasilia, DF, Brazil. Members of the Intensive Care Medicine Societies of Brazil (AMIB), Uruguay (SUMI) and Argentina (SATI) were involved. Participated: Alberto Deicas (physician/SUMI), Daniel Neves Forte (physician/AMIB), Jairo Othero (physician/AMIB), Jefferson Piva (physician/AMIB), Mônica Capalbo (physician/SATI), Newton Brandão (physician/AMIB), Lara Patrícia Kretzer (physician/AMIB), Nara Azeredo (nurse/AMIB), Patrícia Lago (physician/AMIB), Rachel Duarte Moritz (physician/AMIB), Raphaella Ropelato (psychologist/AMIB) and Raquel Pusch (psychologist/AMIB).

Based on the literature, the Forum members made recommendations and suggested integrated actions to provide palliative care for critically ill patients (Charts 1, 2 and 3). In addition, an ICU palliative care flowchart was proposed (Figure 3).



Palliative care should be included in good ICU practices, both for adults and for children. Aiming to improve the care of critically ill patients, recommendations focused on the qualifications of medical and multidisciplinary teams were developed.



1. Curtis JR, Vincent JL. Ethics and end-of-life care for adults in the intensive care unit. Lancet. 2010;376(9749):1347-53.

2. Moritz RD, Lago PM, Deicas A, Nilson C, Machado FO, Othero J, et al. 1o Forum do Grupo de Estudos do Fim da Vida do Cone Sul: proposta para atendimento do paciente portador de doença terminal internado em UTI. Rev Bras Ter Intensiva. 2009;21(3):306-9.

3. Conselho Federal de Medicina. Código de Ética Médica. Disponível em:

4. Moritz RD, Pamplona F. Avaliação da recusa ou suspensão de tratamentos considerados fúteis ou inúteis em UTI. Rev Bras Ter Intensiva. 2003;15(1):40-4.

5. J, Lago P, Othero J, Garcia PC, Fiori R, Fiori H, et al. Evaluating end of life practices in ten Brazilian paediatric and adult intensive care units. J Med Ethics. 2010;36(6):344-8.

6. McDonagh JR, Elliott TB, Engelberg RA, Treece PD, Shannon SE, Rubenfeld GD, Patrick DL, Curtis JR. Family satisfaction with family conferences about end-oflife care in the intensive care unit: increased proportion of family speech is associated with increased satisfaction. Crit Care Med. 2004;32(7):1484-8.

7. Azoulay E, Pochard F, Kentish-Barnes N, Chevret S, Aboab J, Adrie C, Annane D, Bleichner G, Bollaert PE, Darmon M, Fassier T, Galliot R, Garrouste-Orgeas M, Goulenok C, Goldgran-Toledano D, Hayon J, Jourdain M, Kaidomar M, Laplace C, Larché J, Liotier J, Papazian L, Poisson C, Reignier J, Saidi F, Schlemmer B; FAMIREA Study Group. Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med. 2005;171(9):987-94.

8. Lautrette A, Darmon M, Megarbane B, Joly LM, Chevret S, Adrie C, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med. 2007;356(5):469-78. Erratum in: N Engl J Med. 2007;357(2):203.

9. Kuschner WG, Gruenewald DA, Clum N, Beal A, Ezeji-Okoye SC. Implementation of ICU palliative care guidelines and procedures: a quality improvement initiative following an investigation of alleged euthanasia. Chest. 2009;135(1):26-32.

10. World Health Organization. WHO definition of palliative care, 2005. [cited 2010 Jan 12]. Available at:

11. Lanken PN, Terry PB, Delisser HM, Fahy BF, Hansen- Flaschen J, Heffner JE, Levy M, Mularski RA, Osborne ML, Prendergast TJ, Rocker G, Sibbald WJ, Wilfond B, Yankaskas JR; ATS End-of-Life Care Task Force. An Official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med. 2008;177(8):912-27.

12. Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, Rushton CH, Kaufman DC; American Academy of Critical Care Medicine. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine. Crit Care Med. 2008;36(3):953-63. Erratum in: Crit Care Med. 2008;36(5):1699.

13. Curtis JR, Treece PD, Nielsen EL, Downey L, Shannon SE, Braungardt T, et al. Integrating palliative and critical care: evaluation of a quality-improvement intervention. Am J Respir Crit Care Med. 2008;178(3):269-75.

14. Mularski RA. Defining and measuring quality palliative and end-of-life care in the intensive care unit. Crit Care Med 2006;34(11 Suppl):S309-16.

15. Nelson JE, Bassett R, Boss RD, Brasel KJ, Campbell ML, Cortez TB, Curtis JR, Lustbader DR, Mulkerin C, Puntillo KA, Ray DE, Weissman DE; Improve Palliative Care in the Intensive Care Unit Project. Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL-ICU Project (Improving Palliative Care in the ICU). Crit Care Med. 2010;38(9):1765-72.

16. Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-42

17. Carlet J, Thijs LG, Antonelli M, Cassell J, Cox P, Hill N, et al. Challenges in end-of-life care in the ICU. Statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003. Intensive Care Med. 2004;30(5):770-84. Review.



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