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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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Piva JP, Soares M. Cuidados de final de vida nas UTIs brasileiras, certamente não é apenas uma questão legal: treinamento e conhecimento adequados são essenciais para melhorar estes cuidados. Rev Bras Ter Intensiva. 2011;23(4):388-390




End-of-life care in Brazilian ICUs is not just a legal issue: adequate training and knowledge are essential to improve care

Cuidados de final de vida nas UTIs brasileiras, certamente não é apenas uma questão legal: treinamento e conhecimento adequados são essenciais para melhorar estes cuidados

Jefferson Pedro Piva, Márcio Soares

IDepartment of Pediatrics, Hospital de Clínicas de Porto Alegre, School of Medicine, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS), Brazil
IIPediatric Intensive Care Unit, Hospital São Lucas, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS - Porto Alegre (RS), Brazil
IIID'Or Institute for Research and Education - IDOR - Rio de Janeiro (RJ), Brazil
IVPostgraduate Program, Instituto Nacional de Câncer - INCA - Rio de Janeiro (RJ), Brazil

Conflicts of interest: None.

Financial support: Dr. Soares and Dr. Piva are supported in part by individual research grants from the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).

Corresponding author:

Jefferson Pedro Piva
UTI Pediátrica - Hospital São Lucas da PUCRS
Av. Ipiranga 6690 - 5º andar - Jardim Botânico
Zip Code: 90640-002 - Porto Alegre (RS) - Brasil
E-mail: [email protected]



Over the last three decades, end-of-life (EOL) decisions have become a frequent and challenging issue in intensive care units (ICUs) worldwide. Patients with severe, progressive and terminal diseases frequently require ICU admission. In these cases, the ICU staff is faced with medical, moral and ethical decisions involving (sometimes) opposed strategies, such as (a) pursuing an improbable cure that might just prolong the process of dying or (b) recognizing that the patient's condition is terminal and electing to provide palliative care while avoiding aggressive treatment. The EOL decision-making process and the consequent choice of strategy vary around the world, depending on several factors: cultural aspects, religious beliefs, legal burdens, ethical and moral values and medical knowledge regarding terminal diseases and palliative care.(1-5)

There are two common models for EOL decisions. The first is the shared model, in which the physicians (ICU staff) and patients (along with their families) achieve a consensus regarding the diagnosis, prognosis (whether the condition is terminal) and treatment to be delivered. In this model, the medical perspective (centered on principles of beneficence and non-maleficence) is counterbalanced with the desires and autonomy of the patient (or the family). Sometimes physicians express their concern regarding the final decision in this process because they feel obligated to deliver a treatment that they do not completely support, but even in this case, they provide the chosen treatment out of respect for the decision of the patient. A second model is the paternalistic model, in which the physicians (ICU staff) use their medical perspective to guide the patients (and family) toward the final decision. Obviously, this model carries an intrinsic and strong bias because the perspective of the physician might be influenced by factors than go beyond medical issues, such as cultural and moral values that might diverge from the values of the patient. In these situations, it is highly recommended that the medical perspective be shared with other members of the ICU staff, and in particular, the nurses should be included in the decision-making process.(1-3,6)

As a result of the cultural characteristics of certain countries (e.g., France, Italy, Brazil and India), the paternalistic approach has been the preferred model for EOL decisions.(1-3) The paternalistic model assumes that the physician will propose a decision considering the best interests of the patient.(6) However, Brazilian studies have demonstrated that this model, centered on the medical perspective, is far from what the paternalistic model actually entails. Because of legal fears, a lack of knowledge and a lack of training on the ethical aspects of EOL care, Brazilian physicians frequently provide full curative treatment to terminally ill patients up to the last moments of life, with do not resuscitate orders (DNR) being the most frequent LSLT.(7-10) The patient's participation (or that of the family) and nurse's involvement in the Brazilian ICU EOL decision-making process are scarce, even in cases involving children with terminal diseases.(7-11) Legal fear has been cited as the most important reason for this peculiar Brazilian medical behavior regarding EOL decisions.(9,12)

Recently, Forte et al. published the results of a questionnaire submitted to 105 Brazilian ICU physicians selected from 11 university-affiliated ICUs, evaluating EOL decisions involving a fictitious, severely brain damaged patient.(13) The results reinforce two important points: a) legal fears still impact the EOL decisions of Brazilian physicians and b) ethical knowledge has a positive effect on the EOL decision-making process. Moreover, ICU physicians who regularly read about ethical issues were more likely to involve family and nurses in the EOL process, as well as assume pro-active decisions.(13) Additionally, many interventions, including ethics and palliative care consultations, intensive communication strategies, formal family conferences combined with the bereavement brochure were able to improve the quality of EOL care by reducing the length of stay and the use of inappropriate ICU resources, preventing conflicts and minimizing the psychological burden on family members.(14-17)

In this issue of RBTI an article by Santos and Bassit describes the expectations of families of patients saying for a long time in a hospital (+ 30 days), 17% of this time in the ICU. Although 53% of the patients had discussed with their families the possibility of limitation of life support, 76% of them had never discussed this issue with their physicians!(18) Even when patients and families are prone to discuss of limitation of life support in terminal and irreversible diseases, medical teams are failing to create appropriate conditions for a consensual decision.

Lawyers, judges, prosecutors and the Brazilian Medical Council have been involved in a long discussion regarding the legal aspects of EOL decisions. Finally in 2010, two issues were finalized (at least for a while) regarding this discussion. First, a new Medical Ethics Code was created; this code repeatedly mentions the need and ethical duty of the physician to provide palliative care to patients suffering from incurable and terminal illness and to avoid therapeutic obstinacy by always taking into consideration the wishes of the patient or, failing that, his legal representative. Moreover, any breach of these guidelines represents a violation of the Brazilian Medical Ethics Code.(19) Second, in August 2010, the Brazilian Court rejected a motion proposing that physicians should not be allowed to provide life support limitations to terminally ill patient. The court decided that EOL decisions involving terminal ill patients are a medical matter and should not be treated as violations of the Brazilian Civil Code.

Abstracting the legal aspects of this complicated scenario, physicians are now able to concentrate their attention on providing the best care to their patients. There is no doubt that palliative care should be prioritized for the terminal ill patient above curative measures. However, Forte, Santos and Bassit, and from other groups have demonstrated that an emphasis should be made on medical education.(13-18) Physicians who have more extensive knowledge of ethical issues and who are well trained on the various aspects of EOL care are more likely to involve nurses and families in the EOL decision-making process; in addition, their decisions are more frequently in agreement with what they believe is in the best interest of their patients.(13) In other worlds, the lack of knowledge and training impairs the ability of physicians to provide the best care to ICU patients.



1. Devictor D, Nguyen D. Forgoing life-sustaining treatments in children: a comparison between Northern and Southern European pediatric intensive care units. Pediatr Crit Care Med. 2004;5(3):211-5.

2. Lago PM, Devictor D, Piva JP, Bergounioux J. End-of-life care in children: the Brazilian and the international perspectives. J Pediatr (Rio J). 2007;83(2 Suppl):S109-16.

3. Devictor D, Latour JM, Tissières P. Forgoing life-sustaining or death-prolonging therapy in the pediatric ICU. Pediatr Clin N Am. 2008;55(3):791-804, xiii.

4. Truog RD, Meyer EC, Burns JP. Toward interventions to improve end-of-life care in the pediatric intensive care unit. Crit Care Med. 2006;34(11 Suppl):S373-9. Review.

5. 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.

6. Rodriguez-Osorio CA, Dominguez-Cherit G. Medical decision making: paternalism versus patient-centered (autonomous) care. Curr Opin Crit Care. 2008;14(6):708-13.

7. Kipper DJ, Piva JP, Garcia PC, Einloft PR, Bruno F, Lago P, et al. Evolution of the medical practices and modes of death on pediatric intensive care units in southern Brazil. Pediatr Crit Care Med. 2005;6(3):258-63.

8. Lago PM, Piva J, Kipper D, Garcia PC, Pretto C, Giongo M, et al. Life support limitation at three pediatric intensive care units in southern Brazil. J Pediatr (Rio J). 2005;81(2):111-7.

9. Piva 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.

10. Lago PM, Piva J, Garcia PC, Troster E, Bousso A, Sarno MO, Torreão L, Sapolnik R; Brazilian Pediatric Center of Studies on Ethics. End-of-life practices in seven Brazilian pediatric intensive care units. Pediatr Crit Care Med. 2008;9(1):26-31.

11. Lago PM, Nilson C, Pedro Piva J, Vieira AC, Halal MG, de Carvalho Abib GM, Garcia PC. Nurses' participation in the end-of-life process in two paediatric intensive care units in Brazil. Int J Palliat Nurs. 2011;17(6):264, 267-70.

12. Soares M, Terzi RG, Piva JP. End-of-life care in Brazil. Intensive Care Med. 2007;33(6):1014-7.

13. Forte DN, Vincent JL, Velasco IT, Park M. Association between education in EOL care and variability practice: a survey of ICU physicians. Intensive Care Med. 2011, In Press. DOI 10.1007/s00134-011-2400-4.

14. Lilly CM, De Meo DL, Sonna LA, Haley KJ, Massaro AF, Wallace RF, Cody S. An intensive communication intervention for the critically ill. Am J Med. 2000;109(6):469-75.

15. Schneiderman LJ, Gilmer T, Teetzel HD, Dugan DO, Blustein J, Cranford R, et al. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: a randomized controlled trial. JAMA. 2003;290(9):1166-72.

16. Campbell ML, Guzman JA. Impact of a proactive approach to improve end-of-life care in a medical ICU. Chest. 2003;123(1):266-71.

17. 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.

18. Santos MFG, Bassitt DP. Terminalidade da vida em terapia intensiva: posicionamento dos familiares sobre ortotanásia. Rev Bras Ter Intensiva. 2011;23(4):448-54.

19. Conselho Federal de Medicina. Novo Código de Ética Medica (2010) Accessed sept 1st, 2011.



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