Limitação de suporte de vida em três unidades de terapia intensiva pediátrica do sul do Brasil

Abstract

Objectives: To describe causes of death and factors involved in the decision-making process related to life support limitation at three university-affiliated pediatric intensive care units in the south of Brazil.Methods: A retrospective study was conducted, based on a review of the medical records of all deaths occurring during 2002 at three pediatric intensive care units in Porto Alegre. Three previously trained pediatric fellows from each service performed the study. Data were assessed relating to general case characteristics, causes of death (failed cardiopulmonary resuscitation, brain death, do-not-resuscitate orders, withholding or withdrawing lifesustaining treatment -the last three modes were classified as the life support limitation group), length of stay in hospital, end-of-life plans and the participation of patients families and Ethics Committees. The Student t test, Mann Whitney, chi-square, odds ratio and multivariate analyses were used for comparisons.Results: Close to 53.3% of fatal cases had received full cardiopulmonary resuscitation. The incidence of life support limitation was 36%, with statistical differences (p = 0.014) between the three hospitals (25 versus 54.3 and 45.5%, respectively). The most frequent form of life support limitation was a do-not-resuscitate order (70%). Life support limitation was associated with the presence of chronic disease (odds ratio = 8.2; 95%CI 3.2-21.3) and length stay in the pediatric intensive care unit (odds ratio = 4.4; 95%CI 1.6-11.8). The rate of involvement of families and Ethics Committees in the decision-making process was lesser than 10%.Conclusions: Cardiopulmonary resuscitation is offered more frequently than is observed in northern countries. In contrast, life support limitation is offered through do-not-resuscitate orders. These findings and the low participation of the families in the decision-making process reflect the difficulties to be overcome by those professionals who are responsible for handling critically ill children in southern Brazil.J Pediatr (Rio J). 2005;81(2):111-7: Death, ethics, pediatric intensive care, forgoing life support, do-notresuscitate orders.

Morte encefálica: condutas médicas adotadas em sete unidades de tratamento intensivo pediátrico brasileiras

“…6,7,9 Few studies have been published on BD in children. [10][11][12] We believe that, in Brazil, just as in other countries, medical management regarding BD is not uniform, with regional discrepancies. The aim of this study is to assess the reality of BD in Brazilian pediatric intensive care units (PICU), its incidence, adherence to the protocol established by the CFM and the management used in the PICUs of three Brazilian regions.…”

Limitação do suporte de vida em unidade de terapia intensiva pediátrica

“…Em paralelo, considerando a alta taxa de óbitos nas primeiras 24 horas de admissão (22%), situação também descrita em outros estudos realizados no Brasil 14,16 , parece que este fato decorre do retardo no encaminhamento das crianças para o atendimento nos hospitais terciários, o que reflete o insatisfató-rio fluxo do sistema de referência/contrarreferência vigente no país ou, em outras palavras, confirma a inexistência de efetiva comunicação entre as unidades básicas de saúde e as demais instâncias da rede pública de saúde 27 . Outrossim, o fato de 32 dos 33 pacientes que morreram nas primeiras 24 horas terem sido submetidos às manobras de RCR quando de suas admissões parece indicar que os profissionais executaram o procedimento por desconhecerem o diagnóstico da doença de base daquelas crianças e as consideraram passíveis de recuperação.…”

“…As variáveis contínuas foram representadas pela média e dispersão, e as que apresentavam valores atípicos foram apresentadas pela mediana e intervalos interquartis. As variáveis qualitativas foram 16,19 .…”

“…As prováveis condições que justificam essa diferença incluem fatores de natureza socioculturais, religiosas e, até mesmo, as experiências pessoais vividas por membros da equipe médica 24,25 . É importante ressaltar que as manobras de RCR realizadas a partir dos anos 1960 foram originalmente propostas para o atendimento específico de casos de morte súbita, situação diversa dos casos do presente estudo, que teve como sujeitos da pesquisa crianças portadoras de doenças crônicas que apresentaram parada cardiocirculatória como decorrência previsível da evolução natural de suas enfermidades de base 16 .…”

Morte digna da criança: percepção de enfermeiros de uma unidade de oncologia

“…However, in many cases, these advances prolong the dying process at the expense of addi onal suff ering for the pa ent and his or her family (3) .…”