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Abstract Background This study aimed to determine the proportion of organ donors suitable for donation after circulatory death and investigate the current process followed by critical care physicians for declaring circulatory death to establish organ donation. Methods This observational study involved potential organ donors who had recently died after discontinuation of life support. We conducted an online survey of intensivists to determine how these deaths were confirmed. Results Among the 177 patients who died after withdrawal of life-sustaining treatment across 19 intensive care units in 11 institutions, 49 (27.7%) were considered potential donors. According to general medical criteria for organ donation, 20 (11.3%) patients were identified as medically suitable donors. Notably, 116 (73.9%) patients exhibited a flat electrocardiogram within 5 min after the loss of pulse. In the survey, 90 physicians (59.2%) agreed to implement the concept of the 5-min no-touch period for the declaration of circulatory death. Conclusions This study found that 11.3% of the patients who died following the withdrawal of life-sustaining treatment in the intensive care units were identified as suitable donors after circulatory death. Most of critical care physicians agree with the concept of a 5-min no-touch period for the declaration of circulatory death.

Abstract Purpose To develop an ethical and cultural infrastructure for Life-Sustaining Treatment (LST) plan, it is crucial to carefully analyze its impact and ensure that healthcare utilization is maintained at an appropriate level, avoiding excessive medical interventions. This study aims to investigate the effects of LST decisions on both healthcare expenditure and utilization. Methods This cohort study utilized claims data from the National Health Insurance Service, encompassing all medical claims in South Korea. We included individuals who had planned to withdraw or withhold their LST between January and December 2018, identified by claim code IA71, IA72, IA73. We followed a total of 28,295 participants with documented LST plan who were deceased by June 2020. Participants were categorized into LST withdrawal / withholding and LST continuation groups. The dependent variables were healthcare expenditure and utilization. We construct a generalized linear model to analyze the association between these variables. Results Out of the 28,295 participants, 24,436 (86.4%) chose to withdraw or withhold LST, while the rest opted for its continuation. Compared to the LST continuation group, those who chose to withdraw or withhold LST had 0.91 times lower odds for total cost. Additionally, they experienced 0.91 times fewer hospitalization days and 0.92 times fewer outpatient visits than those in the LST continuation group. Conclusion Healthcare expenditure and utilization deceased among those choosing to withdraw or withhold LST compared to those continuing it. These findings underscore the significance of patients actively participating in decision regarding their treatment to ensure appropriate levels of medical intervention for LST. Furthermore, they emphasize the critical role of proper education and the establishment of a cultural framework for LST plans.

Abstract Background Although the Life-Sustaining Treatment (LST) Decision Act was enforced in 2018 in Korea, data on whether it is well established in actual clinical settings are limited. Hospital-acquired pneumonia (HAP) is a common nosocomial infection with high mortality. However, there are limited data on the end-of-life (EOL) decision of patients with HAP. Therefore, we aimed to examine clinical characteristics and outcomes according to the EOL decision for patients with HAP. Methods This multicenter study enrolled patients with HAP at 16 referral hospitals retrospectively from January to December 2019. EOL decisions included do-not-resuscitate (DNR), withholding of LST, and withdrawal of LST. Descriptive and Kaplan–Meier curve analyses for survival were performed. Results Of 1,131 patients with HAP, 283 deceased patients with EOL decisions (105 cases of DNR, 108 cases of withholding of LST, and 70 cases of withdrawal of LST) were analyzed. The median age was 74 (IQR 63–81) years. The prevalence of solid malignant tumors was high (32.4% vs. 46.3% vs. 54.3%, P = 0.011), and the ICU admission rate was lower (42.9% vs. 35.2% vs. 24.3%, P = 0.042) in the withdrawal group. The prevalence of multidrug-resistant pathogens, impaired consciousness, and cough was significantly lower in the withdrawal group. Kaplan–Meier curve analysis revealed that 30-day and 60-day survival rates were higher in the withdrawal group than in the DNR and withholding groups (log-rank P = 0.021 and 0.018). The survival of the withdrawal group was markedly decreased after 40 days; thus, the withdrawal decision was made around this time. Among patients aged below 80 years, the rates of EOL decisions were not different (P = 0.430); however, mong patients aged over 80 years, the rate of withdrawal was significantly lower than that of DNR and withholding (P = 0.001). Conclusions After the LST Decision Act was enforced in Korea, a DNR order was still common in EOL decisions. Baseline characteristics and outcomes were similar between the DNR and withholding groups; however, differences were observed in the withdrawal group. Withdrawal decisions seemed to be made at the late stage of dying. Therefore, advance care planning for patients with HAP is needed.

Objective: Literature shows high in-hospital mortality rates following end-of-life decisions in patients with traumatic spinal cord injury. This study investigated 2-year mortality and end-of-life decisions in patients with traumatic spinal cord injury. Design: Explorative retrospective study in a Dutch level 1 trauma centre. Patients: All consecutive patients between 2015 and 2020 with new traumatic spinal cord injury were selected from the trauma registry. Patients were excluded if myelopathy, cauda equina, or conus medullaris injury was absent or if they were referred to another level 1 trauma centre. Methods: Mortality and end-of-life decisions (i.e. withdrawal and withholding of treatment, and euthanasia) within 2 years were analysed. Demographics, injury and clinical characteristics, and hospital treatment outcomes were compared with survivors. Motivations and critical morbidities concerning end-of-life decisions were assessed. Results: The sample included 219 patients. Two-year mortality was 26% (n = 56), in-hospital mortality was 16%. The deceased were older, had more comorbidities and more severe injuries. end-of-life decisions concerned 42 patients (75%), mostly motivated by loss of independence or poor outcomes. Three patients received euthanasia (5%). The largest group with end-of-life decisions also sustained moderate-severe traumatic brain injuries (n = 11; 26%). Conclusion: Most patients with traumatic spinal cord injury died following an end-of-life decision, with the largest group sustaining concomitant traumatic brain injuries. The incidence of euthanasia was low.

Ethical dilemmas in nursing are most pronounced in palliative and end-of-life care, where we meet the most demanding and complex needs of nursing care. The research discusses the importance of ethics, religion and spirituality in palliative care, from the perspective of three monotheistic religions and the emphasis on end-of-life ethical dilemmas and how religious beliefs can affect end-of-life medical care and nursing. The importance of ethics, religion and spirituality is presented in the research within three basic ethical principles, such as withholding and withdrawal of treatment, unjustified treatment and treatment with palliative sedation, and tried to justify its assessment in light of Jewish, Catholic and Islamic perspectives.

Background The Life-Sustaining Treatment (LST) Decisions Act allows withholding and withdrawal of LST, including cardiopulmonary resuscitation (CPR). In the present study, the incidence of CPR before and after implementation of the Act was compared. Methods This was a retrospective review involving hospitalized patients who underwent CPR at a single center between February 2016 and January 2020 (pre-implementation period, February 2016 to January 2018; post-implementation period, February 2018 to January 2020). The primary outcome was monthly incidence of CPR per 1,000 admissions. The secondary outcomes were duration of CPR, return of spontaneous circulation (ROSC) rate, 24-hour survival rate, and survival-to-discharge rate. The study outcomes were compared before and after implementation of the Act. Results A total of 867 patients who underwent CPR was included in the analysis. The incidence of CPR per 1,000 admissions showed no significant difference before and after implementation of the Act (3.02±0.68 vs. 2.81±0.75, P=0.255). The ROSC rate (67.20±0.11 vs. 70.99±0.12, P=0.008) and survival to discharge rate (20.24±0.09 vs. 22.40±0.12, P=0.029) were higher after implementation of the Act than before implementation. Conclusions The incidence of CPR did not significantly change for 2 years after implementation of the Act. Further studies are needed to assess the changes in trends in the decisions of CPR and other LSTs in real-world practice.

Abstract Background The death rate in intensive care units (ICUs) can reach 20%. More than half occurs after a decision of care withholding/withdrawal. We aimed at describing and evaluating the experience of ICU physicians and nurses involved in the end-of-life (EOL) procedure. Primary objective was the evaluation of the experience of EOL assessed by the CAESAR questionnaire. Secondary objectives were to describe factors associated with a low or high score and to examine the association between Numeric Analogic Scale and quality of EOL. Methods Consecutive adult patients deceased in 52 ICUs were included between April and June 2018. Characteristics of patients and caregivers, therapeutics and care involved after withdrawal were recorded. CAESAR score included 15 items, rated from 1 (traumatic experience) to 5 (comforting experience). The sum was rated from 15 to 75 (the highest, the best experience). Numeric Analogic Scale was rated from 0 (worst EOL) to 10 (optimal EOL). Results Five hundred and ten patients were included, 403 underwent decision of care withholding/withdrawal, and among them 362 underwent effective care withdrawal. Among the 510 patients, mean CAESAR score was 55/75 (± 6) for nurses and 62/75 (± 5) for physicians (P

Background/Aims: Our study aimed to evaluate the long-term outcomes and risk factors for relapse after anti-tumor necrosis factor (TNF)-α cessation in inflammatory bowel disease (IBD) patients because they are not well established. Methods: A retrospective multicenter cohort study was conducted involving patients with Crohn’s disease (CD) or ulcerative colitis (UC) from 10 referral hospitals in Korea who discontinued firstline anti-TNF therapy after achieving clinical remission. Results: A total of 109 IBD patients (71 CD and 38 UC) with a median follow-up duration of 56 months were analyzed. The cumulative relapse rates at 1, 3, and 5 years were 11.3%, 46.7%, and 62.5% for CD patients and 28.9%, 45.3%, and 60.9% for UC patients. Multivariable Cox analysis revealed that discontinuation owing to the clinician’s decision was associated with lower risk of relapse (vs patient’s preference: hazard ratio [HR], 0.13; 95% confidence interval [CI], 0.04 to 0.48; p=0.002) and adalimumab use was associated with higher risk of relapse (vs infliximab: HR, 4.42; 95% CI, 1.24 to 17.74; p=0.022) in CD patients. Mucosal healing was associated with lower risk of relapse (vs nonmucosal healing: HR, 0.12; 95% CI, 0.02 to 0.83; p=0.031) in UC patients. Anti-TNF re-induction was provided to 52 patients, and a response was obtained in 50 patients. However, 25 of them discontinued retreatment owing to a loss of response (n=15), the patient’s preference (n=6), and other factors (n=4). Conclusions: More than 60% of IBD patients in remission under anti-TNF therapy relapsed within 5 years of treatment cessation. Anti-TNF re-induction was effective. However, half of the patients discontinued anti-TNF therapy, and 50% of these patients discontinued treatment owing to loss of response.

Few data exist regarding steroid withdrawal in ABO-incompatible (ABO-i) kidney transplantation (KT). Here, we report a case of steroid withdrawal after ABO-i KT. A 46-year-old man diagnosed with Henoch-Schonlein purpura received ABO-i KT from his 42-year-old sister. The recipient and donor blood types were O and AB, respectively. His preoperative ABO antibody titers were anti-A of 1:16 and anti-B of 1:8 in isoagglutinin test. HLA mismatch was 0 and he received a single 325 mg/m2 dose of intravenous (IV) rituximab 4 weeks before KT. Three sessions of plasma exchange were undertaken before KT and low-dose IV immunoglobulin of 0.1 g/kg was administered after plasma exchange. On the day of the operation, ABO antibody titer decreased to anti-A of 1:4 and anti-B of 1:2. Renal function remained stable after KT. The patient wished to stop steroid treatment despite the risk of rejection after withdrawal. Steroid tapering was initiated at 20 months and accomplished at 26 months after KT. At that time, serum creatinine level was 1.13 mg/dL, and anti-A and anti-B titers were 1:8 and 1:2, respectively. No issues were observed after steroid withdrawal. At 48 months after KT, serum creatinine level was 1.21 mg/dL, and anti-A and anti-B antibody titers were 1:32 and 1:2, respectively. Steroid withdrawal in ABO-i KT might be considered in immunologically low-risk patients.

Abstract Background The purpose of this paper is to describe how end-of-life care is managed when life-support limitation is decided in a Pediatric Intensive Care Unit and to analyze the influence of the further development of the Palliative Care Unit. Methods A 15-year retrospective study of children who died after life-support limitation was initiated in a pediatric intensive care unit. Patients were divided into two groups, pre- and post-palliative care unit development. Epidemiological and clinical data, the decision-making process, and the approach were analyzed. Data was obtained from patient medical records. Results One hundred seventy-five patients were included. The main reason for admission was respiratory failure (86/175). A previous pathology was present in 152 patients (61/152 were neurological issues). The medical team and family participated together in the decision-making in 145 cases (82.8%). The family made the request in 10 cases (9 vs. 1, p = 0.019). Withdrawal was the main life-support limitation (113/175), followed by withholding life-sustaining treatments (37/175). Withdrawal was more frequent in the post-palliative group (57.4% vs. 74.3%, p = 0.031). In absolute numbers, respiratory support was the main type of support withdrawn. Conclusions The main cause of life-support limitation was the unfavourable evolution of the underlying pathology. Families were involved in the decision-making process in a high percentage of the cases. The development of the Palliative Care Unit changed life-support limitation in our unit, with differences detected in the type of patient and in the strategy used. Increased confidence among intensivists when providing end-of-life care, and the availability of a Palliative Care Unit may contribute to improvements in the quality of end-of-life care.

Abstract Background Euthanasia can be thought of as being either active or passive; but the precise definition of “passive euthanasia” is not always clear. Though all passive euthanasia involves the withholding of life-sustaining treatment, there would appear to be some disagreement about whether all such withholding should be seen as passive euthanasia. Main text At the core of the disagreement is the question of the importance of an intention to bring about death: must one intend to bring about the death of the patient in order for withholding treatment to count as passive euthanasia, as some sources would indicate, or does withholding in which death is merely foreseen belong to that category? We may expect that this unclarity would be important in medical practice, in law, and in policy. The idea that withholding life-sustaining treatment is passive euthanasia is traced to James Rachels’s arguments, which lend themselves to the claim that passive euthanasia does not require intention to end life. Yet the argument here is that Rachels’s arguments are flawed, and we have good reasons to think that intention is important in understanding the moral nature of actions. As such, we should reject any understanding of passive euthanasia that does not pay attention to intent. Short conclusion James Rachels’s work on active and passive euthanasia has been immensely influential; but this is an influence that we ought to resist.

Objective: End-of-life(EOL) care decision-making for infants and children is a painful experience. The study aimed to explore the clinical factors influencing the EOL care to withhold/withdraw life-sustaining treatment (WLST) in Chinese pediatric intensive care unit (PICU).Methods: A 14-year retrospective study (2006–2019) for pediatric patients who died in PICU was conducted. Based on the mode of death, patients were classified into WLST group (death after WLST) and fCPR group (death after full intervention, including cardiopulmonary resuscitation). Intergroup differences in the epidemiological and clinical factors were determined.Results: There were 715 patients enrolled in this study. Of these patients, 442 (61.8%) died after WLST and 273 (38.2%) died after fCPR. Patients with previous hospitalizations or those who had been transferred from other hospitals more frequently chose WLST than fCPR (both P < 0.01), and the mean PICU stay duration was significantly longer in the WLST group (P < 0.05). WLST patients were more frequently complicated with chronic underlying disease, especially tumor (P < 0.01). Sepsis, diarrhea, and cardiac attack (all P < 0.05) were more frequent causes of death in the fCPR group, whereas tumor as a direct cause of death was more frequently seen in the WLST group. Logistic regression analysis demonstrated that previous hospitalization and underlying diseases diagnosed before admission were strongly associated with EOL care with WLST decision (OR: 1.6; P < 0.05 and OR: 1.6; P < 0.01, respectively).Conclusions: Pediatric patients with previous hospitalization and underlying diseases diagnosed before admission were associated with the EOL care to WLST.

Introduction: Biologic agents acquired a growing relevance in dermatology, however, adverse events (AE) and reasons to discontinue therapy are not completely known. The objective of this study is to analyse the reasons behind the discontinuation of biologics and characterize the AE in this population of patients. Material and Methods: Descriptive observational study, including patients over 18-years-old under treatment with biologic agents in the Dermatology Department of Hospital de Santarém, Portugal, between January/2007 and December/2017. We analysed reasons for therapeutic discontinuation, defined as the omission of at least 2 consecutive administrations, whatever the reason implicated and whether or not proposed by the dermatologist. Results: A total of 262 cycles of treatment were performed, in 138 patients (59.4% male, 40.6% female). Psoriasis was the most prevalent diagnosis (93.5% of the patients). Cycles of treatment with 8 biologic agents were analysed: etanercept (46.6%), adalimumab (31.3%) and ustekinumab (12.6%) were the most represented. During the study period, 167 suspensions were registered, for which 170 justifications were indicated. The most prevalent causes were: primary or secondary therapeutic failure (35,3%), AE (31.2%), factors related to the patient/noncompliance (17.1%), surgical intervention (7.1%) and excellent clinical response/absence of lesions (6.5%). Among therapeutic discontinuations motivated by AE (n=53), infections were the most frequent cause (35.8%, n=19), followed by malignancies (15.1%, n=8), hematological abnormalities (13.2%, n=7), neurological symptoms (9.4%, n=5) and local reactions at the injection site (5.7%, n=3). Discussion: The main cause for discontinuation of biologics was therapeutic failure, immediately followed by AE. Two different patterns of discontinuation were apparent: definitive suspension, commonly decided by the physician due to primary or secondary therapeutic failure, and temporary discontinuation, frequently without formal medical indication, due to AE, later resuming the same drug. We found a higher percentage of therapeutic cycles discontinued due to AE than reported in the literature. Temporary suspensions of the biologics due to AE, often not sufficiently valued by the dermatologist, are probably under-recognized and contribute to a suboptimal pattern of use of biologics and worse clinical outcomes.

Purpose: The purpose of this study was to describe feelings and actions of nurses following withdrawal of life-sustaining treatment from children being cared for by the nurses. Methods: Data were collected by in-depth interviews with 7 nurses from different hospitals where children receiving nursing care had life-sustaining treatment withdrawn. The interviews were conducted from August 2016 to February 2017 when all data were saturated. Interviews lasted 30~90 minutes and were conducted 2~3 times per participant. Data were analyzed using Giorgi’s phenomenological research methodology. Results: The following factors constituted experiences of nurses working in pediatric wards when life-sustaining treatment was withdrawn from children: “agony and conflict in the aspects of care”, “heavy mind and regret for exhausting care”, “intentionally avoiding parents’ sadness”, “comforting sadness in the heart” and “orientation in the role of caring for children undergoing withdrawal of life-sustaining treatment.” Conclusion: Findings indicate that support systems and intervention programs need to be developed so that nurses can understand and wisely deal with experiences of withdrawal of life-sustaining treatment from children who receive care from nurses.

Abstract Background Treatment-limiting decisions (TLD) for severe traumatic brain injury (sTBI) have been sparsely studied. This study determine prevalence, main reason for, categories and timing of TLDs in a Norwegian regional trauma setting. Methods A retrospective study of a 2-year cohort of 579 sTBI patients admitted to Oslo University Hospital (OUH). Prospectively collected data in the OUH Trauma Registry were combined with retrospective data from a chart review regarding TLDs. Results TLDs were documented for 101/579 sTBI patients (17%). The situation was evaluated as futile in 59 cases and as potentially inappropriate in 42 cases. The three most frequent types of TLDs were withholding of neurosurgery, do not resuscitate orders and withdrawing of organ support. In 70% of cases, the first TLD was made within 2 days after injury, while in 14%, the first TLD was made later than day 7. Twenty percent (20/101) of the first TLDs were later adjusted, revoked in 4 patients and broadening of TLDs in 16 patients. The median time from the decision to death was 2 days (range 1–652). TLDs were documented in 93% of in-hospital death cases (n = 79). In-hospital deaths occurred in 73% of TLD group cases and 1% of non-TLD group cases. Family interaction and multi-team discussions were documented in >88% of cases, but no advanced directives were found, and notifications of patients’ preferences were found in only 7% of cases. Discussion Clinicians should consider limiting treatment if continued treatment is not in the patients best interest. A range of different types of TLDs were applied for patients after sTBI in the trauma hospital setting. Conclusion TLDs were found in 17% of sTBI patients. Value considerations behind TLDs in this care context need to be further explored.

The introduction of the anti-tumor necrosis factorα agents (anti-TNFα) in clinical practice has greatly advanced the treatment of inflammatory bowel disease. The use of these medications results in durable remission in a subset of patients, preventing surgery and hospitalizations. However, there are some concerns about safety and costs associated with their long-term use. Therefore, anti-TNF withdrawal has emerged as an important consideration in clinical practice. Herein our goal was to discuss the available evidence about anti-TNFα discontinuation in IBD that could inform the clinician on the expected rates of relapse, the potential predictors of relapse, as well the response to re-treatment.

Background: The goal of this study was to analyze the process and characteristics of withholding or withdrawal of life support (WLS) in Korean intensive care units (ICUs). Methods: This was a single-centered retrospective analysis of patients who died in the ICUs of a tertiary hospital in Korea from January to December 2012. WLS informed consents and clinical data were analyzed. Results: Of 285 deaths during the study period, informed consents for WLS were obtained from 228 patients (80.0%). All WLS decisions were made by family members after the patient’s loss of decision-making capacity. Decisions were made most frequently by the patient’s son (50.6%). Patients in the WLS group were older than those in the non-WLS group, and older age was associated with the WLS decision. Thirty-seven patients (16.2%) died within one hour of WLS approval, and 182 patients (79.8%) died on the day of WLS approval. The most frequently withheld life support modality was chest compression (100%), followed by defibrillation (95.9%) and pacemaker insertion (63.3%). Conclusions: Aggressive and invasive life support measures were those most frequently withheld or withdrawn by decision-makers in Korean ICUs. The most common proxy was the son, rather than the spouse.

In the last few years, important changes have occurred in the clinical and epidemiological characteristics of patients that were admitted to cardiac intensive care units (CICU). Care has shifted from acute coronary syndrome patients towards elderly patients, with a high prevalence of non-ischemic cardiovascular diseases and a high burden of non-cardiovascular comorbid conditions: both increase the susceptibility of patients to developing life-threatening critical conditions. These conditions are associated with a significant symptom burden and mortality rate and an increased length of stay. In this context, palliative care programs, including withholding/withdrawing life support treatments or the deactivation of implanted cardiac devices, are frequently needed, according to the specific guidelines of scientific societies. However, the implementation of these recommendations in clinical practice is still inconsistent. In this review, we analyze the reasons for this gap and the main cultural changes that are required to improve the care of patients with advanced illness.

Withdrawal from dialysis is ethically appropriate for some patients with multiple comorbidities and a shortened life expectancy. Taiwan has the highest prevalence of dialysis patients in the world, and the National Health Insurance (NHI) program offers renal replacement therapy free of charge. In this review, we discuss its current status and many background issues related to withdrawing dialysis from patients with advanced renal failure in Taiwan. Compared with dialysis therapy, the medical resources for hospice care are relatively sparse. Since the announcement of the Statute for Palliative Care in 2000, there has been a gradual improvement in the laws and health polices supporting dialysis withdrawal. Culture and social customs also have a significant impact on the practice of hospice care. Based on current evidence and in accordance with the local environment, we propose recommendations for the clinical practice of dialysis withdrawal and hospice care. There remains a need to expand upon the community-based hospice care and home care systems to better serve patients. In conclusion, there are cross-cultural differences relating to dialysis withdrawal between Taiwan and Western countries. Our experience and clinical recommendations may be helpful for the countries with NHI systems or for the Eastern countries.

FUNDAMENTO: O manejo ideal da anticoagulação oral (ACO) no período pré- e pós-ablação de fibrilação atrial (FA) ainda é motivo de controvérsia. OBJETIVO: Comparar duas estratégias de anticoagulação: suspensão da warfarina com a utilização de heparina de baixo peso molecular (HBPM) e a realização da ablação sem a suspensão da warfarina, mantendo o RNI terapêutico (entre 2,0 e 3,0). MÉTODOS: 140 pacientes (pt) portadores de FA persistente/ permanente submetidos à ablação por cateter de FA foram divididos em dois grupos: no grupo I (70 pt), a warfarina foi suspensa cinco dias antes do procedimento e utilizada terapia de transição com HBPM (enoxaparina 1 mg/kg 2x/dia pré-ablação e 0,5 mg/kg 2x/dia após o procedimento); no grupo II (70 pt), a warfarina não foi suspensa e o procedimento foi realizado com RNI terapêutico. Ambos os grupos receberam heparina intravenosa (TCA > 350 seg) durante o procedimento. RESULTADOS: No Grupo I, observou-se complicação hemorrágica maior (1,4%) e 4 pt (5,7%) com complicações hemorrágicas menores. No Grupo II, 2 pt (2,8%) apresentaram complicações hemorrágicas menores e 1 pt apresentou sangramento maior; porém, este ocorreu após uso de HBPM por RNI < 2,0. Não houve complicação tromboembólica ou morte cardiovascular nos dois grupos após 16 ± 8 meses. CONCLUSÃO: A realização de ablação por cateter de FA sem a suspensão de ACO e RNI terapêutico é uma estratégia semelhante em segurança e eficácia quando comparada à tradicional transição com HBPM, evitando um período inicial pós-ablação de anticoagulação potencialmente inadequada.BACKGROUND: The ideal management of oral anticoagulation (OAC) before and after catheter ablation for atrial fibrillation (AF) is still controversial. OBJECTIVE: To compare two anticoagulation strategies for catheter ablation for AF: warfarin withholding and use of low-molecular-weight heparin (LMWH); and maintenance of warfarin and therapeutic INR (between 2.0 and 3.0). METHODS: 140 patients (pt) with persistent/permanent AF undergoing catheter ablation for AF were divided into two groups: Group I (70 pt), in which warfarin was withheld five days prior to the procedure and transition to LMWH was used (enoxaparin: 1 mg/kg 2x/day before ablation, and 0.5 mg/kg 2x/day after ablation); Group II (70 pt), in which warfarin was not withheld and the procedure was performed with therapeutic INR. Both groups received intravenous heparin (ACT > 350 seconds) during ablation. RESULTS: In Group I, one pt (1.4%) had a major hemorrhagic complication and four pts (5.7%) had minor hemorrhagic complications. In Group II, two pts (2.8%) had minor hemorrhagic complications and one pt had a major bleeding, which occurred after using LMWH due to INR < 2.0. None of the groups had thromboembolic complications or cardiovascular death over a period of 16 ± 8 months. CONCLUSION: Catheter ablation for AF without withholding OAC and with therapeutic INR is a strategy that has similar safety and efficacy when compared with the traditional transition to LMWH, avoiding the potentially inadequate anticoagulation of the initial post-ablation period.

OBJETIVO: Avaliar as condutas tomadas nas Unidades de Terapia Intensiva (UTI) com os pacientes críticos terminais. MÉTODOS: Os membros do grupo de estudo do final da vida das sociedades Argentina, Brasileira e Uruguaia de Terapia Intensiva elaboraram um questionário no qual constavam avaliações demográficas sobre os participantes, sobre as instituições em que os mesmos trabalhavam e decisões sobre limite de esforço terapêutico (LET). Neste estudo de corte transversal os membros da equipe multiprofissional das sociedades responderam o questionário durante eventos científicos e, via on line. As variáveis foram analisadas através do teste qui-quadrado sendo considerado significativa pABSTRACT OBJECTIVE: To evaluate end-of-life procedures in intensive care units. METHODS: A questionnaire was prepared by the End-of-Life Study Group of the Argentinean, Brazilian and Uruguayan Intensive Care societies, collecting data on the participants’ demographics, institutions and limit therapeutic effort (LTE) decision making process. During this cross sectional study, the societies’ multidisciplinary teams members completed the questionnaire either during scientific meetings or online. The variables were analyzed with the Chi-square test, with a p

JUSTIFICATIVA E OBJETIVOS: Atualmente, há uma tendência crescente de se buscar o "morrer com dignidade", mais do que prolongar inutilmente o sofrimento de pacientes terminais em unidades de terapia intensiva (UTI). O objetivo deste estudo foi avaliar a utilização de condutas que sugerem limitação terapêutica (LT) em pacientes que foram a óbito em UTI Adulto. MÉTODO: Trata-se de um estudo exploratório, retrospectivo, que avaliou prontuários médicos de pacientes que foram a óbito na UTI geral de um hospital privado de Salvador-BA, entre janeiro e agosto de 2003, com internação superior a 24 horas na unidade. Os pacientes foram classificados, em relação ao óbito, em "não resposta a medidas de reanimação", "morte encefálica", "decisão de não reanimar" (DNR), "não adoção ou retirada de medidas de suporte de vida", sendo estas duas últimas consideradas medidas sugestivas de limitação terapêutica. RESULTADOS: Foram incluídos dados referentes a 67 pacientes, correspondendo a 90,4% dos pacientes falecidos na unidade durante o período. Destes, 56,7% eram mulheres e a idade média dos pacientes foi de 66,58 ± 17,86 anos. Medidas sugestivas de LT foram encontradas em 59,7% dos pacientes, sendo a mais importante "não adoção de medidas de suporte" (35,8%), seguida de DNR (17,9%) e "retirada de medidas de suporte" (6%). A utilização de fármacos vasoativos e métodos dialíticos foram as medidas de suporte mais omitidas, enquanto antibioticoterapia foi a mais retirada. A utilização de medidas de LT foi mais freqüente nos pacientes clínicos. CONCLUSÕES: Os dados do presente estudo sugerem altas freqüências de condutas médicas sugestivas de LT em UTI geral no Nordeste do Brasil. Métodos terapêuticos que possam causar desconforto ou sofrimento aos pacientes terminais, como nutrição, sedação e analgesia, raramente foram omitidos ou retirados.BACKGROUND AND OBJECTIVES: There is a growing tendency of looking for "dying with dignity", rather than to prolong death and suffering of terminal patients on intensive care units (ICU). This study aims to evaluate medical practices that suggest therapeutic limitation (TL) in patients who died in an adult ICU. METHODS: A retrospective exploratory study was carried out to evaluate medical records of patients who died in a general adult ICU of a private hospital in Salvador-BA, between January and August of 2003, after at least 24 hours from the admission. The patients were classified, in relation to their deaths, in: "not responding to cardiopulmonary resuscitation", "brain death", "decision not to resuscitate" (DNR) and "withhold or withdrawal life-support measures". RESULTS: Sixty seven patients were included, corresponding to 90.4% of the deaths occurred in this ICU during the referred period. The most of them (56.7%) were women and the patients’ mean age was 66.58 ± 17.86 years. Suggestive measures of TL were found in 59.7% of the patients, being "withhold of life-support measures" the most important (35.8%), followed by DNR (17.9%) and "withdrawal of life-support measures" (6%). The procedures most commonly omitted were use of vasoactive drugs and dialysis, while antibiotics were the most discontinued. The use of TL measures was more frequent in clinical patients. CONCLUSIONS: The results of the present study suggest high frequencies of medical conducts suggestive of TL in a general ICU in Northeast of Brazil. Therapeutic methods that could cause discomfort or suffering to the patients, as nutrition, sedation and analgesia, were rarely omitted or discontinued.

OBJETIVO: estudar o perfil de assistência aos pacientes pediátricos que evoluem para o óbito em um hospital universitário, incluindo descrição dos modelos, comparações entre setores, associações de fatores, participações envolvidas e registro das decisões. MÉTODOS: estudo transversal observacional. Foram revistos por um dos autores os registros médicos e de enfermagem dos pacientes falecidos, tendo sido aplicados entrevistas e questionários aos membros da equipe assistente. O período do estudo foi de 12 meses (de 01º de maio de 2002 a 30 de abril de 2003). RESULTADOS: foram analisados 106 casos. Os modelos de assistência mais empregados no hospital foram não-oferta de suporte de vida (51,9%) e reanimação malsucedida (44,3%). As decisões de não reanimar foram mais tardias no centro de tratamento intensivo (p < 0,05). A categoria restritiva de assistência foi mais prevalente na unidade neonatal e entre os portadores de doenças limitantes da sobrevida (p < 0,05). Entre as formas mais comuns de participação profissional nas decisões, destacaram-se médicos plantonistas e residentes, isoladamente (52,8%), e a equipe médica (31,1%). O envolvimento dos pais ou responsáveis foi registrado em 20,8% dos casos. Na amostra total, foram observados sete casos (6,6%) de registros dúbios ou discordantes da reanimação cardiopulmonar em prontuário. CONCLUSÕES: os procedimentos de restrição terapêutica são freqüentes, especialmente na unidade neonatal. São ainda desprezíveis, entretanto, o diagnóstico de morte encefálica e a suspensão ativa do suporte avançado de vida. As decisões de não-reanimação, especialmente no Centro de Tratamento Intensivo, são geralmente tardias. São falhos os processos de decisões participativas e de registro das decisões em prontuário na amostra.OBJECTIVE: To study the profile of care provided to pediatric patients suffering fatal outcomes at a university hospital, including: description of models, comparisons between units, associated factors, participants involved and records of decisions made. METHODS: Cross-sectional study. One of the investigators reviewed the medical and nursing records of deceased patients. Interviews were held and questionnaires filled out with the care team members over a period of 12 months (May 1, 2002 to April 30, 2003). RESULTS: The study included 106 cases. The most frequent treatment patterns at the hospital were: withholding advanced life support (51.9%) and unsuccessful cardiopulmonary resuscitation (44.3%). The decision to make a do-not-resuscitate order occurred later in the intensive care unit (p < 0.05). The restricted care category was more prevalent in the neonatal unit and among patients with chronic diseases that limit survival (p < 0.05). The professionals that most often participated in the decision-making process were the unit's treating physician and resident (52.8%) and the medical team (31.1%). Parents or guardians were observed to have been involved in 20.8% of cases. For the entire hospital, seven cases (6.6%) of ambiguous or discordant cardiopulmonary resuscitation procedures were found. CONCLUSIONS: Procedures involving limitation of therapy are frequent, especially in the neonatal unit. Diagnosis of brain death and withdrawal of advanced life support are, nevertheless, rare. Decisions to grant do-not-resuscitate orders are generally mate late, especially in the intensive care unit. In this sample procedures for full participation in decisions and for recording decisions were imperfect.

Abstract Renouncement of renal replacement therapy (RRT) is a medical dilemma. This review covers the concept, the magnitude, the prognosis, and discusses strategies and management approaches about this subject in patients with CKD and AKI. Evidence suggests that refusal is more frequent and carries a more guarded prognosis than withdrawal of RRT. When RRT is not expected to be beneficial in terms of survival or quality of life, conservative treatment and palliative care are alternatives. We review the historical evolution of guidelines about renouncement of RRT and palliative care, and highlight the absence of specific recommendations in Brazil. However renouncement of RRT may be ethically and legally accepted in Brazil, as the right to a dignified death. Longer life expectancy, economic pressures, and greater awareness will require a more detailed discussion about indications and sustainable use of RRT, and possibly the elaboration of national guidelines.