La aplicación de las órdenes de no reanimación y la limitación del esfuerzo terapéutico en pacientes ingresados en Medicina Interna en un hospital comarcal

Limiting ICU admission from emergency services and wards

INTRODUCTION

Decisions not to admit a patient to intensive care units (ICU) as a way of limiting life support treatment (LLST) is a practice that can affect the operation of the emergency services and the way in which patients die.

METHODS

Post hoc analysis of the ADENI-UCI study. The main variable analysed was the reason for refusal of admission to the ICU as a measure of LLST. For the present post hoc analysis, the registered patients were divided into 2 groups: the patients assessed in the intensive medicine services from the emergency department and the patients assessed from the conventional hospitalization areas. Student t was used in the comparative statistics when the mean values of the patient sub-cohorts were compared. Categorical variables were compared with the χ² tests.

RESULTS

The ADENI-ICU study included 2,284 decisions not to admit to the ICU as a measure of LLST. Estimated poor quality of life (p=.0158), the presence of severe chronic disease (P=.0169) and futility of treatment (P=.0006) were percentage decisions with greater weight within the population of hospitalized patients. The percentage of disagreement between the consulting physician and the intensivist was significantly lower in patients assessed from the emergency services (P=.0021).

CONCLUSIONS

There are appreciable differences in the reasons for consultation, as well as in those for refusal of admission to an ICU between the consultations made from an emergency department and a conventional hospitalization facility.

Evaluación del conocimiento y práctica de la limitación del esfuerzo terapéutico en personal asistencial de una institución prestadora de servicios de salud para pacientes oncológicos de Medellín, 2018

La limitación del esfuerzo terapéutico (LET) es toda acción que implique suspender o no iniciar tratamientos o medidas terapéuticas en pacientes que no se beneficiarán clínicamente. En Latinoamérica, las investigaciones realizadas dejan en evidencia la falta de familiarización y discordancia que hay alrededor del tema y sus prácticas. El presente estudio buscó objetivizar el conocimiento en LET del personal de salud de una institución de Medellín, a partir de una encuesta autoaplicada que permitió el desarrollo de un estudio descriptivo de tipo transversal, con muestreo no probabilístico. Dentro de los resultados se encontró que el 56,5 % de los encuestados refirió conocer el concepto, y el 90 % manifestó aplicarlo. Sin embargo, había discordancias dentro de los conceptos clave de la definición y el ejercicio.

The advocacy role of nurses in cardiopulmonary resuscitation

BACKGROUND

The decision whether to initiate cardiopulmonary resuscitation may sometimes be ethically complex. While studies have addressed some of these issues, along with the role of nurses in cardiopulmonary resuscitation, most have not considered the importance of nurses acting as advocates for their patients with respect to cardiopulmonary resuscitation.

RESEARCH OBJECTIVE

To explore what the nurse's advocacy role is in cardiopulmonary resuscitation from the perspective of patients, relatives, and health professionals in the Basque Country (Spain).

RESEARCH DESIGN

An exploratory critical qualitative study was conducted from October 2015 to March 2016. Thematic analysis was used to analyse the data.

PARTICIPANTS

Four discussion groups were held: one with patients and relatives (n = 8), two with nurses (n = 7 and n = 6, respectively), and one with physicians (n = 5).

ETHICAL CONSIDERATIONS

Approval was obtained from the Basque Country Clinical Research Ethics Committee.

FINDINGS

Three significant themes were identified: (a) accompanying patients during end of life in a context of medical dominance, (b) maintaining the pact of silence, and (c) yielding to legal uncertainty and concerns.

DISCUSSION

The values and beliefs of the actors involved, as well as pre-established social and institutional rules reduced nurses' advocacy to that of intermediaries between the physician and the family within the hospital environment. On the contrary, in primary health care, nurses participated more actively within the interdisciplinary team.

CONCLUSION

This study provides key information for the improvement and empowerment for ethical nursing practice in a cardiac arrest, and provides the perspective of patients and relatives, nurses and physicians.