Although known and debated since ancient Greece and Rome, the end-of-life ethical dilemmas are increasingly exposed to disputes and controversies. The main reason is the technoscientific progress that has been progressively increasing the life expectancy but not, in the same measure, the quality of life. The process of death, that can be lengthened or shortened by technical procedures, is in the forefront of the end-of-life ethical dilemmas. The meditations and opinions about these questions are sometimes based on misconceptions. A broad and inclusive analysis should consider, among others, a historical review of these topics and point out how various sectors of the society observe and scrutinize these plights. An analysis, about any controversy, is not conscientious if it does not point out a solution or at least a proposition to mitigate the disputes. It is in this context that, in the lack of biomarkers that can predict with accuracy the end-of-life, I recommend in this essay, the living will and other advanced health care directives, as a reasonable solution to lighten to a certain extent the ethical dilemmas of end-of-life.

PurposeThe acute-on-chronic exacerbations of end-stage respiratory diseases often result in prolonged hospital stays, relating these events to ethical conflicts in the fields of medical futility and distributive justice. This study aimed to understand patients’ preferences for life-sustaining treatments when clinically stable and during regular follow-up visits, and to determine the factors that can influence these preferences. ProcedureThis was a prospective, observational, exploratory study using convenience sampling. Over a three-year period, the study enrolled 106 adult outpatients with end-stage pulmonary disease on long-term oxygen treatment with/without noninvasive mechanical ventilation with dyspnoea scores of 6 or more in the modified Borg dyspnoea scale and one of the following: Gold (chronic obstructive pulmonary disease classification) stage IV, diffusing capacity (DLCO) <40%, heart failure (New York Heart Association functional classification (NYHA)) stage III/IV, or systolic pulmonary artery pressure ≥40 mm Hg. ResultsFactors that were influential in preferences were age, gender, household status, NYHA class, and previous exposure to mechanical ventilation. ConclusionsThere was no consensus on life-sustaining treatment preferences. Demographic factors, such as age group, gender, household status, severity of disease, and previous treatment with mechanical ventilation, seemed to affect patients’ preferences.

To investigate whether NT-proBNP can be used as a prognostic factor in septic shock patients admitted to our Respiratory Intensive Care Unit (RICU). We did a retrospective study over a 4 year period. All patients admitted with or who developed septic shock during their RICU stay were enrolled. Patient’s demographic data, comorbidities, NT-proBNP levels, glomerular filtration rate (GFR), severity index APACHE II scores and mortality rate were compared between survivors and non-survivors. NT-proBNP levels were determined within 48-72h of admission and were classified according to patient’s age and renal function. During the study period 31 patients with septic shock were identified. Average age 64 ± 16 years old, 26 were males. Mean APACHE II score 29,2 ± 9,3; mean GFR 66,4 ± 58,2 ml/min/1,7 m2. The most frequent primary diagnosis was Pneumonia. Mortality rate was 87,1% (27 patients). Patients were then divided into two groups according to mortality recorded in the unit. The mean NT-proBNP levels was higher in the survivors group (17530,5 ± 27251 vs 14754,93 ± 23133,43 pg/ml). APACHE II was positively correlated with NT-proBNP (R=0,496, p=0,05). NT-proBNP levels didn9t seem to have influenced mortality (p=0,798). Our results don9t support the use of NT-proBNP levels as a prognostic factor in septic shock patients. However, the positive correlation observed between NT-proBNP levels and APACHE II scores predicts that NT-proBNP can be used at least as a surrogate marker of disease severity. These results may be due to the small sample size and to the high prevalence of chronic respiratory failure and preexisting cardiac diseases among our patients, which can lead to high basal levels of NT-proBNP.

BACKGROUND: In ICUs, many patients are unable to participate in decision-making regarding life-sustaining treatments. This study evaluated the opinions of family members about family and physician participation in life-sustaining treatment decisions and examined factors that influence those decisions. METHODS: This was a prospective exploratory observational study that used convenience sampling. Inquiry interviews were conducted over a 3-year period, with 126 family members (out of 303 potential participants) of patients with acute-on-chronic respiratory failure, who had been admitted to the respiratory ICU and were dependent on invasive or noninvasive mechanical ventilation. Patients of ≤ 18 years old, with a stay of < 3 days, and oncologic patients were excluded. RESULTS: Ninety-eight percent (123/126) of the participant family members had an opinion about their involvement in decision-making about life-sustaining treatments. Physician choice was preferred by 54/123 (44%), 55/123 (45%) wished to share the decision with the physician, and 14/123 (11%) wished the family to decide. All the patients were incompetent at the time of inquiry. Autonomy prior to admission to the respiratory ICU influenced the decision. CONCLUSIONS: A majority of the families relied on physicians to help in the decision-making process about life-sustaining treatments in patients with acute-on-chronic respiratory diseases. From the family's point of view, the principle of autonomy can be exercised by delegating the decision-making process to the physician. To assume a uniform ethical conduct is to antagonize the definition of ethics.

BACKGROUND: End-of-life decisions are an important part of day-to-day medical practice in Respiratory Intensive Care Units (RICU), reflecting the need to prevent unreasonable therapeutic interventions.Noninvasive ventilation (NIV) can be used in the do-not-intubate patient and in palliative care setting. AIM:To determine the outcome of patients with respiratory failure (RF) in whom NIV was performed as a maximal intervention strategy. METHODS:Prospective study of 369 patients admitted to our RICU for 18 months. Age,gender,APACHE II,diagnosis,comorbidities,inpatient days,NIV duration,type of respiratory failure,PaCO 2 on admission,NIV dependence (quantified in hours/day as follows: RESULTS:Among patients in need of ventilatory assistance (n=242), 60 had a decision to forego tracheal intubation (24,8%).Age (y):70±16.Males:60%. APACHE II:16±8.Inpatient days:14±12.Diagnosis,%: chronic respiratory disease 50,heart failure 11,cancer 10,pneumonia 10,neuromuscular disorders 7,others 12. Thirty percent had at least two comorbidities (considering chronic heart failure, chronic renal failure, pulmonary hypertension and dementia).ICU mortality:73%. Mortality,% (hypoxemic RF/hypercapnic RF):100/64,p=0,007.PaCO 2 ,mmHg (alive/dead):62±15/51±17,p=0,03.Mortality,% (NIV DISCUSSION:The presence of hypercapnic RF had better prognosis, as opposed to hypoxemic RF. Greater NIV dependence was correlated with higher mortality. The mortality rate observed was high, as expected in this subset of patients.

Amniotic fluid embolism (AFE) is a rare pathological syndrome, sometimes fatal that arises as an obstetric complication during vaginal delivery, caesarean, immediate postpartum or during pregnancy. It remains as an important cause of fetal and maternal morbidity and mortality. The authors present a clinical report of a young woman who developed an acute respiratory failure during labour demanding invasive mechanical ventilation and an urgent caesarean. In spite of early medical intensive therapy, hypoxemia was refractory and had a progressive worsening leading to multi-organ failure and ultimately to death. Diagnosis was confirmed through the identification of fetal material in the lumen of maternal pulmonary microcirculation.

Amniotic fluid embolism (AFE) is a rare pathological syndrome, sometimes fatal that arises as an obstetric complication during vaginal delivery, caesarean, immediate postpartum or during pregnancy. It remains as an important cause of fetal and maternal morbidity and mortality. The authors present a clinical report of a young woman who developed an acute respiratory failure during labour demanding invasive mechanical ventilation and an urgent caesarean. In spite of early medical intensive therapy, hypoxemia was refractory and had a progressive worsening leading to multi-organ failure and ultimately to death. Diagnosis was confirmed through the identification of fetal material in the lumen of maternal pulmonary microcirculation.

Objective: The aim of our study was to detect the impact of the etiology of severe COPD exacerbations admitted to a respiratory intensive care unit (RICU). Methods: Retrospective study evaluating all episodes of severe COPD exacerbations admitted from Jan/2005 to Sept/2010 in our RICU. Patients with lung cancer were excluded. Regarding the etiology of exacerbation we divided into three groups: heart failure, respiratory infection, others/undefined. Different parameters were analyzed: APS, APACHE II, TISS, length of stay in RICU, days on invasive mechanical ventilation, mortality. In the comparative analysis, episodes with more than one cause of exacerbation were excluded. Results: Data were collected from 141 out of 184 episodes admitted to RICU. Mean age was 70±10, 76% were male. Mean APACHEII was 24.6±7.9 and mortality during the RICU admission was 30%. Comparative analysis between different etiology of severe COPD exacerbation Heart failure Respiratory infection Others/undefined p (n=29) (n=67) (n=40) Age (years) 73.2±8.7 69.6±10.6 67.2±10.1 0.0480 APS 16±6.5 14.4±6.8 15.4±9.3 0.3289 APACHE II 25.9±7.0 23.9±7.1 24.6±9.9 0.2654 TISS 22.4±5.8 23.3±5.5 21.4±7.3 0.2622 Duration of stay in RICU (days) 17.6±16.4 12±8.8 9.5±12.3 0.0041 Days on invasive mechanical ventilation 6.5±10.1 6.6±9.0 3.8±10.8 0.0151 Mortality 51.7% 28.3% 20% 0.0156 Conclusions: In our study we found higher mortality, longer duration of stay in the RICU for patients with severe COPD exacerbations caused by heart failure.

Todo o acto médico deve estar assente em princípios éticos. Estes códigos de conduta que regem a relação do médico com o doente são dirigidos ao médico (principio de beneficência e não maleficência) ou orientados para o doente (principio de autonomia). Assim sendo, em determinadas circunstancias, pode haver alguma tensão entre os princípios. Tendo como ponto de partida um caso clínico, e feita uma reflexão a atitude do médico numa situação de conflito de princípios, a luz de fundamentos éticos, bem como numa perspectiva jurídica.The doctor -patient relationship should be established in ethical principles. The codes of conduct that guide the relation between the doctor and the patient are addressed to the physician (principle of beneficence and non -maleficence) or oriented to the patient (principle of autonomy). As such, in certain circumstances there can be some tension between the principles. Based on a case report in a setting of principles conflict, ethical and legal considerations are made so far as the doctor’s attitude is concerned.

Isolated ventricular noncompaction is an extremely rare cardiomyopathy, not fully clarified.It is characterized by persistent embryonic myocardium morphology without associated cardiac abnormalities.Since first description in 1984, few clinical studies were done. Data in the literature are lacking and most reports consist on a few case studies.Doppler ecocardiogram is considered the reference method for diagnosis.Diagnosis remains difficult since there are similarities with other cardiac defects, clinical manifestations are non-specific and echocardiographic criteria are not universally accepted.As a consequence diagnosis may be easily missed.Moreover, clinical and echocardiographic features were just recently clarified.Treatment is directed towards important clinical manifestations (heart failure, arrhythmias and embolic events).We present a clinical case of severe cardio-respiratory failure in previously healthy and asymptomatic young male, which was the initial presentation of an isolated ventricular noncompaction.A brief review of available literature is done concerning to this case study.

Resumo: Todo o acto médico deve estar assente em princípios éticos. Estes códigos de conduta que regem a relação do médico com o doente são dirigidos ao médico (princípio de beneficência e não maleficência) ou orientados para o doente (princípio de autonomia). Assim sendo, em determinadas circunstâncias, pode haver alguma tensão entre os princípios.Tendo como ponto de partida um caso clínico, é feita uma reflexão à atitude do médico numa situação de conflito de princípios, à luz de fundamentos éticos, bem como numa perpectiva jurídica.Rev Port Pneumol 2009; XV (3): 529-536 Abstract: The doctor-patient relationship should be established in ethical principles. The codes of conduct that guide the relation between the doctor and the patient are addressed to the physician (principle of beneficence and non-maleficence) or oriented to the patient (principle of autonomy). As such, in certain circumstances there can be some tension between the principles.Based on a case report in a setting of principles conflict, ethical and legal considerations are made so far as the doctor’s attitude is concerned.Rev Port Pneumol 2009; XV (3): 529-536 Palavras-chave: Princípio de beneficência, princípio de autonomia, consentimento informado, conflito de princípios, Key-words: Principle of beneficence, principle of autonomy, informed consent, principles conflict

The doctor-patient relationship should be established in ethical principles. The codes of conduct that guide the relation between the doctor and the patient are addressed to the physician (principle of beneficence and non-maleficence) or oriented to the patient (principle of autonomy). As such, in certain circumstances there can be some tension between the principles.Based on a case report in a setting of principles conflict, ethical and legal considerations are made so far as the doctor's attitude is concerned.

O fim da vida e os cuidados médicos são ciclicamente notícia nos órgãos da comunicação social. A posição da Igreja católica, em relação à qual existe um grande desconhecimento, tem estado, paradoxalmente, na origem de alguma controvérsia. Neste artigo, analisamos e reflectimos sobre os vários documentos daquela instituição religiosa, bem como a opinião de algumas personalidades que estudaram esta temática numa perspectiva católica.End-of-life care cyclically occupies the headlines of the mass media. The disposition of the Catholic church, this matter, although unknown to many, has been the subject of discussion and controversy. In this article we analysed various documents of that religious institution, as well as the opinion of some well known personalities who studied this theme from a Catholic perspective.

O fim da vida e os cuidados médicos são ciclicamente notícia nos órgãos da comunicação social. A posição da Igreja católica, em relação à qual existe um grande desconhecimento, tem estado, paradoxalmente, na origem de alguma controvérsia.

Distanásia ou qualquer um dos seus sinónimos é uma consequência do excesso terapêutico em relação ao prognóstico esperado. A obstinação terapêutica é um dos dilemas éticos mais angustiantes no quotidiano de medicina intensiva, apesar de a sua apreciação encontrar um suporte normativo em várias instituições e organizações. A manutenção ou não suspensão da ventilação mecânica numa determinada circunstância de fim de vida pode ser considerado como um exemplo paradigmático de obstinação terapêutica. A compreensão desta postura passa pela análise e reflexão do acto médico à luz de alguns conceitos ético-filosóficos.Dysthanasia or any of its synonyms is a consequence of excessive technical science, without any reasonable chance of achieving a therapeutic benefit for the patient. Medical futility is a distressing ethical dilemma of intensive care medicine. Its recognition has led to a precept support in various institutions and organizations. Not withdrawing or withholding mechanical ventilation in certain circumstances can be considered as a paradigmatic model of medical futility. The understanding of this posture implies a philosophical approach and reflexion of medical practice.

Dysthanasia or any of its synonyms is a consequence of excessive technical science, without any reasonable chance of achieving a therapeutic benefit for the patient. Medical futility is a distressing ethical dilemma of intensive care medicine. Its recognition has led to a precept support in various institutions and organizations. Not withdrawing or withholding mechanical ventilation in certain circumstances can be considered as a paradigmatic model of medical futility. The understanding of this posture implies a philosophical approach and reflexion of medical practice.

A idade como critério de limitação de determinadas intervenções terapêuticas tem estado na origem de um dos debates bioéticos da actualidade. O aumento da esperança média de vida à nascença e o crescente envelhecimento da população, por um lado, e a escassez de recursos económicos, por outro, estão na origem desta controvérsia. Na defesa das duas teses estão argumentos económicos e éticos. Espera-se da sociedade, principalmente dos sectores mais envolvidos nesta polémica, o estudo e a reflexão necessária para o consenso possível.

At the present moment, one of the debates concerning bioethics is focussed on age as criterion for rationing health care. The increase in average life expectancy and aging population on one side, and the scarcity of the economic resources on the other, are the main reasons for the controversy. The two sides of the dispute contest on the economic and ethical arguments. The society, mainly the sectors more involved in the dispute, should concern in the study and reflection of this problem, in order to attain the conceivable consensus.

Os autores tiveram como objectivo avaliar a ventilação mecânica prolongada (VMP) (³ 15 dias) tendo em consideração: - grupos de diagnóstico, gravidade e sobrevivência.De 1990 a 2002 todos os doentes submetidos a ventilação mecânica (VM) admitidos na nossa UCI foram incluídos. Os doentes com VM ³ 15 e < 15 dias foram comparados no que respeita: - idade, grupos de diagnostico, APACHE II e mortalidade. O follow-up após a alta foi analisado para os doentes com VMP.Dos 1715 doentes submetidos a VM no período em estudo, 63% eram do sexo masculino. A maioria dos doentes com VMP (40,2%) tinham patologia pulmonar crónica, nomeadamente DPOC. Os doentes com VM ³ 15 e < 15 dias foram comparados.VM diasDoentes (n)VM dias (media)Idade mediaAPACHE IIMortalidaden (%)≥ 1551046.662.323.8274 (53.7)< 1512055.459.423.5455 (37.8)p=0.002pnsp<0.0001pns=p>0.05Dos doentes com VMP que tiveram alta (n=236), 13 (5,5%) ficaram dependentes de VM invasiva; 26 (11%) faleceram após 40,1±38 meses e 104 (44%) estavam vivos ao fim de 21±29,9 meses após a alta.Em conclusão os doentes com VMP tiveram uma maior taxa de mortalidade durante o internamento na UCI. apesar de terem APACHE II idênticos. Daqueles que sobreviveram somente 5,5% ficaram dependentes VM invasiva. No follow-up 44% dos doentes com VMP estavam vivos após 21 meses. : Our aim was to evaluate prolonged mechanical ventilation (PMV) (³ 15 days) in what concerns:- diagnostic groups, severity and survival.During 1990-2002 all mechanically ventilated (MV) patients admitted in the study period were included. MV ³ 15 and < 15 days patients were compared in terms of: - age, diagnostic groups, APACHE II and mortality rate. Outpatient follow-up was analyzed for PMV patients.Out of 1715 MV patients in the study period, 63% were males. The majority of PMV (40,2%) had chronic pulmonary diseases, generally COPD. MV ³ 15 and < 15 days patients are compared.VM daysPatients(n)MV dyas (mean)AverageageAPACHE IIMortalityn (%)≥ 1551046.662.323.8274 (53.7)< 1512055.459.423.5455 (37.8)p=0.002pnsp<0.0001pns=p>0.05From discharged patients (n=236), 13 (5,5%) were dependent on invasive MV; 26 (11%) died in a 40,1±38 months period and 104 (44%) were alive in 21±29,9 months after discharge.In conclusion in spite of a similar APACHE II, PMV patients had higher ICU mortality rate. From survivors only 5,5% rested dependent on invasive MV. The follow-up of PMV showed a 44% survival rate at more or less 21 months. Key words: prolonged mechanical ventilation, follow-up, Palavras chave: ventilação mecânica prolongada, follow-up

Os autores tiveram como objectivo avaliar a ventilação mecânica prolongada (VMP) (³ 15 dias) tendo em consideração: - grupos de diagnóstico, gravidade e sobrevivência. De 1990 a 2002 todos os doentes submetidos a ventilação mecânica (VM) admitidos na nossa UCI foram incluídos. Os doentes com VM ³ 15 e < 15 dias foram comparados no que respeita: - idade, grupos de diagnostico, APACHE II e mortalidade. O follow-up após a alta foi analisado para os doentes com VMP. Dos 1715 doentes submetidos a VM no período em estudo, 63% eram do sexo masculino. A maioria dos doentes com VMP (40,2%) tinham patologia pulmonar crónica, nomeadamente DPOC. Os doentes com VM ³ 15 e < 15 dias foram comparados.VM diasDoentes (n)VM dias (media)Idade mediaAPACHE IIMortalidaden (%)≥ 1551046.662.323.8274 (53.7)< 1512055.459.423.5455 (37.8)p = 0.002pnsp<0.0001pns = p > 0.05 pns = p > 0.05 Dos doentes com VMP que tiveram alta (n = 236), 13 (5,5%) ficaram dependentes de VM invasiva; 26 (11%) faleceram após 40,1 ± 38 meses e 104 (44%) estavam vivos ao fim de 21 ± 29,9 meses após a alta. Em conclusão os doentes com VMP tiveram uma maior taxa de mortalidade durante o internamento na UCI. apesar de terem APACHE II idênticos. Daqueles que sobreviveram somente 5,5% ficaram dependentes VM invasiva. No follow-up 44% dos doentes com VMP estavam vivos após 21 meses. Our aim was to evaluate prolonged mechanical ventilation (PMV) (³ 15 days) in what concerns:- diagnostic groups, severity and survival. During 1990-2002 all mechanically ventilated (MV) patients admitted in the study period were included. MV ³ 15 and < 15 days patients were compared in terms of: - age, diagnostic groups, APACHE II and mortality rate. Outpatient follow-up was analyzed for PMV patients. Out of 1715 MV patients in the study period, 63% were males. The majority of PMV (40,2%) had chronic pulmonary diseases, generally COPD. MV ³ 15 and < 15 days patients are compared.VM daysPatients(n)MV dyas (mean)AverageageAPACHE IIMortalityn (%)≥ 1551046.662.323.8274 (53.7)< 1512055.459.423.5455 (37.8)p = 0.002pnsp<0.0001pns = p > 0.05 pns = p > 0.05 From discharged patients (n = 236), 13 (5,5%) were dependent on invasive MV; 26 (11%) died in a 40,1 ± 38 months period and 104 (44%) were alive in 21 ± 29,9 months after discharge. In conclusion in spite of a similar APACHE II, PMV patients had higher ICU mortality rate. From survivors only 5,5% rested dependent on invasive MV. The follow-up of PMV showed a 44% survival rate at more or less 21 months.