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Background <p>End-of-life decisions in critically ill patients lacking decisional capacity are ethically challenging. Addressing patient values—such as autonomy, dignity, and comfort—provides a person-centered basis for care, yet systematic value assessment remains inconsistent. Structured family conferences guided by a bioethical framework may help align treatment with patient preferences. This study describes how often life-sustaining treatment (LST) modifications in a Brazilian ICU were aligned with documented patient values.</p> Methods <p>This retrospective observational case series reviewed electronic medical records of neurologically incapacitated adults admitted to a tertiary public ICU in São Paulo, Brazil (February 2022–August 2023). Eligible patients met predefined palliative care triggers. Data were extracted using standardized forms, focusing on demographics, clinical features, family conferences, decisions, and outcomes. Family conferences followed a structured bioethical framework and a communication model based on neurobiology to elicit patient values, which were categorized into predefined domains. Descriptive analyses were performed. The study followed STROBE guidelines, was ethics-approved with consent waiver, and did not influence clinical care.</p> Results <p>Of 179 consecutive intensive care unit admissions screened, 40 patients met eligibility criteria. Most were male (65%) with a mean age of 63.5 years. Palliative care triggers included advanced age with severe comorbidities or multi-organ failure (32.5%) and cerebral ischemia (32.5%). Family conferences occurred in 57.5% of patients, typically within three days, involving sons or spouses. Patient values were documented in 50% of the cases. Of the total sample (<i>n</i> = 40), the most frequently reported values were autonomy (37.5%) and avoidance of suffering (12.5%). Overall, 55% had LST modified—withholding (50%), withdrawal (7.5%)—and 42.5% of modifications were documented value-based, representing 73.9% of patients with family conferences. Outcomes included death with LST (25%), natural death after withholding/withdrawal (25%), discharge home (25%), hospice (20%), and ward transfer (5%).</p> Conclusions <p>Structured family conferences supported by a bioethical and communication frameworks were associated with a high frequency of treatment decisions explicitly aligned with patient values. These findings demonstrate that systematic value-based decision-making is feasible in resource-limited public hospitals. Prospective multicenter studies are needed to confirm these results and evaluate their impact on quality of care and clinical outcomes.</p>

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The use of bioethical decision-making framework in the ICU of a public Brazilian hospital: a retrospective observational case series

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2026年3月2日

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  • Daniel Mendonça Dantas,
  • Fabrício Ferreira Lipi,
  • Sofia Carolina Cantuario de Oliveira,
  • Matheus Parra Barcelos de Mendonça,
  • Juliana Blassioli Suyama,
  • Gabriel Lehvy Cantarin Gonçalves,
  • Bernardo Ramos De Godoy,
  • Vivian Meloni Bagini,
  • Victor Moitinho Mariano,
  • Ludhmila Abrahão Hajjar,
  • Daniel Neves Forte

摘要

Background

End-of-life decisions in critically ill patients lacking decisional capacity are ethically challenging. Addressing patient values—such as autonomy, dignity, and comfort—provides a person-centered basis for care, yet systematic value assessment remains inconsistent. Structured family conferences guided by a bioethical framework may help align treatment with patient preferences. This study describes how often life-sustaining treatment (LST) modifications in a Brazilian ICU were aligned with documented patient values.

Methods

This retrospective observational case series reviewed electronic medical records of neurologically incapacitated adults admitted to a tertiary public ICU in São Paulo, Brazil (February 2022–August 2023). Eligible patients met predefined palliative care triggers. Data were extracted using standardized forms, focusing on demographics, clinical features, family conferences, decisions, and outcomes. Family conferences followed a structured bioethical framework and a communication model based on neurobiology to elicit patient values, which were categorized into predefined domains. Descriptive analyses were performed. The study followed STROBE guidelines, was ethics-approved with consent waiver, and did not influence clinical care.

Results

Of 179 consecutive intensive care unit admissions screened, 40 patients met eligibility criteria. Most were male (65%) with a mean age of 63.5 years. Palliative care triggers included advanced age with severe comorbidities or multi-organ failure (32.5%) and cerebral ischemia (32.5%). Family conferences occurred in 57.5% of patients, typically within three days, involving sons or spouses. Patient values were documented in 50% of the cases. Of the total sample (n = 40), the most frequently reported values were autonomy (37.5%) and avoidance of suffering (12.5%). Overall, 55% had LST modified—withholding (50%), withdrawal (7.5%)—and 42.5% of modifications were documented value-based, representing 73.9% of patients with family conferences. Outcomes included death with LST (25%), natural death after withholding/withdrawal (25%), discharge home (25%), hospice (20%), and ward transfer (5%).

Conclusions

Structured family conferences supported by a bioethical and communication frameworks were associated with a high frequency of treatment decisions explicitly aligned with patient values. These findings demonstrate that systematic value-based decision-making is feasible in resource-limited public hospitals. Prospective multicenter studies are needed to confirm these results and evaluate their impact on quality of care and clinical outcomes.