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

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.