Ethics in the use of prognostic scores in intensive care units: an integrative review

Santos, Roberta Nascimento de Oliveira Lemos dos; Brito, Luciana Stoimenoff; Rego, Sergio Tavares de Almeida

doi:10.1590/1983-80422022302535EN

Acessibilidade / Reportar erro

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

Research • Rev. Bioét. 30 (2) • Apr-Jun 2022 • https://doi.org/10.1590/1983-80422022302535EN copy

Ethics in the use of prognostic scores in intensive care units: an integrative review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Facing COVID-19 caused many problems in the healthcare field, due to the rise in the intensive care demand. To solve this crisis, caused by the scarcity of resources of high complexity, decision-making has been guided by prognostic scores; however, this process includes a moral dimension, although less evident. With na integrative review, this article sought to reflect on the reasonability of using severity indicators to define the allocation of the scarce resources in healthcare. We observed that the work carried out on resource scarcity situations causes moral overload, converging to the search for standard and objective solutions, such as the use of prognostic scores. We conclude that their isolated and indiscriminate use is not ethically acceptable and deserves cautious evaluation, even in emergency situations, such as COVID-19.

COVID-19; Ethics; Organ dysfunction scores; Apache; Uncertainty; Bioethics; Healthcare rationing

Title	Year	Main characteristic
“Prognostic scoring systems: facing difficult decisions with objective data” ¹¹11. Sasse K. Prognostic scoring systems: facing difficult decisions with objective data. Camb Q Healthc Ethics [Internet]. 1993 [acesso 24 nov 2021];2(2):185-91. DOI: 10.1017/S096318010000089X	1993	Advocates the need to make the scoring criteria explicit
“The low frequency of futility in an adult intensive care unit setting” ¹²12. Halevy A, Neal RC, Brody BA. The low frequency of futility in an adult intensive care unit setting. Arch Intern Med [Internet]. 1996 [acesso 24 nov 2021];156(1):100-4. Disponível: https://bit.ly/3sK9svt https://bit.ly/3sK9svt...	1996	Evaluates therapeutic futility in the ICU. Sets markers used to determine the probability of death at 90%
“Resuscitation decisions in the elderly: a discussion of current thinking” ¹³13. Bruce-Jones PN. Resuscitation decisions in the elderly: a discussion of current thinking. J Med Ethics [Internet]. 1996 [acesso 24 nov 2021];22(5):286-91. DOI: 10.1136/jme.22.5.286	1996	Argues that the decision about cardiopulmonary resuscitation in older adults can be based on medical prognostic scores, which should also be presented to patients to assist them in decision-making
“Strong vasopressor support may be futile in the intensive care unit patient with multiple organ failure” ¹⁴14. Abid O, Akça S, Haji-Michael P, Vincent JL. Strong vasopressor support may be futile in the intensive care unit patient with multiple organ failure. Crit Care Med [Internet]. 2000 [acesso 24 nov 2021];28(4):947-9. DOI: 10.1097/00003246-200004000-00006	2000	Reports that SOFA was used as a criterion to administer norepinephrine treatment
“Withdrawal of medical treatment in the ICU. A cohort study of 318 cases during 1994-2000” ¹⁵15. Nolin T, Andersson R. Withdrawal of medical treatment in the ICU. A cohort study of 318 cases during 1994-2000. Acta Anaesthesiol Scand [Internet]. 2003 [acesso 24 nov 2021];47(5):501-7. DOI: 10.1034/j.1399-6576.2003.00128.x https://doi.org/10.1034/j.1399-6576.2003...	2003	Examines the frequency of the decision to withdraw basic life support based on prognosis and treatment failures
“Year in review in intensive care medicine, 2005. II. Infection and sepsis, ventilator-associated pneumonia, ethics, haematology and haemostasis, ICU organization and scoring, brain injury” ¹⁶16. Andrews P, Azoulay E, Antonelli M, Brochard L, Brun-Buisson C, Dobb G et al. Year in review in intensive care medicine, 2005. II. Infection and sepsis, ventilator-associated pneumonia, ethics, haematology and haemostasis, ICU organisation and scoring, brain injury. Intensive Care Med [Internet]. 2006 [acesso 24 nov 2021];32(3):380-90. DOI: 10.1007/s00134-005-0060-y https://doi.org/10.1007/s00134-005-0060-...	2006	Shows markers as effective if age-adjusted
“Limitación del esfuerzo terapêutico tras el ingreso en una Unidad de Medicina Intensiva. Análisis de factores associados” ¹⁷17. Iribarren-Diarasarri S, Latorre-García K, Muñoz-Martínez T, Poveda-Hernández Y, Dudagoitia-Otaolea JL, Martínez-Alutiza S et al. Limitación del esfuerzo terapéutico tras el ingreso en una unidad de medicina intensiva: análisis de factores asociados. Med Intensiva [Internet]. 2007 [acesso 24 nov 2021];31(2):68-72. DOI: 10.1016/S0210-5691(07)74778-2 https://doi.org/10.1016/S0210-5691(07)74...	2007	Points out the limitation of ICU therapeutic efforts via prognostic scores
“Year in review 2006: Critical Care: resource management” ¹⁸18. Schultz MJ, Kuiper M, Spronk PE, Vroom MB, Gajic O. Year in review 2006: critical care: resource management. Crit Care [Internet]. 2007 [acesso 24 nov 2021];11(4):1-6. Disponível: https://bit.ly/3Gc7Y2X https://bit.ly/3Gc7Y2X...	2007	Describes prognostic scores as effective when monitored continuously with all parameters in a modern ICU for better resource allocation
“Influence of malignancy on the decision to withhold or withdraw life-sustaining therapy in critically ill patients” ¹⁹19. Cavallazzi R, Hirani A, Vasu TS, Pachinburavan M, Kane GC. Influence of malignancy on the decision to withhold or withdraw life-sustaining therapy in critically ill patients. Am J Hosp Palliat Care [Internet]. 2009 [acesso 24 nov 2021];26(6):464-9. DOI: 10.1177/1049909109341872	2009	Indicates the influence of malignancy, prognostic scores, and age on the decision to withdraw life support
“Review article: Towards a considered and ethical approach to organ support in critically ill patients with cirrhosis” ²⁰20. Berry PA, Thomson SJ, Rahman TM, Ala A. Towards a considered and ethical approach to organ support in critically-ill patients with cirrhosis. Aliment Pharmacol Ther [Internet]. 2013 [acesso 24 nov 2021];37(2):174-82. DOI: 10.1111/apt.12133	2013	Reflects on the use of scores to withdraw or maintain ICU treatment
“Outcomes and prognostic factors of patients with lung cancer and pneumonia-induced respiratory failure in a medical intensive care unit: A single-center study” ²¹21. Chang Y, Huh JW, Hong SB, Lee DH, Suh C, Kim SW et al. Outcomes and prognostic factors of patients with lung cancer and pneumonia-induced respiratory failure in a medical intensive care unit: a single-center study. J Crit Care [Internet]. 2014 [acesso 24 nov 2021];29(3):414-9. DOI: 10.1016/j.jcrc.2014.01.005 https://doi.org/10.1016/j.jcrc.2014.01.0...	2014	Points out that when two scores are low, non-ICU admission can be considered
“Prognostic factors associated with hospital survival in comatose survivors of cardiac arrest” ²²22. Sathianathan K, Tiruvoipati R, Vij S. Prognostic factors associated with hospital survival in comatose survivors of cardiac arrest. World J Crit Care Med [Internet]. 2016 [acesso 24 nov 2021];5(1):103-10. DOI: 10.5492/wjccm.v5.i1.103	2016	Shows that APACHE II and APACHE III were used as a prognostic score correlating with mortality after 24 hours of cardiac arrest
“Outcome of colon cancer initially presenting as colon perforation and obstruction” ²³23. Chen TM, Huang YT, Wang GC. Outcome of colon cancer initially presenting as colon perforation and obstruction. World J Surg Oncol [Internet]. 2017 [acesso 24 nov 2021];15(164):1-7. DOI: 10.1186/s12957-017-1228-y	2017	Argues that APACHE was used as a severity criterion for patients with colon perforation or obstruction
“Shock subtypes by left ventricular ejection fraction following out-of-hospital cardiac arrest” ²⁴24. Anderson RJ, Jinadasa SP, Hsu L, Ghafouri TB, Tyagi S, Joshua J et al. Shock subtypes by left ventricular ejection fraction following out-of-hospital cardiac arrest. Crit Care [Internet]. 2018 [acesso 24 nov 2021];22(162):1-10 DOI: 10.1186/s13054-018-2078-x https://doi.org/10.1186/s13054-018-2078-...	2018	Describes the use of prognostic scores as a means of choosing treatment
“Clinical outcomes of patients undergoing primary percutaneous coronary intervention for acute myocardial infarction requiring the intensive care unit” ²⁵25. Parhar K, Millar V, Zochios V, Bruton E, Jaworksi C, West N, Vuylsteke A. Clinical outcomes of patients undergoing primary percutaneous coronary intervention for acute myocardial infarction requiring the intensive care unit. J Intensive Care [Internet]. 2018 [acesso 24 nov 2021];6(5):1-10. DOI: 10.1186/s40560-018-0275-y	2018	Reports the use of prognostic scores for coronary intervention in acute myocardial infarction
“Outcome and prognostic factors of patients with right-sided infective endocarditis requiring intensive care unit admission” ²⁶26. Georges H, Leroy O, Airapetian N, Lamblin N, Zogheib E, Devos P, Preau S. Outcome and prognostic factors of patients with right-sided infective endocarditis requiring intensive care unit admission. BMC Infect Dis [Internet]. 2018 [acesso 24 nov 2021];18(85):1-8. DOI: 10.1186/s12879-018-2989-9	2018	Notes that disease severity was evaluated with SOFA and SAPS scores in patients with infective endocarditis
“Quality assessments of end-of-life care by medical record review for patients dying in intensive care units in Taiwan” ²⁷27. Lo ML, Huang CC, Hu TH, Chou WC, Chuang LP, Chiang MC et al. Quality assessments of end-of-life care by medical record review for patients dying in intensive care units in Taiwan. J Pain Symptom Manage [Internet]. 2020 [acesso 24 nov 2021];60(6):1092-9. DOI: 10.1016/j.jpainsymman.2020.07.002 https://doi.org/10.1016/j.jpainsymman.20...	2020	Indicates measurement of end-of-life quality in critically ill ICU patients and the score of the prognostic models used as inclusion criteria in the study

Title	Year	Main characteristic
“Risk-adjustment in hepatobiliarypancreatic surgery” ²⁹29. Kocher HM, Tekkis PP, Gopal P, Patel AG, Cottam S, Benjamin IS. Risk-adjustment in hepatobiliarypancreatic surgery. World J Gastroenterol [Internet]. 2005 [acesso 24 nov 2021];11(16):2450-55. DOI: 10.3748/wjg.v11.i16.2450 https://doi.org/10.3748/wjg.v11.i16.2450...	2005	Evaluates the performance of p-Possum, ASA, APACHE and Child Pugh classification in predicting mortality and morbidity in hepatobiliarypancreatic surgery
“Serum lipopolysaccharide-binding protein concentrations in trauma victims” ³⁰30. Cunningham SC, Malone DL, Bochicchio GV, Genuit T, Keledjian K, Tracy JK, Napolitano LM. Serum lipopolysaccharide-binding protein concentrations in trauma victims. Surg Infect [Internet]. 2006 [acesso 24 nov 2021];7(3):251-61. DOI: 10.1089/sur.2006.7.251	2006	Evaluates whether concentrations of a plasma protein (LBP) are predictive of outcome (mortality)
“Futilidade terapêutica e insuficiência respiratória: realização de um estudo de coorte prospectiva” ³¹31. Batista CC, Goldbaum MA Jr, Sztiler F, Goldim JR, Fritscher CC. Futilidade terapêutica e insuficiência respiratória: realização de um estudo de coorte prospectiva. Rev Bras Ter Intensiva [Internet]. 2007 [acesso 24 nov 2021];19(2):151-60. DOI: 10.1590/S0103-507X2007000200003	2007	Compares two predictive indexes of prognosis (Unicamp II and APACHE II), showing that such indexes can help in decision-making regarding therapeutic futility
“A prognostic model for 6-month mortality in elderly survivors of critical illness” ³²32. Baldwin MR, Narain WR, Wunsch H, Schluger NW, Cooke JT. Maurer MS et al. A prognostic model for 6-month mortality in elderly survivors of critical illness. Chest [Internet]. 2013 [acesso 24 nov 2021];143(4):910-9. DOI: 10.1378/chest.12-1668 https://doi.org/10.1378/chest.12-1668...	2013	Predicts, derives and validates a prognosis model after discharge (6 months) of surviving older ICU patients
“Characterization of patients who were mechanically ventilated in general medicine wards” ³³33. Izhakian S, Buchs AE. Characterization of patients who were mechanically ventilated in general medicine wards. Isr Med Assoc J [Internet]. 2015 [acesso 24 nov 2021];17(8):496-9. Disponível: https://bit.ly/3PFrlWo https://bit.ly/3PFrlWo...	2015	Addresses prognosis in mechanically ventilated older patients using laboratory values, medical diagnosis, and demographic and ventilation data, relating them to mortality
“Diagnostic value of Pentraxin-3 in patients with sepsis and septic shock in accordance with latest sepsis-3 definitions” ³⁴34. Hamed S, Behnes M, Pauly D, Lepiorz D, Barre M, Becher T et al. Diagnostic value of Pentraxin-3 in patients with sepsis and septic shock in accordance with latest sepsis-3 definitions. BMC Infect Dis [Internet]. 2017 [acesso 24 nov 2021];17(554):1-10. DOI: 10.1186/s12879-017-2606-3 https://doi.org/10.1186/s12879-017-2606-...	2017	Assesses the diagnostic and prognostic factor of PTX-3 in patients with sepsis or septic shock in the ICU
“Early warning score independently predicts adverse outcome and mortality in patients with acute pancreatitis” ³⁵35. Jones MJ, Neal CP, Ngu WS, Dennison AR, Garcea G. Early warning score independently predicts adverse outcome and mortality in patients with acute pancreatitis. Langenbecks Arch Surg [Internet]. 2017 [acesso 24 nov 2021];402(5):811-9. DOI: 10.1007/s00423-017-1581-x	2017	Compares established prognostic scores (examples: APACHE II) and early warning scores (EWS) in patients with acute pancreatitis
“Neutrophil to lymphocyte ratio and platelet to lymphocyte ratio are superior to other inflammation-based prognostic scores in predicting the mortality of patients with gastrointestinal perforation” ³⁶36. Shimoyama Y, Umegaki O, Agui T, Kadono N, Minami T. Neutrophil to lymphocyte ratio and platelet to lymphocyte ratio are superior to other inflammation-based prognostic scores in predicting the mortality of patients with gastrointestinal perforation. JA Clin Rep [Internet]. 2017 [acesso 24 nov 2021];3(49):1-5. DOI: 10.1186/s40981-017-0118-1	2017	Addresses the neutrophil/lymphocyte ratio as an independent predictor of survival with various clinical conditions, comparing various prognostic factors
“Simplified prognostic model for critically ill patients in resource limited settings in South Asia” ³⁷37. Haniffa R, Mukaka M, Munasinghe SB, Silva AP, Jayasinghe KSA, Beane A et al. Simplified prognostic model for critically ill patients in resource limited settings in South Asia. Crit Care [Internet]. 2017 [acesso 24 nov 2021];21(250):1-8. DOI: 10.1186/s13054-017-1843-6 https://doi.org/10.1186/s13054-017-1843-...	2017	Proposes a simplified critical care prognostic model (TropICS) for use in limited resources settings without electronic equipment
“Development and internal validation of the multivariable CIPHER (Collaborative Integrated Pregnancy High-dependency Estimate of Risk) clinical risk prediction model” ³⁸38. Payne BA, Ryan H, Bone J, Magee LA, Aarvold AB, Ansermino M et al. Development and internal validation of the multivariable CIPHER (Collaborative Integrated Pregnancy High-dependency Estimate of Risk) clinical risk prediction model. Crit Care [Internet]. 2018 [acesso 24 nov 2021];22(278):1-13. DOI: 10.1186/s13054-018-2215-6 https://doi.org/10.1186/s13054-018-2215-...	2018	Develops and validates the CIPHER model to predict death or severe morbidity for pregnant or postpartum women, given their unique physiology
“Soluble TREM-1 Serum Level can Early Predict Mortality of Patients with Sepsis, Severe Sepsis and Septic Shock” ³⁹39. Jedynak M, Siemiatkowski A, Mroczko B, Groblewska M, Milewski R, Szmitkowski M. Soluble TREM-1 serum level can early predict mortality of patients with sepsis, severe sepsis and septic shock. Arch Immunol Ther Exp [Internet]. 2018 [acesso 24 nov 2021];66(4):299-306. DOI: 10.1007/s00005-017-0499-x	2018	In search of a simple model that facilitates early prognosis, the authors test a biomarker (sTREM-1) as a new severity score
“Development and external validation of a prognostic nomogram for acute decompensation of chronic hepatitis B cirrhosis” ⁴⁰40. Gao F, Li X, Wan G, Li Y, Zhang Q, Liu Y et al. Development and external validation of a prognostic nomogram for acute decompensation of chronic hepatitis B cirrhosis. BMC Gastroenterol [Internet]. 2018 [acesso 24 nov 2021];18(179):1-9. DOI: 10.1186/s12876-018-0911-y https://doi.org/10.1186/s12876-018-0911-...	2018	Develops a nomogram for diagnostic prediction in patients with acute decompensation due to liver cirrhosis
“Microbial dysbiosis and mortality during mechanical ventilation: a prospective observational study” ⁴¹41. Lamarche D, Johnstone J, Zytaruk N, Clarke F, Hand L, Loukov D et al. Microbial dysbiosis and mortality during mechanical ventilation: a prospective observational study. Respir Res [Internet]. 2018 [acesso 24 nov 2021];19(245):1-12. DOI: 10.1186/s12931-018-0950-5 https://doi.org/10.1186/s12931-018-0950-...	2018	Proposes microbial diversity in the respiratory tract as a new prognostic indicator and criticizes the use of APACHE II for this purpose
“The prognostic performance of qSOFA for community-acquired pneumonia” ⁴²42. Tokioka F, Okamoto H, Yamazaki A, Itou A, Ishida T. The prognostic performance of qSOFA for community-acquired pneumonia. J Intensive Care [Internet]. 2018 [acesso 24 nov 2021];6(46):1-8. DOI: 10.1186/s40560-018-0307-7	2018	Evaluates the prognostic performance of qSOFA, CURB-65 and PSI for both death and ICU admission. It concludes that the three predictors are not significantly different
“Pneumonia in patients with cirrhosis: risk factors associated with mortality and predictive value of prognostic models” ⁴³43. Xu L, Ying S, Hu J, Wang Y, Yang M, Ge T et al. Pneumonia in patients with cirrhosis: risk factors associated with mortality and predictive value of prognostic models. Respir Res [Internet]. 2018 [acesso 24 nov 2021];19(242):1-11. DOI: 10.1186/s12931-018-0934-5 https://doi.org/10.1186/s12931-018-0934-...	2018	Discusses the possibility of optimizing risk stratification in patients with pneumonia due to liver cirrhosis, comparing various prognostic models
“Investigation of microcirculation in patients with venoarterial extracorporeal membrane oxygenation life support” ⁴⁴44. Yeh YC, Lee CT, Wang CH, Tu YK, Lai CH, Wang YC et al. Investigation of microcirculation in patients with venoarterial extracorporeal membrane oxygenation life support. Crit Care [Internet]. 2018 [acesso 24 nov 2021];22(200):1-9. DOI: 10.1186/s13054-018-2081-2 https://doi.org/10.1186/s13054-018-2081-...	2018	Establishes microcirculatory parameters as a prognosis in cardiogenic shock
“A multicenter, prospective evaluation of the Chinese Society of Thrombosis and Hemostasis Scoring System for disseminated intravascular coagulation” ⁴⁵45. Luo L, Wu Y, Niu T, Han Y, Feng Y, Ding Q et al. A multicenter, prospective evaluation of the Chinese Society of Thrombosis and Hemostasis Scoring System for disseminated intravascular coagulation. Thromb Res [Internet]. 2018 [acesso 24 nov 2021];173:131-40. DOI: 10.1016/j.thromres.2018.11.022 https://doi.org/10.1016/j.thromres.2018....	2019	Evaluates the use of CDSS (Chinese Society of Thrombosis and Hemostasis Scoring System for disseminated intravascular coagulation)
“Prognostic accuracy of the serum lactate level, the SOFA score and the qSofa score for mortality among adults with Sepsis” ⁴⁶46. Liu Z, Meng Z, Li Y, Zhao J, Wu S, Gou S, Wu H. Prognostic accuracy of the serum lactate level, the SOFA score and the qSOFA score for mortality among adults with Sepsis. Scand J Trauma Resusc Emerg Med [Internet]. 2019 [acesso 24 nov 2021];27(51):1-10. DOI: 10.1186/s13049-019-0609-3	2019	Explores and compares diagnostic accuracy of the serum lactate level, qSOFA and SOFA for mortality in septic patients
“Prognostic values of the Berlin definition criteria, blood lactate level, and fibroproliferative changes on high-resolution computed tomography in ARDS patients” ⁴⁷47. Kamo T, Tasaka S, Suzuki T, Asakura T, Suzuki S, Yagi K et al. Prognostic values of the Berlin definition criteria, blood lactate level, and fibroproliferative changes on high-resolution computed tomography in ARDS patients. BMC Pulm Med [Internet]. 2019 [acesso 24 nov 2021];19(37):1-9. DOI: 10.1186/s12890-019-0803-0 https://doi.org/10.1186/s12890-019-0803-...	2019	Evaluates the severity criteria of Berlin and other systems, such as high-definition tomography and serum lactate level, for ARDS prognosis
“Circulating microRNAs as biomarkers for Sepsis secondary to pneumonia diagnosed via Sepsis 3.0” ⁴⁸48. Zhang W, Jia J, Liu Z, Si D, Ma L, Zhang G. Circulating microRNAs as biomarkers for Sepsis secondary to pneumonia diagnosed via Sepsis 3.0. BMC Pulm Med [Internet]. 2019 [acesso 24 nov 2021];19(93):1-8. DOI: 10.1186/s12890-019-0836-4	2019	Investigates the use of microRNAs (miRNA) values as a biomarker for prognostic scores in cases of sepsis secondary to pneumonia
“Indicators of severe prognosis of scrub typhus: prognostic factors of scrub typhus severity” ⁴⁹49. Kim HL, Park HR, Kim CM, Cha YJ, Yun NR, Kim DM. Indicators of severe prognosis of scrub typhus: prognostic factors of scrub typhus severity. BMC Infect Dis [Internet]. 2019 [acesso 24 nov 2021];19(283):1-5. DOI: 10.1186/s12879-019-3903-9	2019	Evaluates tumor necrosis factor alpha (TNF-a) levels as a prognostic factor of disease severity (scrub typhus)
“The prognostic value of troponin in pediatric polytrauma” ⁵⁰50. Braun CK, Schaffer A, Weber B, Huber-Lang M, Kalbitz M, Preßmar J. The prognostic Value of Troponin in pediatric Polytrauma. Front Pediatr [Internet]. 2019 [acesso 24 nov 2021];7(477):1-10. DOI: 10.3389/fped.2019.00477	2019	Discusses the use of troponin (TNT) as a predictive factor of prognosis in pediatric polytraumatized patients at the time of hospital admission.
“Hemodynamics in Shock Patients Assessed by Critical Care Ultrasound and Its Relationship to Outcome: A Prospective Study” ⁵¹51. Zou T, Yin W, Li Y, Deng L, Zhou R, Wang X et al. Hemodynamics in shock patients assessed by critical care ultrasound and its relationship to outcome: a prospective study. Biomed Res Int [Internet]. 2020 [acesso 24 nov 2021]; 5175393. DOI: 10.1155/2020/5175393 https://doi.org/10.1155/2020/5175393...	2020	Evaluates the use of critical care ultrasound (CCUS) as a tool for prognosis of patients in shock
“Obstetric early warning score for prognostication of critically ill obstetric patient” ⁵²52. Khergade M, Suri J, Bharti R, Pandey D, Bachani S, Mittal P. Obstetric early warning score for prognostication of critically ill obstetric patient. Indian J Crit Care Med [Internet]. 2020 [acesso 24 nov 2021];24(6):398-403. DOI: 10.5005/jp-journals-10071-23453	2020	Studies the use of Obstetric Early Warning Score (OEWS) for a prognostic clinical score of ICU pregnant patients

Title	Year	Main characteristic
“Ethical implications of risk stratification in the acute care setting” ⁵³53. Knaus W. Ethical implications of risk stratification in the acute care setting. Camb Q Healthc Ethics [Internet]. 1993 [acesso 24 nov 2021];2(2):193-6. DOI: 10.1017/s0963180100000906	1993	Shows APACHE as a tool for dealing with complex situations, providing reasonably accurate information that can be used to develop better decisions for critically ill patients. It considers the system a mere support in decision-making
“The ethical appropriateness of using prognostic scoring systems in clinical management” ⁵⁴54. Luce JM, Wachter RM. The ethical appropriateness of using prognostic scoring systems in clinical management. Crit Care Clin [Internet]. 1994 [acesso 24 nov 2021];10(1):229-41. DOI: 10.1016/S0749-0704(18)30158-1	1994	Views prognostic scores as an aid in medical decision rather than a determinant. It stresses that they improve communication between patient/family/doctors
“Limitation of life support: Frequency and practice in a London and a Cape Town intensive care unit” ⁵⁵55. Turner JS, Michell WL, Morgan CJ, Benatar SR. Limitation of life support: frequency and practice in a London and a Cape Town intensive care unit. Intensive Care Med [Internet]. 1996 [acesso 24 nov 2021];22(10):1020-5. DOI: 10.1007/BF01699222	1996	Examines reasons for withdrawing life support. It indicates multiple organ failure as the sole factor
“Ethik in der Intensivmedizin” ⁵⁶56. List WF. Ethik in der Intensivmedizin. Anaesthesist [Internet]. 1997 [acesso 24 nov 2021];46:261-6. Disponível: https://bit.ly/3NtteU7 https://bit.ly/3NtteU7...	1997	Argues that severity scores (examples: APACHE, SOFA, MPM, SAPS) can only be used for groups of patients, scientific exams or ICU quality, and not for individual triage
“Evaluation of triage decisions for intensive care admission” ⁹9. Sprung CL, Geber D, Eidelman LA, Baras M, Pizov R, Nimrod A et al. Evaluation of triage decisions for intensive care admission. Crit Care Med [Internet]. 1999 [acesso 24 nov 2021];27(6):1073-9. DOI: 10.1097/00003246-199906000-00021 https://doi.org/10.1097/00003246-1999060...	1999	Shows that, despite the prognostic scores, triage for ICU admission is based on another order of priorities, according to which the number of available beds is more significant
“End-of-life decisions in Greek intensive care units: a multicenter cohort study” ⁵⁷57. Kranidiotis G, Gerovasili V, Tasoulis A, Tripodaki E, Vasileiadis I, Magira E et al. End-of-life decisions in Greek intensive care units: a multicenter cohort study. Crit Care [Internet]. 2010 [acesso 24 nov 2021];14:1-9. DOI: 10.1186/cc9380 https://doi.org/10.1186/cc938...	2010	Considers that the lack of response to treatment was the sole limiting factor in therapy
“Ten common questions (and their answers) on medical futility” ⁵⁸58. Swetz KM, Burkle CM, Berge KH, Lanier WL. Ten common questions (and their answers) on medical futility. Mayo Clin Proc [Internet]. 2014 [acesso 24 nov 2021];89(7):943-59. DOI: 10.1016/j.mayocp.2014.02.005	2014	Regarding prognostic scores, it understands that there is no way to accurately determine the days of life of a patient and that such rigid data cannot be predictive of choice to continue or start important medical care
“Predicting the future-big data, machine learning, and clinical medicine” ⁵⁹59. Obermeyer Z, Emanuel EJ. Predicting the future: big data, machine learning, and clinical medicine. N Engl J Med [Internet]. 2016 [acesso 24 nov 2021];375:1216-9. DOI: 10.1056/NEJMp1606181	2016	Criticizes prognostic models and shows how AI can help in the future
“Intensive care unit prognostic factors in critically ill patients with advanced solid tumors: a 3-year retrospective study” ⁶⁰60. Xia R, Wang D. Intensive care unit prognostic factors in critically ill patients with advanced solid tumors: a 3-year retrospective study. BMC Cancer [Internet]. 2016 [acesso 24 nov 2021];16(188):1-7. DOI: 10.1186/s12885-016-2242-0	2016	Shows that both SOFA and APACHE perform poorly. It concludes that both play a limited role in ICU decision-making
“Common intensive care scoring systems do not outperform age and Glasgow coma scale score in predicting mid-term mortality in patients with spontaneous intracerebral hemorrhage treated in the intensive care unit” ⁶¹61. Fallenius M, Skrifvars MB, Reinikainen M, Bendel S, Raj R. Common intensive care scoring systems do not outperform age and glasgow coma scale score in predicting mid-term mortality in patients with spontaneous intracerebral hemorrhage treated in the intensive care unit. Scand J Trauma Resusc Emerg Med [Internet]. 2017 [acesso 24 nov 2021];25(102):1-9. DOI: 10.1186/s13049-017-0448-z	2017	Argues that there is no justification for using prognostic scores in patients with spontaneous intracerebral hemorrhage (ICH) in the ICU
“Estimating severity of influenza epidemics from severe acute respiratory infections (Sari) in intensive care units” ⁶²62. Asten L, Pinzon AL, Lange DW, Jonge E, Dijkstra F, Marbus S et al. Estimating severity of influenza epidemics from severe acute respiratory infections (SARI) in intensive care units. Crit Care [Internet]. 2018 [acesso 24 nov 2021];22(351):1-10. DOI: 10.1186/s13054-018-2274-8 https://doi.org/10.1186/s13054-018-2274-...	2018	Analyzes the severity of influenza epidemics due to acute respiratory infections in the ICU. It suggests that APACHE showed no difference in predictive values, despite the peak in the pandemic and rising mortality showing its seasonality
“Performance of critical care prognostic scoring systems in low and middle-income countries: a systematic review” ⁶³63. Haniffa R, Isaam I, Silva AP, Dondorp AM, Keizer NF. Performance of critical care prognostic scoring systems in low and middle-income countries: a systematic review. Crit Care [Internet]. 2018 [acesso 24 nov 2021];22(18):1-22. DOI: 10.1186/s13054-017-1930-8	2018	Shows that the most commonly used predictive models in the Global North cannot be used in low-income countries

Conselho Federal de Medicina SGAS 915, lote 72, CEP 70390-150, Tel.: (55 61) 3445-5932, Fax: (55 61) 3346-7384 - Brasília - DF - Brazil
E-mail: bioetica@portalmedico.org.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] Correspondence: Roberta Nascimento de Oliveira Lemos dos Santos – Rua Leopoldo Bulhões, 1480, sala 919, Manguinhos CEP 21041-210. Rio de Janeiro/RJ, Brasil.