DANIEL NEVES FORTE
Projetos de Pesquisa
Unidades Organizacionais
Instituto Central, Hospital das Clínicas, Faculdade de Medicina - Médico
LIM/51 - Laboratório de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina
LIM/51 - Laboratório de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina
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bookPart Cuidados paliativos em UTI(2015) FORTE, Daniel Neves- Exploring the Relationship between Shared Decision-Making, Patient-Centered Medicine, and Evidence-Based Medicine(2021) PAEZ, Gustavo; FORTE, Daniel Neves; GABEIRAS, Maria del Pilar LopezShared decision-making is a possible link between the best of patient-centered medicine and evidence-based medicine. This article seeks to describe the link between them. It discusses to what extent the integration of such perspectives is successful in assuring respect for the patient's autonomy. From the evidence herein, we conclude that if the doctor-patient relationship and communication are strengthened to cover all issues relevant to the patient's health and values, is it possible for him or her to achieve more autonomous decisions by this linkage of shared decision-making and patient-centered medicine? Summary: Shared decision-making is a possible link between the best of patient-centered medicine and evidence-based medicine. This article seeks to describe the link between them.
bookPart Abordagem inicial do paciente grave(2013) FORTE, Daniel Neves; JúNIOR, Antônio Paulo Nassar; MARTINS, Herlon Saraiva- Fatores potencialmente associados à decisão de admissão à unidade de terapia intensiva em um país em desenvolvimento: um levantamento de médicos brasileiros(2017) RAMOS, João Gabriel Rosa; PASSOS, Rogerio da Hora; BAPTISTA, Paulo Benigno Pena; FORTE, Daniel NevesABSTRACT Objective: To evaluate the factors potentially associated with the decision of admission to the intensive care unit in Brazil. Methods: An electronic survey of Brazilian physicians working in intensive care units. Fourteen variables that were potentially associated with the decision of admission to the intensive care unit were rated as important (from 1 to 5) by the respondents and were later grouped as ""patient-related,"" ""scarcity-related"" and ""administrative-related"" factors. The workplace and physician characteristics were evaluated for correlation with the factor ratings. Results: During the study period, 125 physicians completed the survey. The scores on patient-related factors were rated higher on their potential to affect decisions than scarcity-related or administrative-related factors, with a mean ± SD of 3.42 ± 0.7, 2.75 ± 0.7 and 2.87 ± 0.7, respectively (p < 0.001). The patient's underlying illness prognosis was rated by 64.5% of the physicians as always or frequently affecting decisions, followed by acute illness prognosis (57%), number of intensive care unit beds available (56%) and patient's wishes (53%). After controlling for confounders, receiving specific training on intensive care unit triage was associated with higher ratings of the patient-related factors and scarcity-related factors, while working in a public intensive care unit (as opposed to a private intensive care unit) was associated with higher ratings of the scarcity-related factors. Conclusions: Patient-related factors were more frequently rated as potentially affecting intensive care unit admission decisions than scarcity-related or administrative-related factors. Physician and workplace characteristics were associated with different factor ratings.
- Oncologists' and Intensivists' Attitudes Toward the Care of Critically Ill Patients with Cancer(2019) NASSAR JR., Antonio Paulo; DETTINO, Aldo Lourenco Abadde; AMENDOLA, Cristina Prata; SANTOS, Rodrigo Alves dos; FORTE, Daniel Neves; CARUSO, PedroBackground: Patients with cancer represent an important proportion of intensive care unit (ICU) admissions. Oncologists and intensivists have distinct knowledge backgrounds, and conflicts about the appropriate management of these patients may emerge. Methods: We surveyed oncologists and intensivists at 2 academic cancer centers regarding their management of 2 hypothetical patients with different cancer types (metastatic pancreatic cancer and metastatic breast cancer with positive receptors for estrogen, progesterone, and HER-2) who develop septic shock and multiple organ failure. Results: Sixty intensivists and 46 oncologists responded to the survey. Oncologists and intensivists similarly favored withdrawal of life support measures for the patient with pancreatic cancer (33/46 [72%] vs 48/60 [80%], P = .45). On the other hand, intensivists favored more withdrawal of life support measures for the patient with breast cancer compared to oncologists (32/59 [54%] vs 9/44 [21%], P < .001). In the multinomial logistic regression, the oncology specialists were more likely to advocate for a full-code status for the patient with breast cancer (OR = 5.931; CI 95%, 1.762-19.956; P = .004). Conclusions: Oncologists and intensivists share different views regarding life support measures in critically ill patients with cancer. Oncologists tend to focus on the cancer characteristics, whereas intensivists focus on multiple organ failure when weighing in on the same decisions. Regular meetings between oncologists and intensivists may reduce possible conflicts regarding the critical care of patients with cancer.
- Association between education in EOL care and variability in EOL practice: a survey of ICU physicians(2012) FORTE, Daniel Neves; VINCENT, Jean Louis; VELASCO, Irineu Tadeu; PARK, MarceloThis study investigated the association between physician education in EOL and variability in EOL practice, as well as the differences between beliefs and practices regarding EOL in the ICU. Physicians from 11 ICUs at a university hospital completed a survey presenting a patient in a vegetative state with no family or advance directives. Questions addressed approaches to EOL care, as well physicians' personal, professional and EOL educational characteristics. The response rate was 89%, with 105 questionnaires analyzed. Mean age was 38 +/- A 8 years, with a mean of 14 +/- A 7 years since graduation. Physicians who did not apply do-not-resuscitate (DNR) orders were less likely to have attended EOL classes than those who applied written DNR orders [0/7 vs. 31/47, OR = 0.549 (0.356-0.848), P = 0.001]. Physicians who involved nurses in the decision-making process were more likely to be ICU specialists [17/22 vs. 46/83, OR = 4.1959 (1.271-13.845), P = 0.013] than physicians who made such decisions among themselves or referred to ethical or judicial committees. Physicians who would apply ""full code"" had less often read about EOL [3/22 vs. 11/20, OR = 0.0939 (0.012-0.710), P = 0.012] and had less interest in discussing EOL [17/22 vs. 20/20, OR = 0.210 (0.122-0.361), P < 0.001], than physicians who would withdraw life-sustaining therapies. Forty-four percent of respondents would not do what they believed was best for their patient, with 98% of them believing a less aggressive attitude preferable. Legal concerns were the leading cause for this dichotomy. Physician education about EOL is associated with variability in EOL decisions in the ICU. Moreover, actual practice may differ from what physicians believe is best for the patient.
- Prognostication in urgent intensive care unit referrals: a cohort study(2020) RAMOS, Joao Gabriel Rosa; DIAS, Roger Daglius; PASSOS, Rogerio da Hora; BATISTA, Paulo Benigno Pena; FORTE, Daniel NevesObjectives Prognostication is an essential ability to clinicians. Nevertheless, it has been shown to be quite variable in acutely ill patients, potentially leading to inappropriate care. We aimed to assess the accuracy of physician's prediction of hospital mortality in acutely deteriorating patients referred for urgent intensive care unit (ICU) admission. Methods Prospective cohort of acutely ill patients referred for urgent ICU admission in an academic, tertiary hospital. Physicians' prognosis assessments were recorded at ICU referral. Prognosis was assessed as survival without severe disabilities, survival with severe disabilities or no survival. Prognosis was further dichotomised in good prognosis (survival without severe disabilities) or poor prognosis (survival with severe disabilities or no survival) for prediction of hospital mortality. Results There were 2374 analysed referrals, with 2103 (88.6%) patients with complete data on mortality and physicians' prognosis. There were 593 (34.4%), 215 (66.4%) and 51 (94.4%) deaths in the groups ascribed a prognosis of survival without disabilities, survival with severe disabilities or no survival, respectively (p<0.001). Sensitivity was 31%, specificity was 91% and the area under the receiver operating characteristic curve was 0.61 for prediction of mortality. After multivariable analysis, severity of illness, performance status and ICU admission were associated with an increased likelihood of incorrect classification, while worse predicted prognosis was associated with a lower chance of incorrect classification. Conclusions Physician's prediction was associated with hospital mortality, but overall accuracy was poor, mainly due to low sensitivity to detect risk of poor prognosis.
bookPart Analgesia, sedação e bloqueio neuromuscular em UTI(2012) FORTE, Daniel NevesbookPart Cuidados paliatvos na unidade de terapia intensiva(2022) FORTE, Daniel Neves- Utilidade da avaliação de bactérias revestidas por anticorpos em aspirados traqueais para o diagnóstico de pneumonia associada à ventilação mecânica: um estudo caso-controle(2016) RANZANI, Otavio Tavares; FORTE, Daniel Neves; FORTE, Antonio Carlos; MIMICA, Igor; FORTE, Wilma Carvalho NevesObjetivo: A pneumonia associada à ventilação mecânica (PAVM) é o principal tipo de infecção adquirida no ambiente hospitalar em pacientes em UTIs. O diagnóstico de PAVM é desafiador, principalmente devido a limitações dos métodos diagnósticos disponíveis. O objetivo deste estudo foi determinar se a avaliação de bactérias revestidas por anticorpos (BRA) pode melhorar a especificidade de culturas de aspirado traqueal (AT) no diagnóstico de PAVM. Métodos: Estudo diagnóstico caso-controle envolvendo 45 pacientes sob ventilação mecânica. Amostras de AT foram obtidas de pacientes com e sem PAVM (casos e controles, respectivamente), e verificamos o número de bactérias revestidas com anticorpos monoclonais conjugados com FITC (IgA, IgM ou IgG) ou anticorpo polivalente conjugado com FITC. Utilizando microscopia de imunofluorescência, foi determinada a proporção de BRA em um número fixo de 80 bactérias. Resultados: A mediana das proporções de BRA foi significativamente maior nos casos (n = 22) que nos controles (n = 23) — IgA (60,6% vs. 22,5%), IgM (42,5% vs. 12,5%), IgG (50,6% vs. 17,5%) e polivalente (75,6% vs. 33,8%) — p < 0,001 para todos. A acurácia dos melhores pontos de corte para o diagnostico de PAVM em relação aos BRA monoclonais e polivalentes foi > 95,0% e > 93,3%, respectivamente. Conclusões: O número de BRA em amostras de AT foi maior nos casos que nos controles. Nossos achados indicam que a avaliação de BRA no AT é uma ferramenta promissora para aumentar a especificidade do diagnóstico de PAVM. A técnica pode ser custo-efetiva e, portanto, útil em locais com poucos recursos, com as vantagens de minimizar resultados falso-positivos e evitar o tratamento excessivo.