{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T05:16:54Z","timestamp":1788239814955,"version":"build-2803163510"},"reference-count":72,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T00:00:00Z","timestamp":1788220800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med."],"abstract":"<jats:p>\n                    Significant medical advancements over the last century have reduced in-hospital mortality but raised concerns about prolonged hospitalizations and aggressive treatments potentially compromising the quality of life of critically ill patients. In Brazil, healthcare professionals often encounter ethical dilemmas and hesitancy when navigating orthothanasia and life-sustaining treatment decisions. This review examines the fundamental aspects of palliative care in the Intensive Care Unit (ICU), addressing the research question:\n                    <jats:italic>What are the fundamental aspects of palliative care in the ICU?<\/jats:italic>\n                    The study is positioned as a narrative review with systematic evidence collection, allowing for a multidimensional synthesis of clinical evidence, ethical frameworks, and regulatory challenges. The review focuses on four interrelated dimensions: (1) core clinical components (symptom management, communication, and decision-making); (2) ethical frameworks, specifically principalism and virtue ethics, guiding end-of-life decisions; (3) spiritual and existential care; and (4) contextual challenges in the Brazilian ICU setting, including barriers to life support limitation and strategies to prevent dysthanasia. Data were gathered from systematic searches in PubMed (MEDLINE), Scopus, LILACS, and the Virtual Health Library (VHL), spanning publications from 2004 to 2024, supplemented by legal resolutions and clinical guidelines. From 111 articles identified after deduplication, 36 were selected for full-text analysis following independent screening by two researchers. Key findings underscore the importance of structured communication, individualized symptom management protocols, and the role of virtue-based competencies in mitigating moral distress. Context-specific barriers in Brazil include legal uncertainty and training deficits. The reviewed evidence supports the implementation of structured goals-of-care conferences and interdisciplinary protocols to improve care quality and prevent dysthanasia.\n                  <\/jats:p>","DOI":"10.3389\/fmed.2026.1914706","type":"journal-article","created":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T04:26:41Z","timestamp":1788236801000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Palliative care in the intensive care unit: fundamental aspects, ethical frameworks, and challenges in the Brazilian context"],"prefix":"10.3389","volume":"13","author":[{"given":"Brenno Cardoso","family":"Gomes","sequence":"first","affiliation":[{"name":"Universidade Federal do Paran\u00e1, Departamento de Cl\u00ednica M\u00e9dica","place":["Curitiba, Brazil"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anibal","family":"Basile Filho","sequence":"additional","affiliation":[{"name":"Universidade de S\u00e3o Paulo, Campus de Ribeir\u00e3o Preto, Ribeir\u00e3o Preto","place":["Curitiba, Brazil"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"suffix":"Jr","given":"Joao M.","family":"Silva","sequence":"additional","affiliation":[{"name":"Universidade de S\u00e3o Paulo, Campus de Ribeir\u00e3o Preto, Ribeir\u00e3o Preto","place":["Curitiba, Brazil"]},{"name":"Universidade de S\u00e3o Paulo","place":["S\u00e3o Paulo, Brazil"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,1]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"344","DOI":"10.1136\/jme.2009.035113","article-title":"Evaluation of end-of-life practices in ten Brazilian pediatric and adult intensive care units","volume":"36","author":"Piva","year":"2010","journal-title":"J Med Ethics"},{"key":"ref2","doi-asserted-by":"crossref","first-page":"422","DOI":"10.1590\/S0103-507X2008000400016","article-title":"End-of-life and palliative care in the intensive care unit","volume":"20","author":"Moritz","year":"2008","journal-title":"Rev Bras Ter Intensiva."},{"key":"ref3","volume-title":"Palliative Care","year":"2020"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"953","DOI":"10.1097\/CCM.0b013e3181659096","article-title":"Recommendations for end-of-life care in the intensive care unit: a consensus statement from the American College of Critical Care Medicine","volume":"36","author":"Truog","year":"2008","journal-title":"Crit Care Med"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"2318","DOI":"10.1097\/CCM.0b013e31828cf12c","article-title":"Choosing and using triage criteria for ICU palliative care consultation: a report from the IPAL-ICU advisory board","volume":"41","author":"Nelson","year":"2013","journal-title":"Crit Care Med"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"219","DOI":"10.1089\/jpm.2013.0409","article-title":"Evidence-based palliative care in the intensive care unit: a systematic review of interventions","volume":"17","author":"Aslakson","year":"2014","journal-title":"J Palliat Med"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"770","DOI":"10.1007\/s00134-004-2241-5","article-title":"Challenges in end-of-life care in the ICU. Declaration of the 5th international consensus conference on critical care: Brussels, Belgium; April 2003","volume":"30","author":"Carlet","year":"2004","journal-title":"Intensive Care Med"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"344","DOI":"10.1590\/S0103-507X2012000400007","article-title":"Intensive care: study on physicians' attitudes and perceptions towards end-of-life decisions","volume":"24","author":"Moritz","year":"2012","journal-title":"Rev Bras Ter Intensiva"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"26","DOI":"10.1097\/01.PCC.0000298654.92048.bd","article-title":"End-of-life clinics in seven Brazilian pediatric intensive care units","volume":"9","author":"Lago","year":"2008","journal-title":"Pediatr Crit Care Med"},{"key":"ref10","first-page":"14","article-title":"1st forum of the research group on the end of life of the Brazilian Association of Intensive Care Medicine","volume":"21","author":"Moritz","year":"2009","journal-title":"Rev Bras Ter Intensiva"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"255","DOI":"10.1097\/00003465-200509000-00011","article-title":"Perceptions and responses of critical care nurses to moral distress","volume":"28","author":"Gutierrez","year":"2005","journal-title":"Crit Care Nurs Q"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"428","DOI":"10.1177\/0969733014538890","article-title":"Ethical conflicts and the reflection process in undergraduate nursing students in Brazil","volume":"22","author":"Ramos","year":"2015","journal-title":"Nurs Ethics"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"297","DOI":"10.1136\/jme.29.5.297","article-title":"A virtue ethics approach to moral dilemmas in medicine","volume":"29","author":"Gardiner","year":"2003","journal-title":"J Med Ethics"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"257","DOI":"10.1111\/j.1466-769X.2006.00284.x","article-title":"Facilitating the development of moral insight in practice: teaching ethics and teaching virtue","volume":"7","author":"Begley","year":"2006","journal-title":"Nurs Philos"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"428","DOI":"10.1016\/j.jpainsymman.2017.07.028","article-title":"State of the science of spirituality and palliative care research part I: definitions, measurement, and outcomes","volume":"54","author":"Balboni","year":"2017","journal-title":"J Pain Symptom Manag"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"642","DOI":"10.1089\/jpm.2014.9427","article-title":"Improving the spiritual dimension of whole person care: reaching national and international consensus","volume":"17","author":"Puchalski","year":"2014","journal-title":"J Palliat Med"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"5","DOI":"10.1186\/s41073-019-0064-8","article-title":"SANRA \u2014 a scale for the quality assessment of narrative review articles","volume":"4","author":"Baethge","year":"2019","journal-title":"Res Integr Peer Rev"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"101","DOI":"10.1016\/S0899-3467(07)60142-6","article-title":"Writing narrative literature reviews for peer-reviewed journals: secrets of the trade","volume":"5","author":"Green","year":"2006","journal-title":"J Chiropr Med"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"100381","DOI":"10.1016\/j.ssaho.2022.100381","article-title":"Systematic-narrative hybrid literature review: a strategy for integrating a concise methodology into a manuscript","volume":"7","author":"Turnbull","year":"2023","journal-title":"Soc Sci Humanit Open"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"1017","DOI":"10.1002\/jrsm.1751","article-title":"Narrative reanalysis: a methodological framework for a new brand of reviews","volume":"15","author":"Hall","year":"2024","journal-title":"Res Synth Methods"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"127","DOI":"10.1111\/j.1467-8519.2012.01981.x","article-title":"A costly separation between withdrawing and withholding treatment in intensive care","volume":"28","author":"Wilkinson","year":"2014","journal-title":"Bioethics"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"1318","DOI":"10.1164\/rccm.201505-0924ST","article-title":"An official ATS\/AACN\/ACCP\/ESICM\/SCCM policy statement: responding to requests for potentially inappropriate treatments in intensive care units","volume":"191","author":"Bosslet","year":"2015","journal-title":"Am J Respir Crit Care Med"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"835","DOI":"10.1378\/chest.08-0235","article-title":"Practical guidance for evidence-based ICU family conferences","volume":"134","author":"Curtis","year":"2008","journal-title":"Chest"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"e825","DOI":"10.1097\/CCM.0000000000003299","article-title":"Clinical practice guidelines for the prevention and Management of Pain, agitation\/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU","volume":"46","author":"Devlin","year":"2018","journal-title":"Crit Care Med"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"CD006911","DOI":"10.1002\/14651858.CD006911.pub3","article-title":"Music interventions for improving psychological and physical outcomes in cancer patients","volume":"8","author":"Bradt","year":"2016","journal-title":"Cochrane Database Syst Rev"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"73","DOI":"10.1097\/00003246-199901000-00029","article-title":"Patient responses during rapid terminal weaning from mechanical ventilation: a prospective study","volume":"27","author":"Campbell","year":"1999","journal-title":"Crit Care Med"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"581","DOI":"10.1177\/0269216309107024","article-title":"European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care","volume":"23","author":"Cherny","year":"2009","journal-title":"Palliat Med"},{"key":"ref28","first-page":"3","volume-title":"Methods in Medical Ethics","author":"Sulmasy","year":"2010"},{"key":"ref29","doi-asserted-by":"publisher","first-page":"104","DOI":"10.1007\/s00134-006-0405-1","article-title":"Attitudes of European physicians, nurses, patients and families regarding end-of-life decisions: the ETHICATT study","volume":"33","author":"Sprung","year":"2007","journal-title":"Intensive Care Med"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"2607","DOI":"10.1056\/NEJMsb052907","article-title":"Appropriate use of artificial nutrition and hydration \u2014 fundamental principles and recommendations","volume":"353","author":"Casarett","year":"2005","journal-title":"N Engl J Med"},{"key":"ref31","doi-asserted-by":"publisher","first-page":"79","DOI":"10.1177\/0148607109347209","article-title":"Ethical issues in artificial nutrition and hydration: a review","volume":"34","author":"Geppert","year":"2010","journal-title":"JPEN J Parenter Enteral Nutr"},{"key":"ref32","doi-asserted-by":"publisher","first-page":"1478","DOI":"10.1093\/annonc\/mdq620","article-title":"Artificial nutrition and hydration in the last week of life in cancer patients: a systematic literature review of practices and effects","volume":"22","author":"Raijmakers","year":"2011","journal-title":"Ann Oncol"},{"key":"ref33","doi-asserted-by":"publisher","first-page":"359","DOI":"10.1056\/NEJMsa035086","article-title":"Nurses' experiences with hospice patients who refuse food and fluids to hasten death","volume":"349","author":"Ganzini","year":"2003","journal-title":"N Engl J Med"},{"key":"ref34","doi-asserted-by":"publisher","first-page":"1263","DOI":"10.1001\/jama.1994.03520160047041","article-title":"Comfort care for terminally ill patients: the appropriate use of nutrition and hydration","volume":"272","author":"McCann","year":"1994","journal-title":"JAMA"},{"key":"ref35","author":"Hursthouse","year":""},{"key":"ref36","doi-asserted-by":"crossref","DOI":"10.1093\/oso\/9780195082890.001.0001","volume-title":"The Virtues in Medical Practice","author":"Pellegrino","year":"1993"},{"key":"ref37","doi-asserted-by":"publisher","first-page":"121","DOI":"10.5430\/jnep.v4n1p121","article-title":"G.R.A.C.E. For nurses: cultivating compassion in nurse\/patient interactions","volume":"4","author":"Halifax","year":"2014","journal-title":"J Nurs Educ Pract"},{"key":"ref38","doi-asserted-by":"publisher","first-page":"990","DOI":"10.1164\/rccm.202112-2787ED","article-title":"Providing compassionate care in the ICU","volume":"205","author":"Curtis","year":"2022","journal-title":"Am J Respir Crit Care Med"},{"key":"ref39","doi-asserted-by":"publisher","first-page":"e019701","DOI":"10.1136\/bmjopen-2017-019701","article-title":"What are healthcare providers' understandings and experiences of compassion? The healthcare compassion model: a grounded theory study of healthcare providers in Canada","volume":"8","author":"Sinclair","year":"2018","journal-title":"BMJ Open"},{"key":"ref40","doi-asserted-by":"publisher","first-page":"1057","DOI":"10.1097\/ACM.0000000000004114","article-title":"What is the state of compassion education in health care? A systematic review of compassion training programs","volume":"96","author":"Sinclair","year":"2021","journal-title":"Acad Med"},{"key":"ref41","doi-asserted-by":"publisher","first-page":"116","DOI":"10.1111\/cp.12130","article-title":"The effects of compassion cultivation training (CCT) on health care workers","volume":"21","author":"Scarlet","year":"2017","journal-title":"Clin Psychol"},{"key":"ref42","doi-asserted-by":"publisher","first-page":"e0207261","DOI":"10.1371\/journal.pone.0207261","article-title":"Caring for the caregivers: evaluation of the effect of an eight-week pilot mindful self-compassion (MSC) training program on nurses' compassion fatigue and resilience","volume":"13","author":"Delaney","year":"2018","journal-title":"PLoS One"},{"key":"ref43","doi-asserted-by":"publisher","first-page":"873","DOI":"10.1093\/scan\/nst060","article-title":"Differential pattern of functional brain plasticity after compassion and empathy training","volume":"9","author":"Klimecki","year":"2014","journal-title":"Soc Cogn Affect Neurosci"},{"key":"ref44","doi-asserted-by":"publisher","first-page":"1914","DOI":"10.1007\/s12671-020-01342-5","article-title":"Effects of mindfulness-based interventions on self-compassion in health care professionals: a Meta-analysis","volume":"11","author":"Wasson","year":"2020","journal-title":"Mindfulness (N Y)"},{"key":"ref45","doi-asserted-by":"publisher","first-page":"98","DOI":"10.1016\/j.ijnurstu.2016.10.002","article-title":"Effectiveness of a mindfulness-based intervention on oncology nurses' burnout and compassion fatigue symptoms: a non-randomized study","volume":"64","author":"Duarte","year":"2016","journal-title":"Int J Nurs Stud"},{"key":"ref46","doi-asserted-by":"publisher","first-page":"200","DOI":"10.1016\/j.jpainsymman.2015.02.013","article-title":"Palliative care professionals' inner life: exploring the relationships among awareness, self-care, and compassion satisfaction and fatigue, burnout, and coping with death","volume":"50","author":"Sanso","year":"2015","journal-title":"J Pain Symptom Manag"},{"key":"ref47","doi-asserted-by":"publisher","first-page":"308","DOI":"10.1097\/SPC.0000000000000079","article-title":"Spirituality and religiosity in supportive and palliative care","volume":"8","author":"Delgado-Guay","year":"2014","journal-title":"Curr Opin Support Palliat Care"},{"key":"ref48","year":"2012"},{"key":"ref49","doi-asserted-by":"publisher","first-page":"463","DOI":"10.1590\/s1983-80422013000300011","article-title":"Advance directives of will: a Brazilian model","volume":"21","author":"Dadalto","year":"2013","journal-title":"Rev Bioet"},{"key":"ref50","year":"2006"},{"key":"ref51","first-page":"e-024456","article-title":"National palliative care policy: challenges of professional qualification in palliative care in Brazil","volume":"70","author":"Salman","year":"2024","journal-title":"Rev Bras Cancerol"},{"key":"ref52","doi-asserted-by":"publisher","first-page":"e3324","DOI":"10.1590\/1518-8345.3858.3324","article-title":"Palliative care in primary health care: a scope review","volume":"28","author":"Justino","year":"2020","journal-title":"Rev Lat Am Enfermagem"},{"key":"ref53","doi-asserted-by":"publisher","first-page":"285","DOI":"10.4037\/ajcc2020222","article-title":"Impact of exposure to death or near-death of patients on compassion fatigue in pediatric intensive care nurses","volume":"29","author":"Richardson","year":"2020","journal-title":"Dimens Crit Care Nurs"},{"key":"ref54","doi-asserted-by":"publisher","first-page":"26","DOI":"10.11606\/issn.2316-9044.v20i3p26-50","article-title":"The importance of the implementation of palliative care in the unified health system","volume":"20","author":"Schaefer","year":"2020","journal-title":"Rev Direito Sanit"},{"key":"ref55","doi-asserted-by":"publisher","first-page":"1094","DOI":"10.1016\/j.jpainsymman.2012.05.011","article-title":"Mapping the development of palliative care capacity: a global update","volume":"45","author":"Lynch","year":"2013","journal-title":"J Pain Symptom Manag"},{"key":"ref56","doi-asserted-by":"publisher","first-page":"e20240021en","DOI":"10.62675\/2965-2774.20240021-en","article-title":"Position statement of the Brazilian palliative care academy on withdrawing and withholding life-sustaining interventions in the context of palliative care","volume":"36","author":"Vidal","year":"2024","journal-title":"Crit Care Sci"},{"key":"ref57","doi-asserted-by":"publisher","first-page":"790","DOI":"10.1001\/jama.290.6.790","article-title":"End-of-life practices in European intensive care units: the Ethicus study","volume":"290","author":"Sprung","year":"2003","journal-title":"JAMA"},{"key":"ref58","doi-asserted-by":"publisher","first-page":"S109","DOI":"10.2223\/jped.1627","article-title":"End-of-life care in children: the Brazilian and international perspectives","volume":"83","author":"Lago","year":"2007","journal-title":"J Pediatr"},{"key":"ref59","doi-asserted-by":"publisher","first-page":"461","DOI":"10.1001\/archinte.167.5.461","article-title":"Toward shared decision making at the end of life in intensive care units: opportunities for improvement","volume":"167","author":"White","year":"2007","journal-title":"Arch Intern Med"},{"key":"ref60","doi-asserted-by":"publisher","first-page":"949","DOI":"10.7326\/0003-4819-112-12-949","article-title":"Medical futility: its meaning and ethical implications","volume":"112","author":"Schneiderman","year":"1990","journal-title":"Ann Intern Med"},{"key":"ref61","doi-asserted-by":"publisher","first-page":"1173","DOI":"10.1056\/NEJMp1215620","article-title":"Generalist plus specialist palliative care \u2014 creating a more sustainable model","volume":"368","author":"Quill","year":"2013","journal-title":"N Engl J Med"},{"key":"ref62","doi-asserted-by":"publisher","first-page":"e0706","DOI":"10.1097\/CCE.0000000000000706","article-title":"Facing futility: a practical approach","volume":"4","author":"Kopar","year":"2022","journal-title":"Crit Care Explor"},{"key":"ref63","doi-asserted-by":"publisher","first-page":"162","DOI":"10.1055\/s-0040-1710370","article-title":"End-of-life problems in intensive care units","volume":"42","author":"Metaxas","year":"2021","journal-title":"Semin Respir Crit Care Med"},{"key":"ref64","doi-asserted-by":"publisher","first-page":"461","DOI":"10.1200\/JCO.2012.44.6443","article-title":"Why is spiritual care infrequent at the end of life? Spiritual care perceptions among patients, nurses, and physicians and the role of training","volume":"31","author":"Balboni","year":"2013","journal-title":"J Clin Oncol"},{"key":"ref65","doi-asserted-by":"publisher","first-page":"502","DOI":"10.1089\/jpm.2016.0308","article-title":"Chaplains working in palliative care: who they are and what they do","volume":"20","author":"Jeuland","year":"2017","journal-title":"J Palliat Med"},{"key":"ref66","doi-asserted-by":"publisher","first-page":"268","DOI":"10.1097\/DCC.0000000000000692","article-title":"Managing compassion fatigue in intensive care unit nurses: a systematic review","volume":"41","author":"Yee","year":"2022","journal-title":"Crit Care Nurs Q"},{"key":"ref67","doi-asserted-by":"publisher","first-page":"197","DOI":"10.1097\/JTN.0000000000000663","article-title":"Addressing compassion fatigue in emergency and intensive trauma care settings: a pilot study","volume":"29","author":"Beres","year":"2022","journal-title":"J Trauma Nurs"},{"key":"ref68","doi-asserted-by":"publisher","first-page":"124","DOI":"10.1111\/j.1532-5415.2007.01507.x","article-title":"A systematic review of satisfaction with care at the end of life","volume":"56","author":"Dy","year":"2008","journal-title":"J Am Geriatr Soc"},{"key":"ref69","doi-asserted-by":"publisher","first-page":"593","DOI":"10.1590\/1983-80422015233096","article-title":"Palliative care and primary health care: scoping review","volume":"23","author":"Saito","year":"2015","journal-title":"Rev Bioet."},{"key":"ref70","doi-asserted-by":"publisher","first-page":"2549","DOI":"10.1056\/NEJMra1411746","article-title":"Comfort care for patients dying in the hospital","volume":"373","author":"Blinderman","year":"2015","journal-title":"N Engl J Med"},{"key":"ref71","doi-asserted-by":"publisher","first-page":"543","DOI":"10.1378\/chest.10-0595","article-title":"Randomized, controlled trials of interventions to improve communication in intensive care: a systematic review","volume":"139","author":"Scheunemann","year":"2011","journal-title":"Chest"},{"key":"ref72","doi-asserted-by":"publisher","first-page":"2271","DOI":"10.1001\/jama.2013.282081","article-title":"Effect of communication skills training for residents and nurse practitioners on quality of communication with patients with serious illness: a randomized trial","volume":"310","author":"Curtis","year":"2013","journal-title":"JAMA"}],"container-title":["Frontiers in Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2026.1914706\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T04:26:43Z","timestamp":1788236803000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2026.1914706\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,1]]},"references-count":72,"alternative-id":["10.3389\/fmed.2026.1914706"],"URL":"https:\/\/doi.org\/10.3389\/fmed.2026.1914706","relation":{},"ISSN":["2296-858X"],"issn-type":[{"value":"2296-858X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,1]]},"article-number":"1914706"}}