THERAPEUTI C FUTI LI TY AS AN ETHI CAL I SSUE: I NTENSI VE CARE UNI T NURSES
1Kar en Kn opp de Car v alh o2 Valér ia Ler ch Lunar di3
Car v alh o KK, Lu n ar di VL. Th er apeu t ic f u t ilit y as an et h ical issu e: in t en siv e car e u n it n u r ses. Rev Lat in o- am En fer m agem 2 0 0 9 m aio- j u n h o; 1 7 ( 3 ) : 3 0 8 - 1 3 .
Ther apeut ic fut ilit y in int ensive car e unit s ( I CUs) is st ill lit t le discussed am ong nur sing pr ofessionals r esponsible for im plem ent ing pr escr ibed pr ocedur es, w hich t hey m ight disagr ee on. Ther efor e, int er v iew s w er e car r ied out w it h I CU nur ses t o under st and how t hey ar e coping w it h t he im plem ent at ion of fut ile t r eat m ent s. Based on t he an aly sis of collect ed d at a, t h e f ollow in g cat eg or ies em er g ed : Th er ap eu t ic f u t ilit y : w h at is it ?; Th er ap eu t ic fut ilit y ext ends suffer ing; Ther apeut ic fut ilit y w it h healing as a pr ior it y; Coping w it h t her apeut ic fut ilit y: hum anized car e? The st udy indicat es t he need t o evaluat e t her apeut ic m easur es pr ovided t o t er m inal pat ient s w it h a view t o im pr oving t heir qualit y of life in t his final phase. When healing is no longer possible, car e is necessar y w it h a v iew t o r espect ing t he sick per son’s int egr it y because car e is t he essence of t he nur sing pr ofession.
DESCRI PTORS: t her apeut ics; healt h; deat h; et hics; nur sing
LA OBSTI NACI ÓN TERAPÉUTI CA COMO UNA CUESTI ÓN ÉTI CA: ENFERMERAS
DE UNI DADES DE TERAPI A I NTENSI VA
La obst inación t er apéut ica, pr esent e en las Unidades de Ter apia I nt ensiv a ( UTI S) , aún es poco discut ida ent r e los p r of esion ales d e en f er m er ía q u e son r esp on sab les p or la im p lem en t ación d e las t er ap éu t icas y con las cu a l es p u ed en d i sco r d a r . Así, p a r a co m p r en d er , co m o l a s en f er m er a s d e UTI s, v i en en en f r en t a n d o l o s t r at am ient os fút iles fuer on r ealizadas ent r ev ist as con est as pr ofesionales. A par t ir del análisis de cont enido de los dat os, f u er on con st r u idas cat egor ías: Obst in ación t er apéu t ica: ¿Qu é es eso?; La obst in ación t er apéu t ica com o la cont inuidad del sufr im ient o; la obst inación t er apéut ica com o la pr efer encia de la cur a; el enfr ent am ient o de la obst inación t er apéut ica: ¿Es un cuidado hum anizado? La evaluación de m edidas t er apéut icas que necesit an ser ut ilizadas en pacient es en pr oceso de m or ir y de m uer t e, de m odo que puedan vivir su vida con calidad es fundam ent al. Cuando no exist en posibilidades de cur ar , es necesar io efect uar el cuidado r espet ando la int egr idad de la per sona enfer m a. El cuidado es la base del ej er cicio pr ofesional de la enfer m er ía.
DESCRI PTORES: t er apéu t ica; salu d; m u er t e; ét ica; en fer m er ía
OBSTI NAÇÃO TERAPÊUTI CA COMO QUESTÃO ÉTI CA: ENFERMEI RAS DE
UNI DADES DE TERAPI A I NTENSI VA
A o b st i n a çã o t e r a p ê u t i ca , p r e se n t e n a s u n i d a d e s d e t e r a p i a i n t e n si v a ( UTI s) , a i n d a é p o u co d i scu t i d a especialm ent e por enfer m eir as, r esponsáv eis por im plem ent ar pr ocedim ent os, dos quais, m uit as v ezes, podem discor dar . Par a com pr eender com o enfer m eir as de UTI s v êm enfr ent ando a aplicação de m edidas t er apêut icas que r econhecem com o fút eis, for am r ealizadas ent r ev ist as com essas pr ofissionais e análise de cont eúdo dos dados, const r uindo- se cat egor ias: - “ Obst inação t er apêut ica: o que é isso?” ; - “ A obst inação t er apêut ica com o o pr olongam ent o do sofr im ent o” ; - “ A obst inação t er apêut ica com o a pr ior ização da cur a” ; - “ Enfr ent am ent o da obst inação t er apêut ica: cuidado hum anizado?” . O t r abalho dem onst r a a necessidade de av aliar as m edidas t er apêut icas a ser em ut ilizadas com pacient es em pr ocesso de m or r er e de m or t e, de m odo que possam viver a fase final de sua vida com qualidade. Quando a cur a não é m ais possível, é necessár io cuidar , r espeit ando a int egr idade da pessoa doent e, pois o cuidado é a base do ex er cício pr ofissional da enfer m agem .
DESCRI TORES: t er apêu t ica; saú de; m or t e; ét ica; en fer m agem
1Paper ext ract ed fr om Mast er ’s Thesis; 2RN, Hospit al Univer sit ár io Dr. Miguel Riet Cor r êa Jr, Fundação Univer sidade do Rio Gr ande, Brazil, M.Sc. in Nur sing,
Facult y, Univer sidade Cat ólica de Pelot as, Br azil, e- m ail: knoppcar [email protected] .br. 3Ph.D. in Nur sing, Fundação Univer sidade do Rio Grande, Br azil, e- m ail:
vlunardi@t erra.com .br.
I NTRODUCTI ON
T
her e ar e m ult iple et hical issues inv olv ed in care provided t o people who are experiencing t he dyingprocess and deat h in t he environm ent of an int ensive
care unit ( I CU) . Much has been discussed on t his t hem e
by several professionals from t he healt h area and ot her
areas, specifically t he pat ient ’s right t o die wit h dignit y
an d t h er ap eu t ic f u t ilit y. Th er ap eu t ic f u t ilit y is also
em ployed as a synonym of fut ile and useless t reat m ent ,
which leads t o a slow and prolonged deat h accom panied
by suffer ing. I t is a m edical at t it ude t hat , aim ing t o
sav e t he liv es of t er m inal pat ient s, subm it s t hem t o
great suffering. By t his at t it ude, one only ext ends t he
dying process, butnot life per se( 1).
Along t he t ex t , t he follow ing t er m s hav e t he
s a m e m e a n i n g : f u t i l e m e d i c a l a c t , d y s t h a n a s i a ,
t her apeut ic fut ilit y and t herapeut ic t enacit y.
Nursing is beginning t o discuss t he issue and
ar t icles on t h e d y in g p r ocess an d d eat h ap p oin t t o
t he possibilit y of ext ending t he life of pat ient s w it hout
consider at ion of t heir qualit y of life and r eal chances
of survival, as w ell as nurses’ difficult ies and suffering
in t hese sit uat ions( 2- 3). The t hem e is consider ed of gr eat relevance for nursing because t his pr ofession per for m s
m a n y o f t h e p r e s c r i b e d t h e r a p i e s . Th u s , h e a l t h
professionals need t o discuss t hese pract ices so as t o
define w hat is current ly expect ed as a m odel of healt h
and life.
I ssu e s r e l a t e d t o t h e r a p e u t i c f u t i l i t y a r e
possibly present in t he rout ine of I CUs w here different
decisions ar e t aken r egar ding t he t r eat m ent of pat ient s
in t he t erm inal phase of t he disease w it hout previous
discussion w it h t he pat ient s t hem selves, t heir fam ilies
and t he healt h t eam and ar e usually r est r ict ed t o one
p er son ’s con sid er at ion , g en er ally t h e p h y sician on
dut y( 4- 5). Ther apeut ic pr ocedur es depend on m edical cr i t e r i a , b u t a f f e ct h e a l t h t e a m w o r k a s a w h o l e ,
sp e ci f i ca l l y n u r si n g w h i ch , w h e n co m p l y i n g w i t h
t h e r a p e u t i cs t h e y d o n o t a g r e e w i t h , ca n su f f e r
i n t en sel y an d q u est i o n t h e v al u es u n d er l y i n g t h i s
pr act ice( 1 , 6 ).
Th e r e f o r e , w e so u g h t t o u n d e r st a n d h o w
nur ses ar e facing t he im plem ent at ion of t her apeut ic
m easu r es t h ey con sider fu t ile.
METHODOLOGI CAL TRAJECTORY
Th is qu alit at iv e, ex plor at or y an d descr ipt iv e
st u d y w as d ev elop ed accor d in g t o Resolu t ion 1 9 6 /
96( 7), appr ov ed by t he Resear ch Et hics Com m it t ee of o n l y o n e o f t h e s t u d i e d h o s p i t a l s b e c a u s e t h e
c o m m i t t e e a t t h e o t h e r i n s t i t u t i o n w a s b e i n g
e st a b l i sh e d . Al l p a r t i ci p a n t s si g n e d t h e f r e e a n d
in for m ed con sen t t er m .
Dat a collect ion w as carried out in t w o hospit als
in a cit y in Rio Gr an de do Su l, Br azil: Hospit al A –
lar g e p r iv at e in st it u t ion , w it h n u n s w or k in g in t h e
n u r sin g t eam , in com m an d posit ion s an d in ser v ice
coor dinat ion; Hospit al B – pr ivat e t eaching inst it ut ion
w it h u n der gr adu at e an d gr adu at e st u den t s. I CUs of
each o f t h e t w o h o sp i t al s h av e t en b ed s an d o n e
r esp on sib le n u r se, on e n u r sin g t ech n ician f or each
t w o beds an d on e ph y sician on du t y f or each w or k
shift , in addit ion t o one phy siot her apist . The nur sing
pr ofessionals’ w eek ly w or k load is 4 4 hour s.
Th e st u dy par t icipan t s w er e n u r ses w or k in g
at t he I CUs of t hese hospit als for m or e t han a y ear
a n d w h o a g r e e d t o p a r t i ci p a t e : f o u r n u r se s f r o m
Hospit al A and t w o nur ses fr om Hospit al B, ident ified
by let t er E follow ed by Ar abic num ber s fr om one t o
six . Sem i- st r uct ur ed int er v iew s w er e car r ied out w it h
t he follow ing quest ions: What do y ou under st and by
t h er ap eu t ic f u t ilit y ? Do y ou b eliev e it ex ist s at t h e
I CU y ou w or k at ? I f y es, how do y ou feel w hen y ou
have t o im plem ent t her apeut ic m easur es you consider
f u t i l e ? W h a t f e e l i n g s d o y o u e x p e r i e n c e i n t h e
im plem ent at ion of t hese t r eat m ent s? How do you cope
w it h t hese sit uat ions? What st rat egies do you believe
could be used?
Cat egor ies of analy sis w er e elabor at ed aft er
su ccessi v e r ea d i n g o f t h e i n t er v i ew s, w h i ch w er e
ar r anged and classified by sim ilar it ies and differ ences
accor ding t o t he descr ibed essences and codificat ion
of collect ed dat a( 8) . This perm anent relat ion w it h t he st udy’s t heoret ical fram ework aim ed t o underst and how
pr ofessionals ident ify sit uat ions of t herapeut ic fut ilit y,
how t hey experience it and what fact ors influence t he
decision m aking process, wit h a view t o appoint ing t he
feelings ex per ienced and pot ent ial st r at egies t o cope
wit h t hese sit uat ions. Four cat egories of analysis were
const r uct ed and ar e pr esent ed her ein.
RESULTS AND DI SCUSSI ON
Ther apeut ic fut ilit y : What is t his?
To u n d er st an d h ow n u r ses ar e cop in g w it h
con sid er f u t ile, f ir st , t h ey h ad t o ack n ow led g e t h e
ex ist ence of t hese t r eat m ent s in t he I CUs t hey w or k
at . The m aj or it y w as not fam iliar w it h t he m eaning of
t h er apeu t ic f u t ilit y ( E1 , E4 , E5 , E6 ) at t h e m om en t
t hey w er e quest ioned about t heir under st anding and
w het her t hese t r eat m ent s w er e pr escr ibed in t he I CU
t hey w or ked at . Thus, w e opt ed t o r ead t he definit ion
of t herapeut ic fut ilit y( 9) aft er t he fir st quest ion and it s r esp ect iv e an sw er.
The lar ger par t of nur ses, despit e not being
fam iliar w it h t he t er m , affir m ed aft er it s clar ificat ion
t h at t h ey ex per ien ced t h e pr oblem at t h e I CU t h ey
w or k ed at an d con sid er ed it v er y f r eq u en t , as t h is
r epor t show s: Well, I didn’t know w hat t he t er m m eant , so I
had t o ask you about it ‘cause I had no idea, but aft er you t old m e
w hat it is, I know w e exper ience it a lot her e at t he I CU ( E1) .
The r epor t ed lack of k now ledge on t he t er m
r e f l e c t s t h e p r e v a l e n c e , e v e n n o w a d a y s , o f a
predom inant ly t echnicist m odel in t he hospit al cont ext
in w h ich p r act ice an d t ech n iq u e ar e ov er v alu ed in
d e t r i m e n t o f a m o r e h u m a n i st o n e( 1 0 ). Th u s, t h e n u r se s’ w o r k se e m s st a n d a r d i ze d a n d p r e se r v i n g
order in t he unit and seeing t o t he pat ient ’s biological
needs are t he priorit y. St ill, per haps even t hese needs
ar e n ot b ein g m et b ecau se t h ey ar e an aly zed an d
defin ed m ost ly by h ealt h pr ofessionals, ign or in g t he
p a t i e n t ’ s w i l l . Ch a n g e s i n m a n y p r a c t i c e s s t i l l
consider ed adequat e and accept able in I CUs m ay be
possible t hr ough t he ex er cising of t hink ing.
Al t h o u g h t h er a p eu t i c f u t i l i t y i s a p r o b l em
rout inely faced in I CUs, it s percept ion and quest ioning
b y p r o f e ssi o n a l s m a y r e q u i r e f u r t h e r t h e o r e t i ca l
k now ledge. Lack of k now ledge on t he issue leads t o
t h e p e r c e p t i o n t h a t d y s t h a n a s i a i s n o r m a l a n d
necessar y in pat ient s’ t r eat m ent .
Ther apeut ic fut ilit y ex t ends suffer ing
Som e nur ses explained t hat t hey under st and
t h er ap eu t i c f u t i l i t y as a w ay t o ex t en d t h e l i f e o f
t erm inal pat ient s, ext ending t heir suffering as w ell. I t
m eans t o ext end t he t im e of a pat ient w hom you know is going t o
die, you know it ’s useless t o use any possible r esour ce. I t w on’t
r ever t his condit ion. I feel sor r y for t hese people, not because
t hey’re going t o die, but because t hey go t hrough all t his suffering
and you know it ’s useless ( E5) .
S o m e n u r s e s , p o s s i b l y d u e t o l a c k o f
under st anding and consider at ion about w hat can, or
bet t er y et , w h at n eeds t o be don e f or each pat ien t
w h o ex p er ien ces a sit u at ion of t er m in al illn ess( 1 1 ),
r ep or t ed f eelin g t h at t h ey ar e im p lem en t in g f u t ile
therapeutics that cause suffering to patients, which leads
to antagonistic feelings. [ …] som etim es you get angry, ‘cause
you’re doing som e futile thing and you’re not changing that patient’s
situation, but then you create bonds and think that it’s better and
think that deep, deep down, who knows, there’s hope (E3).
I n t h e t h e r a p e u t i c f u t i l i t y p e r s p e c t i v e ,
u n s p e c i f i e d i n v e s t m e n t i n t h e p a t i e n t s ’ h e a l i n g
t r eat m ent , coupled w it h feelings of hope in pat ient s’
i m p r o v e m e n t , se e m s t o b e m o t i v a t e d b y n u r se s’
difficult ies in dealing w it h deat h and t he dying process
and not by t he ack now ledgm ent of pow er lessness in
p r ev en t in g t h em . Th u s, t h er ap ies ar e n eed ed t h at
m aint ain t he illusion t hat cure w ill be achieved even if
one does not see it s r eal possibilit y.
The im plem ent at ion of dyst hanasia also seem s
t o b e b a se d o n n u r se s’ r e l i g i o u s co n ce p t i o n t h a t
disease and consequent suffer ing can be r edem pt ion
f or d eb t cau sed b y m ist ak es com m it t ed d u r in g t h e
pat ient ’s life. I keep t hinking, gosh, som et im es I t hink t hat w e
have t o pay for a lot of t hings here on eart h, it t akes so long t o die,
it get s even longer w it h t hem w orking so hard like t his, it ext ends
it even m or e ( E6) . This w ay, ext ending life as m uch as
possible w it hout consider ing t he qualit y of life t hat is
being ex t ended, as w ell as pat ient s’ suffer ing in t he
p r o cess, n o t q u est i o n i n g t h ei r w i sh es an d o p t i o n s
regarding what t hey are put t ing up wit h, seem s t o be
j ust ified [ …] I have very religious people working here at t he I CU
who believe we have t o keep t rying as long as t here’s life ( E3) .
Qualit y of life, in t erm s of t herapeut ic fut ilit y,
even if subj ect ive, can be under st ood as a pr ocess of
dy ing w it hout pain and suffer ing, r espect ing pat ient s’
w ishes and allow ing t hem and t heir fam ily m em ber s
t o shar e t heir ex per iences( 10).
Ther apeut ic fut ilit y w it h healing as t he pr ior it y
Ot h e r n u r se s a p p o i n t e d t h a t t h e r a p e u t i c
f u t ilit y m ean s t o im p lem en t t h er ap y t h ey con sid er
f u t ile, h ow ev er, n ecessar y becau se h ealin g pat ien t s
is a pr ior it y, as t his r epor t show s: [ …] her e at t he I CU w e
have t he habit of invest ing in t he pat ient , m any t im es w e know
it ’s about a t erm inal pat ient and t here’s no ret urn. The invest m ent
is consider able in t er m s of ex pensiv e ant ibiot ics, v ent ilat ion,
bet t er r espir at or s; w e only don’t w or k on pat ient s w it h cer ebr al
deat h. On t he ot hers we invest as m uch as we can. There’re cases
t he pat ient w ill not sur vive and t he physician keeps t r ying. We
know t hat t hat a pat ient w ill not r ecover , only t hat , at least m e, I
t alk for m yself, I ’ll go if I have t o adm inist er som e m edicat ion, I
angr y, it is r ight for m e. I go w it h t he cer t aint y t hat t hat is w hat
I have t o do ( E1) .
Ma n y o f t h e m e a su r e s a d o p t e d b y t h e se
p r o f essi o n a l s m i g h t b e b a sed o n t h e b en ef i cen ce
pr inciple and t hey believ e t hat , t hr ough m aint enance
of life, t hey ar e fav or ing t he pat ient and m inim izing
har m , deat h, appar ent ly in t he fait h t hat “ w hile t her e’s
life, t here’s hope”. Expressions like t his are frequent ly
h ear d in t h e h osp it al con t ex t an d sh ow t h e h ealt h
professionals’ need t o deal w it h condit ions of cert aint y,
w it hout t im e for doubt s or quest ions. Thus, decisions
ab ou t lif e an d d eat h sh ou ld b e m ad e u n d er t h ese
par am et er s an d it is n ecessar y t o k eep f igh t in g f or
l i f e u n t i l o n e i s ce r t a i n a b o u t d e a t h( 1 ). Th i s w ay, pr of ession als m igh t be im plem en t in g car e based on
t he at t em pt t o avoid t he pat ient s’ deat h.
Becau se t h e p at ien t is d is- id en t if ied d u r in g
t his pr ocess, his( er ) r eal pot ent ial t o r ecov er cannot
be disregarded, because t her e is no t im e t o lose w it h
quest ioning. When healt h is only absence of disease
an d m ed icin e is on ly t ech n oscien t if ic an d cu r at iv e,
t h e h ealt h t eam ’ at t en t ion t en ds t o r est r ict it self t o
t he pat hology under t r eat m ent . How ev er, one has t o
quest ion if beneficence can be r educed t o t he sim ple
achiev em ent of cur e, r egar dless of it s r eal possibilit y
and associat ed suffering. I n t he per spect ive of healt h
as g lob al w ellb ein g , in v olv in g p h y sical, m en t al an d
s o c i a l a s p e c t s , o n e h a s t o a t t e n d t h e p a t i e n t
consider ing beneficence as a set of v alues t hat lead
t o w ellbeing( 12).
Of t e n t i m e s, h e a l t h p r o f e ssi o n a l s m a y n o t
r e a l i z e o r ca n e v e n d e n y t h e y a r e d e ci d i n g t h e
p a t i en t s’ f a t e. Ho w ev er, d i f f er en t a ct i o n s l i k e t h e
physician’s decision of hospit alizing or not hospit alizing
som eone at t he I CU, opt ing for one t r eat m ent or t he
o t h e r, v e r b a l o r d e r s t o p e r f o r m ca r d i o p u l m o n a r y
resuscit at ion or not and t he im plem ent at ion of rout ine
n u r sin g car e ar e d ecision s m ad e on t h e liv in g an d
a l so d y i n g p r o cesses o f p eo p l e a n d o n h o w t h ei r
f am ilies w ill ex per ien ce t h e pat ien t ’s dy in g pr ocess,
t h at is, on ly t h e p at ien t ’s p h y sical r em ov al d u e t o
h osp it alizat ion in a closed en v ir on m en t of d if f icu lt
access is con sider ed.
Th e n u r ses t h em sel v es so m et i m es i n i t i at e
ca r d i o p u l m o n a r y r e su sci t a t i o n b a se d o n p r e v i o u s
v e r b a l o r i e n t a t i o n . I t i s c o m m o n f o r t h e s e
pr ofessionals t o st ar t t he pr ocedur e in case of night
shift s unt il t he phy sician is pr esent . Ot her t im es, t he
phy sician on dut y per for m s t his pr ocedur e, how ever,
m ak in g t h is decision w it h ou t pr ev iou s con sider at ion
of t he pat ient ’s chances of r ecov er y, nor his( er ) w ill
and/ or t hat of fam ily m em ber s. This decision is solely
b a se d o n t h e a t t e m p t t o a v o i d d e a t h . Th e r e a r e
e x t r e m e c a s e s w h e n t h e f a m i l y s p o n t a n e o u s l y
int er fer es, lik e in t he follow ing r epor t . I had a 15- y ear
gir l hospit alized her e because of r espir at or y failur e for a ver y
long t im e, we never found out about t he diagnosis. She went back
t o t he r oom , st opped br eat hing t w o t im es and cam e back t o us,
and w e alw ays r ever t ed t he sit uat ion, alw ays. And t he last t im e
sh e w as h osp it alized h er e, I t h in k t h at it w as h er f ou r t h
hospit alizat ion in t he I CU, she cam e wit h cardio respirat ory arrest
and w e’d t r y t o r ever t t he sit uat ion; all beds w er e occupied, w e
set up an ext r a bed in t he I CU and got an elevent h bed. When w e
st ar t ed t o w or k w it h t he pat ient , she w as alr eady int ubat ed, her
m ot her knocked on t he door and asked m e not t o t ry t o resuscit at e
t he gir l. At t he t im e it w as shocking and I didn’t even t hink about
it , it seem ed I had not hear d t hat , I denied it . I w ent back, t alked
t o t he physician w ho w as also t aken aback, ever ybody w as t aken
aback, t he physician w ent t o t he door , t alked t o t he m ot her . She
said: “ m y daught er is suffer ing, it has been an year I ’m suffer ing
w it h t his, m y daught er is suffer ing, and I don’t see she’s com ing
back, I don’t see any recovery and I don’t want you t o resuscit at e
m y daught er .” The physician cam e back and said: “ Let ’s st op” .
When she said t hat , I got par alyzed. Like, t o t r y t o under st and
t hat m ot her, because it ’s difficult for a m ot her t o com e t o you and
say: “ don’t r esuscit at e m y child anym or e.” We r eally didn’t , w e
st opped everyt hing, w ho w as w it h t he am bu bag t ook it out . That
aft er noon w as t ot ally silent , ev er y one t ak ing car ing of t heir
pat ient s, you could have hear d a pin dr op ( E1) .
Th i s w a y, t h e r a p e u t i c r e s o u r c e s c a n b e
abusively used, valuing life regardless of it s condit ions,
creat ing sit uat ions in w hich t herapeut ic fut ilit y can be
obser v ed, and t her e is no clear definit ion of w hat is
t he best for t he pat ient , as can also be per ceiv ed in
t his r epor t : [ …] you see t he pat ient is t her e only because of t he
m edicat ion. You know t hat effect w ill st op and he’s going t o st op
again. The pat ient st ops and t hey keep r esuscit at ing him . I ’ve
even hear d: “ …w e’ve got t o keep him up t o eight o’clock w hich is
w hen m y shift ends” ( E5) .
Resuscit at ion m aneuver s can be im plem ent ed
d u e t o h e a l t h p r o f e ssi o n a l s’ f e a r o f b e i n g l e g a l l y
c h a r g e d w i t h n o t p r o v i d i n g t h e r a p e u t i c c a r e t o
p at ien t s. How ev er, in ot h er sit u at ion s, t h er e is t h e
opt ion not t o per for m car diopulm onar y r esuscit at ion
an d t h er e is n o r ecor d w h at soev er in t h e p at ien t ’s
file. Ev en w hen t hese m aneuv er s ar e per for m ed, t he
fam ily is not previously consult ed. Healt h professionals
seem som ew hat afr aid and uncer t ain, and t her e even
seem s t o be som e lack of know ledge on t he ext ent t o
The choice not t o r esuscit at e t he pat ient does
not ex clude ot her nur sing and m edical car e because
it does not im ply in abandoning basic necessar y care.
As t h e p at ien t is con sid er ed in cu r ab le, t h er ap eu t ic
r esou r ces d est in ed t o car e sh ou ld ov er com e t h ose
dest in ed t o cu r e. Th u s, basic n u r sin g car e lik e or al
h y gien e, sk in car e, ch an gin g t h e pat ien t ’s posit ion ,
am ong ot her s, should be m aint ained( 13).
Coping w it h t her apeut ic fut ilit y : hum anized car e?
For issues relat ed t o t herapeut ic fut ilit y, som e
nur ses appoint ed t he adopt ion of hum anized car e as
a coping st rat egy, t hough t hey did not indicat e how t o
put it in pract ice. We consider t hat t he im plem ent at ion
of h u m an ized car e m ain ly im plies per son alizin g t h e
pat ient hospit alized in t he I CU.
Th e r e p o r t o f E1 , w h e n s h e r e f e r s t o a
quadr iplegic pat ient w ho w as hospit alized in t he unit
for m any m ont hs and pr esent ed sever al com plicat ions,
in clu d in g r esp ir at or y f ailu r e an d t r ach eot om y w it h
consequent difficult y for w eaning fr om t he r espirat or,
w eight loss, am ong ot hers, show s nur ses’ difficult y t o
co m m u n i ca t e w i t h p a t i e n t s, h i n d e r i n g k n o w l e d g e
about w hat t hey w ish for t hem selves, w hich can favor
t herapeut ic fut ilit y. He doesn’t t alk, so w e know not hing, and
of cour se, w e don’t have t he gut s t o ask if he know s he can’t
m ove. I t ’s such a sit uat ion… We alr eady t old him he couldn’t
m ove, t hat he has t o t ake exam s, w e’r e not sur e. Ever y t im e w e
t alk t o him , we end up giving him som e hope because we’re never
sur e. I n nur sing, nobody is sur e, w e’r e t r ying, w ill t ake exam s
“ let ’s see if you’ll m anage t o r ecover , t her e’s physiot her apy” , w e
alw ays give him som e hope. We never say t o t he pat ient w hat he
r eally has. Things not w ell r esolved ar e ver y difficult t o cope
w it h ( E1) .
Man y pr of ession als f ace dif f icu lt ies t o list en
t o pat ien t s. Bef or e t h ey t r y t o ex pr ess t h em selv es,
t h e y a l r e a d y g i v e t h e m a p p a r e n t l y c o n v e n i e n t
ex plan at ion s, as a pr ot ect ion n ot t o addr ess issu es
r egar ding t he diagnosis and pr ognosis of t he disease,
d e a t h a n d d y i n g . Po s s i b l y d u e t o d i f f i c u l t i e s i n
addressing t his issue, opport unit ies for dialoguing are
n ot cr eat ed , w h ich m ay r est r ict p at ien t s’ p ot en t ial
doubt s and quest ions.
I t seem s t o be n ecessar y t o list en m or e t o
pat ient s, t alk about t heir v alues r elat ed t o t he dy ing
pr ocess and deat h, life per spect iv e, how t he disease
sym pt om s and t r eat m ent affect t hem . I t is im por t ant
t hat m or e t han one pr ofessional t alk s t o t he pat ient ,
o b t a i n s i n f o r m a t i o n a n d d i scu sses i t i n p er i o d i ca l
m ult ipr ofessional m eet ings on t he best w ay t o m ov e
ahead. Alt hough nur ses usually occupy gr eat par t of
t heir scarce t im e w it h several t asks, w hich are usually
t oo m an y, d ialog is n ecessar y, d u e t o it s essen t ial
i m p o r t a n c e t o e s t a b l i s h c r i t e r i a f o r p a t i e n t s ’
t r eat m ent( 14).
I t is also im por t ant t o clar ify opt ions of car e
a n d t h ei r p o t en t i a l co n seq u en ces d u r i n g a d i a l o g
b e t w e e n n u r se a n d p a t i e n t . Fo r p a t i e n t s t o h a v e
o p t i o n s, t h ey n eed t o k n o w t h ese o p t i o n s. I n t h e
palliat iv e car e m odel, w h ich is ch ar act er ized by t h e
c o n t r o l o f p a t i e n t s w i t h a c t i v e a n d p r o g r e s s i v e
d i s e a s e s i n a n a d v a n c e d p h a s e , f o r w h i c h t h e
prognost ic is lim it ed and care is focused on qualit y of
life, spending t im e clar ify ing opt ions t o pat ient s and
t heir fam ily m em ber s is essent ial( 15).
Th er ef or e, dialog can be est ablish ed bef or e
procedures and t herapies are im plem ent ed, asking for
t he pat ient ’s consent , acknowledging t he individual and
p r eser v in g t h e h u m an n at u r e of r elat ion s b et w een
individuals who experience radical sit uat ions of ext rem e
v u ln er ab ilit y. Ask in g f or con sen t is a m in im u m an d
m andat ory procedure t hat shows responsibilit y for t he
p at ien t an d p r ot ect s h im ( er ) f r om p ot en t ial ab u se,
assuring and prom ot ing an et hical relat ionship bet ween
people who do not know each ot her( 16).
I n a d d i t i o n t o d i a l o g i n g w i t h t h e p a t i e n t ,
nurses should also t alk t o t he nursing t eam , physicians
and ot her pr ofessionals w ho m ight pr ov ide car e and
a l s o e s t a b l i s h c o - r e s p o n s i b i l i t y a n d c o n s t r u c t
t eam w or k as a w ay t o pr oduce gr eat er com m it m ent
of everyone in t he pat ient ’s benefit , j oint ly est ablishing
t he best act ions t o be adopt ed. I n t his com plexit y of
r elat ion s, t h e set of pr of ession als is r espon sible f or
get t in g in v olv ed w it h pat ien t s an d f am ily m em ber s,
including t hem in t he car e deliver ed as a w ay t o m ake
t hem act ive and capable of assum ing t heir ow n car e.
We b e l i e v e t h a t e x e r ci si n g t h i n k i n g i s a n
im p or t an t st r at eg y t o p r ov id e t ools f or t h e car e of
pat ien t s in t h e t er m in al ph ase of disease, an d also
per m it s r eflect ion on t he best act ions t o be adopt ed
w it h a v iew t o av oiding dy st hanasia.
Et hical issues lik e t her apeut ic fut ilit y should
b e i n cl u d e d i n t h e e d u ca t i o n p r o ce ss o f n u r si n g
p r o f essi o n al s, i d eal l y i n si t u at i o n s o f p r act i ce an d
su per v ised t r ain in g, aim in g t o edu cat e pr ofession als
capable of ally ing t echnical com pet ence w it h hum an
CONCLUSI ON
Ther apeut ic fut ilit y is a cur r ent pr oblem and
is very present in I CUs w her e sever al high t echnology
eq u ip m en t s can p r eser v e lif e, ev en in cases w h er e
v i t a l o r g a n s a n d o t h e r s t r u c t u r e s a r e s e v e r e l y
af f ect ed .
Ref lect in g on t h e m ean in g s of ex p er ien ced
pr act ices and v alues consider ed in t he ev aluat ion for
choosing t herapies is im por t ant as it perm it s changing
pr act ice. Not im plem en t in g h ealin g t r eat m en t s does
not m ean let t ing t he pat ient die, but it act ually m eans
t o accept t he deat h pr ocess t hat cannot be av oided.
Nu r ses ca n co n t r i b u t e t o m a i n t a i n q u a l i t y o f l i f e,
p er f or m in g car e t h at d im in ish es p h y sical p ain an d
psy ch ic su f f er in g an d at t en din g t o pat ien t s’ w ill, as
w ell as fav or ing closeness t o fam ily m em ber s.
A et h ical r elat ion w h er e pat ien t s’ au t on om y
is r espect ed can be est ablished t hr ough sm all at t it udes
l i k e d e ci d i n g t o g e t h e r w i t h p a t i e n t s o n t h e m o st
convenient m om ent for t heir bed- bat h, accept ing t heir
r efusal t o t ake som e m edicat ion, m aking t heir pr ivacy
a p r ior it y w h en p er f or m in g p r oced u r es t h at ex p ose
t h e i r b o d y, ca l l i n g t h e m b y t h e i r n a m e , sh o w i n g
con cer n if an y pr ocedu r e cau ses pain . Ot h er copin g
st r at egies can be discussed by healt h t eam s w ho w or k
at t he I CU, and ot her st udies and discussions on t he
t opic ar e n eeded.
Th e st u dy r ev eals t h e n eed an d im por t an ce
of assu m in g t h is con sid er ab le et h ical ch allen g e t o
evaluat e t her apeut ic m easur es t hat should be included
in pat ient s’ t r eat m ent in t he dying pr ocess and deat h,
so as t o assure t hat t hey live t he final phase of t heir
liv es w it h qualit y. Consider ing t hat , w hen cur e is no
longer possible, car e is necessar y, and concer n w it h
t h e p a t i e n t a n d r e sp e ct f o r h i s( e r ) i n t e g r i t y a r e
essen t ial, k eep in g in m in d t h at car e is in h er en t t o
ex er cise t h e n u r sin g pr ofession .
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