DYSTHANASI A, EUTHANASI A, ORTHOTANASI A: THE PERCEPTI ONS OF NURSES
W ORKI NG I N I NTENSI VE CARE UNI TS AND CARE I MPLI CATI ONS
Ch aian e Am or im Bion do1 Mar ia Júlia Paes da Silva2 Lígia Mar ia Dal Secco3
Biondo CA, Silva MJP, Secco LMD. Dy st hanasia, eut hanasia, or t hot anasia: t he per cept ions of nur ses w or k ing in int ensiv e car e unit s and car e im plicat ions. Rev Lat ino- am Enfer m agem 2009 set em br o- out ubr o; 17( 5) : 613- 9.
This st udy aim ed t o analyze t he per cept ions of nur ses w or king in t he I nt ensive Car e Unit ( I CU) of a Univer sit y Hospit al in Br azil concer ning dy st hanasia, or t hot anasia and eut hanasia and char act er ize pot ent ial im plicat ions of t heir per cept ions for car e. This quant it at ive st udy w as car r ied out w it h t he applicat ion of a quest ionnair e t o 2 7 n u r ses af t er ap p r ov al f r om t h e in st it u t ion ’s Et h ics Com m it t ee an d au t h or izat ion f r om p ar t icip an t s w er e obt ained. None of t he nur ses w er e able t o ex plain eut hanasia, half of t hem ex plained dy st hanasia, and only a t hir d explained or t hot anasia, 65.39% r ecognized som e of t hese pr ocesses in t heir daily pr act ice, 25.9% believed nur ses cannot pr ovide any cont r ibut ion even being fam iliar w it h t hese concept s and t heir applicabilit y, 82.36% believed t hat know ledge of bioet hical pr inciples is r elevant but only 14.81% w er e able t o m ent ion t hese pr inciples. Th e b ases of n u r ses’ p r of ession al p r act ice w er e n ot h om og en eou s an d k n ow led g e ab ou t t h e su b j ect w as lim it ed. Or t h ot an asia, bioet h ical pr in ciples an d t h e deliv er y of h u m an ized car e sh ou ld be t h e f ou n dat ion of n u r sin g car e.
DESCRI PTORS: bioet hical issues; hum anizat ion of assist ance; int ensiv e car e unit s; eut hanasia; com m unicat ion
DI STANASI A, EUTANASI A Y ORTOTANASI A: PERCEPCI ONES DE LOS ENFERMEROS DE
UNI DADES DE TERAPI AS I NTENSI VA E I MPLI CACI ONES EN LA ASI STENCI A
Los obj et iv os de est e est udio fuer on analizar las per cepciones de los enfer m er os que act úan en la UTI de un hospit al univer sit ar io, en Br asil, sobr e dist anasia, or t ot anasia y eut anasia y car act er izar las posibles im plicaciones en la asist encia. Se t r at a de u na in v est igación con abor daj e cuan t it at iv o, aplicándose un cuest ionar io en 2 7 enfer m er os, después de la aut or ización del Com it é de Ét ica de la I nst it ución y de la acept ación for m al de los suj et os. Ningún enfer m er o supo ex plicar la eut anasia, la m it ad ofr eció un concept o de dist anasia y apenas un t er cio la or t ot an asia. Del t ot al, 6 5 , 3 9 % r econ ocen alg u n o d e esos p r ocesos en su p r áct ica d iar ia, 2 5 , 9 % afir m an que no cr een que el enfer m er o pueda cont r ibuir sabiendo esos concept os y su aplicabilidad, 82, 36% r elat ar on ser im por t an t e saber los pr in cipios bioét icos, sin em bar go solam en t e 1 4 , 8 1 % su pier on cit ar los. El fundam ent o par a act uar pr ofesionalm ent e, ent r e los enfer m er os, no fue hom ogéneo y el conocim ient o acer ca del t em a t odav ía es lim it ado. La búsqueda por la or t ot anasia, los pr incipios bioét icos y la hum anización de la asist encia deber ían ser fundam ent os de su asist encia.
DESCRI PTORES: discusiones bioét icas; hum anización de la at ención; unidades de t er apia int ensiv a; eut anasia; com u n icación
DI STANÁSI A, EUTANÁSI A E ORTOTANÁSI A: PERCEPÇÕES DOS ENFERMEI ROS DE
UNI DADES DE TERAPI A I NTENSI VA E I MPLI CAÇÕES NA ASSI STÊNCI A
Os obj et iv os dest e est udo for am analisar as per cepções dos enfer m eir os que at uam em UTI de um hospit al u n iv er sit ár io, n o Br asil, sobr e dist an ásia, or t ot an ásia e eu t an ásia e car act er izar as possív eis im plicações n a assist ência. Tr at a- se de pesquisa com abor dagem quant it at iv a, aplicando- se quest ionár io em 27 enfer m eir os, após au t or ização do Com it ê de Ét ica da I n st it u ição e aceit e f or m al dos su j eit os. Nen h u m en f er m eir o sou be con cei t u ar eu t an ási a, m et ad e con cei t u ou d i st an ási a e ap en as u m t er ço a or t ot an ási a. Do t ot al , 6 5 , 3 9 % r econ h ecem algu m desses pr ocessos em su a pr át ica diár ia, 2 5 , 9 % af ir m am n ão acr edit ar qu e o en f er m eir o p od e con t r ib u ir sab en d o d esses con ceit os e su a ap licab ilid ad e, 8 2 , 3 6 % r elat ar am ser im p or t an t e sab er os pr incípios bioét icos, m as som ent e 14,81% souber am cit á- los. O fundam ent o do agir pr ofissional dos enfer m eir os não foi hom ogêneo e o conhecim ent o acer ca do t em a ainda é lim it ado. A busca pela or t ot anásia, os pr incípios bioét icos e a hum anização da assist ência dev er iam ser fundam ent os de sua assist ência.
DESCRI TORES: t em as b i o ét i co s; h u m an i zação d a assi st ên ci a; u n i d ad es d e t er ap i a i n t en si v a; eu t an ási a; co m u n i cação
1RN, Specialist in I nt ensive Car e, e- m ail: chaianeusp@gm ail.com ; 2RN, Ph.D. in Nur sing, Full Pr ofessor, Escola de Enfer m agem , Univer sidade de São Paulo,
Br azil, e- m ail: j uliaps@usp.br ; 3RN, I CU Sur gical, Hospit al das Clínicas, Faculdade de Medicina, Univer sidade de São Paulo, M.Sc. in Nur sing, Br azil, e- m ail:
ligiam ds@hcnet .usp.br.
I NTRODUCTI ON
D
yst hanasia is t he t erm for fut ile or useless t r eat m ent , w hich does not benefit a t er m inal pat ient .I t is a pr ocess t hr ough w hich one m er ely ext ends t he
d y i n g p r o ce ss a n d n o t l i f e p e r se . Co n se q u e n t l y,
pat ient s have a pr olonged and slow deat h, fr equent ly
accom pan ied by su f f er in g, pain an d an gu ish . Wh en
one invest s in healing a pat ient w ho has no chance of
cu r e , s/ h e i s a ct u a l l y u n d e r m i n i n g t h e p e r so n ’ s
dignit y( 1). Adv anced m easur es and t heir lim it s should
b e assessed t o b en ef it t h e p at ien t an d n ot t o h old
science as an end in it self( 2).
Eut hanasia is cur r ent ly concept ualized as an
act ion t hat aim s t o end t he life of a hum an being t aking
int o account hum anist ic consider at ions in r elat ion t o
t he per son or societ y( 3); it is unet hical and illegal in
Brazil( 2). Nurses should be aw are of t heir et hical code,
w h i c h c l e a r l y p r o h i b i t s ( a r t i c l e 2 9 ) : “ Pr o m o t i n g
eu t h an asia or p ar t icip at in g in p r act ice in t en d ed t o
facilit at e a pat ient ’s deat h”( 4).
Or t hot anasia r efer s t o t he ar t of pr om ot ing a
hum ane and cor r ect deat h, not subj ect ing pat ient s t o
m ist hanasia or dyst hanasia and not abbr eviat ing deat h
eit her, t hat is, subj ect ing t hem t o eut hanasia. I t s gr eat
challenge is t o enable t er m inal pat ient s t o keep t heir
dignit y, w here t here is a com m it m ent t o t he w ell being
of pat ient s in t he final phase of a disease( 3).
The fundam ent als of pr ofessional pr act ice ar e
based on f ou r bioet h ical pr in ciples of t h e pr in ciplist
m odel an d cor r obor at e t h e pr om ot ion of w ell bein g
f or people in t h e dy in g pr ocess: au t on om y, j u st ice,
b en ef icen ce an d n on m alef icen ce, an d sh ou ld g u id e
pr ofessionals’ pr act ices, r eflect ions and at t it udes( 5).
Healt h pr om ot ion and bioet hics ar e j oined for
t h e d ef en se o f l i f e an d h av e t h e co m m o n g o al o f
i m p r o v i n g q u a l i t y o f l i f e a n d r e s p e c t i n g h u m a n
dignit y( 6). Dying w it h dignit y is a consequence of living
w it h dignit y and not only sur v iv ing w it h suffer ing( 3).
Life should be lived w it h dignit y and t he dying pr ocess,
w hich is a const it uent part of hum an life, should occur
w it h d ig n it y. Th er ef or e, w e sh ou ld d em an d f or t h e
r ig h t of a r esp ect f u l d eat h , in clu d in g r ef lect in g on
e x c e s s i v e t h e r a p e u t i c m e t h o d s( 2 ). Fr o m t h i s
p er sp ect iv e, n u r ses ar e k ey t o t h e p r eser v at ion of
pat ient s’ dignit y.
Not discu ssin g t h ese issu es r esu lt s in m or e
suffering for vict im s of dyst hanasia and result s in t heir
dignit y being inj ur ed in t he dy ing pr ocess. Ther e w ill
be a con t r adict ion in pr ofession als’ beh av ior s w h er e
t here is a great deal of invest m ent in pat ient s w it h no
chance t o r ecov er, w her eas t hese r esour ces could be
used t o save lives w it h real chances of recovery, w hich
con seq u en t ly g en er at e q u est ion s ab ou t t h e cr it er ia
used in I CUs( 7).
The part icipat ion of nurses in t hese processes
is essent ial in ident ifying sit uat ions in w hich bioet hical
p r i n c i p l e s a n d r i g h t s o f p a t i e n t s a r e n o t b e i n g
c o n s i d e r e d s o a s t o i n t e r v e n e w h e n n e c e s s a r y,
e n su r i n g h u m a n i za t i o n a n d t h e p a t i e n t ’ s o v e r a l l
secur it y( 5). To achieve t his goal, it is unquest ionable
t h at n u r ses n eed t o h av e appr opr iat e k n ow ledge of
t h e c o n c e p t s o f d y s t h a n a s i a , e u t h a n a s i a a n d
or t h ot an asia.
A con sider able am ou n t of r esear ch is fou n d
i n La t i n A m e r i c a a d d r e s s i n g t e r m i n a l p a t i e n t s .
How ev er, t h er e i s a scar ci t y of p u b l i cat i on s ab ou t
pr act ices, decision- m ak ing pr ocesses, inv olv em ent of
f a m i l y m e m b e r s a n d p a t i e n t s , o r c h a n g e s i n
t r eat m en t s b ased on aw ar en ess an d r esp on sib ilit y
dem anded by bioet hics( 8).
All n u r sin g pr of ession als, in clu din g t h ose in
leader ship posit ions and w it h post gr aduat e educat ion
a r e a l so r e sp o n si b l e f o r se a r ch i n g a n d a d o p t i n g
r e s p e c t f u l , e t h i c a l a n d r e s p o n s i b l e m e a s u r e s i n
addit ion t o h u m an izin g t h e car e deliv er y pr ocess in
o r d e r t o p r o v i d e t h e h i g h e st b e n e f i t p o ssi b l e t o
pat ient s( 5).
OBJECTI VES
To an aly ze t h e p er cep t ion s of d y st h an asia,
eut hanasia and or t hot anasia of nur ses w or king in t he
I CU of a lar ge univ er sit y hospit al.
To char act er ize, t hr ough t he nur ses’ r epor t s,
pot ent ial im plicat ions for nur sing car e based on t heir
k n ow ledge abou t t h ese su bj ect s.
METHOD
This ex plorat or y, descr ipt iv e and quant it at iv e
st u dy w as car r ied ou t t h r ou gh a qu est ion n air e w it h
27 ( 100% ) nur ses w ho w or k in nine I CUs of a lar ge
u n i v e r si t y h o sp i t a l i n Sã o Pa u l o , SP, Br a zi l a f t e r
a p p r o v a l o f t h e Re se a r ch Et h i cs Co m m i t t e e w a s
ob t ain ed .
Nu r se s w e r e co n t a ct e d i n t h e i r u n i t s a n d
agr eed t o par t icipat e in t he st udy signed a fr ee and
i n f o r m e d c o n s e n t t e r m . Th e n t h e y r e c e i v e d t h e
quest ionnaire t hat cont ained eight sem i- open quest ions
r egar ding t heir pr ofessional back gr ound: infor m at ion
relat ed t o t im e since graduat ion, t im e w or king in I CUs
a n d w h e t h e r t h e y a t t e n d e d g r a d u a t e p r o g r a m s.
I nst rum ent s w ere collect ed aft er being fully com plet ed
and t hen analy zed aft er w ar ds so t hat w hen answ er s
st ar t ed t o r epeat , dat a collect ion w as suspended. Dat a
collect ion last ed t hr ee m ont hs.
Answ er s w er e gr ouped by t hem at ic unit and
pr esent ed accor ding t o t he fr equency t hey appear ed.
Discussion w as carried out based on t he t hem es t hat
em er ged in t he r epor t s.
RESULTS
Tw e n t y - s e v e n n u r s e s w e r e i n t e r v i e w e d ,
9 6 . 3 % w er e f em a l e. Th e a v er a g e a g e w a s 3 9 . 3 7
y ear s, SD of 9 . 6 y ear s, t h e y ou n gest w as 2 3 y ear s
old and t he oldest w as 59 y ear s old. The av er age of
t im e since gr aduat ion w as 7.9 year s and t im e w or king
i n I CUs w as 5 . 2 y ear s, SD o f 6 . 5 an d 4 . 4 y ear s,
r esp ect iv ely.
N u r s e s w i t h s p e c i a l i z a t i o n a m o u n t e d t o
48.15% of t he t ot al. Of t hese, 46.15% w er e specialist s
in int ensiv e t her apy and 53.85% in ot her fields such
as h o sp i t al ad m i n i st r at i o n , n ep h r o l o g y, o b st et r i cs,
em er gency ser v ices, or gans and t issues pr ocur em ent
an d pr e- h ospit al car e.
N o n e o f t h e i n t e r v i e w e e s e x p l a i n e d t h e
concept of eut hanasia, confir m ing t he cur r ent lack of
u n d e r st a n d i n g o f t h i s co n ce p t , h o w e v e r, 5 5 . 5 5 %
r efer r ed t o it as an act ion t hat abbr eviat es life. They
did not correlat e t his fact t o hum anist ic considerat ions
for people or t o societ y, w hich is t he current concept ;
2 2 . 2 2 % b eliev ed it w as an act ion t h at ab b r ev iat es
t h e l i f e o f a t e r m i n a l p a t i e n t a n d 2 2 . 2 2 % e i t h e r
a ck n o w l ed g ed t h ey w er e u n a b l e t o d escr i b e i t o r
in cor r ect ly descr ibed it .
D y st h a n a si a i s u n d e r st o o d a s t h e a ct o f
a r t i f i ci a l l y ex t en d i n g l i f e w i t h n o b en ef i t s f o r t h e
pat ien t in t h e v iew of 5 4 . 5 % n u r ses an d as a slow
deat h w it h suffer ing by 9.1% of t hem ; 36.4% eit her
d id n ot an sw er, ack n ow led g ed t h ey w er e u n ab le t o
answ er or incor r ect ly answ er ed it .
Or t h o t a n a si a w a s d e scr i b e d b y 3 2 . 1 % a s
d e a t h i n i t s n a t u r a l t i m e , n o t p o s t p o n i n g o r
abbr eviat ing it ; 14.3% deat h w it h no suffer ing or “ good
d eat h ” ; 5 3 . 6 % d id n ot an sw er, ack n ow led g ed t h ey
w er e unable t o answ er or incor r ect ly answ er ed it .
The m aj or it y of nur ses ( 65.39% ) st at ed t hat
t hese pr ocesses occur in t heir daily pr act ice, am ong
t h e s e , 8 2 . 3 5 % m e n t i o n e d d y s t h a n a s i a , 5 2 . 9 4 %
or t hot anasia and 1 1 . 7 6 % eut hanasia.
A m o n g t h e s u b j e c t s w h o r e p o r t e d t h e
occu r r en ce of dy st h an asia, 7 9 % cor r ect ly descr ibed
it . Or t hot anasia w as cor r ect ly descr ibed by 67% and
5 0 % d e s c r i b e d e u t h a n a s i a a s a n a c t i o n t h a t
abbr ev iat es lif e.
We asked if know ledge about t hese concept s
w o u l d e n a b l e n u r se s t o co n t r i b u t e so m e h o w a n d
appr opr iat ely apply t hem in t heir daily r out ine and, if
t he answ er w as y es, how t hey could cont r ibut e. The
m aj or it y ( 70.4% ) answ er ed yes and 25.9% answ er ed
n o. Am on g t h ose w h o b eliev ed t h at k n ow led g e on
t he subj ect w ould enable nur ses t o cont r ibut e, 42.9%
said t heir cont r ibut ion w ould be t o pr ovide appr opr iat e
car e, an d 2 3 . 8 % b eliev ed t h ey cou ld con t r ib u t e t o
scient ific know ledge but also underst ood t hat t he final
decision about t r eat m ent r esides w it h t he phy sician.
Also, 9 . 5 % b eliev ed t h ey cou ld con t r ib u t e t h r ou g h
d i a l o g w i t h t h e e n t i r e t e a m , p a t i e n t s a n d f a m i l y
m e m b e r s , 9 . 5 % r e p o r t e d t h e y c o u l d c o n t r i b u t e
t h r ou gh t h e r eflect ion of t h eir act ion s u n der a legal
per spect ive, 4.8% believed t hat one “ should invest in
t herapies” w henever t here w as st ill life, 4.8% believed
nur ses can cont r ibut e but not in t he inst it ut ion t hey
w or k for and 4.8% do not know how t o cont r ibut e.
When ask ed about w hat guided t hem in t he
face of a sit uat ion w hen dy st hanasia w as alr eady in
effect , an sw er s w er e div er se: 2 1 . 6 2 % believ ed t h at
t he ideal of deliv er ing car e w it h dignit y guided t heir
pr act ice; 10.81% t hat pr oviding suppor t t o t he fam ily;
10.81% r epor t ed t hey w er e guided by t heir beliefs or
op in ion ; 8 . 1 1 % b y com m u n icat in g w it h t h e t eam ;
8 . 1 1 % t h r ou g h r esp ect ; 5 . 4 % t h r ou g h k n ow led g e;
5.4% based t heir act ions on et hics; 2.7% t heir belief
in God; 2.7% com m on sense; 2.7% r apid solut ion of
sit uat ions and 18.92% do not know or did not answ er.
Discussion about t he bioet hical principles and
r eflect ions involved are ver y long, how ever, t he m odel
is st ill one of t he m ost com m on and accept ed in Br azil,
a l so a p p r o p r i a t e i n i t s a p p l i ca t i o n t o h e a l t h ca r e
because it suppor t s m aint aining t he dignit y of pat ient s.
I n t his way, t his was t he m odel used in t his st udy.
Wh en ask ed abou t t h e bioet h ical pr in ciplist
m odel, 1 4 . 8 1 % of t h e n u r ses w er e able t o m en t ion
a n d n o n m a l e f i c e n c e . Th e o t h e r s ( 8 2 . 3 6 % )
incom plet ely answ er ed it but r epor t ed t hey consider ed
t his know ledge im por t ant in t heir daily r out ine: 35.29%
t o g u id e an d ad ap t car e, 2 3 . 5 3 % t o av oid er r or s,
14.71% t o r espect pat ient s and 8.83% t o follow et hics.
The m aj or it y, 88.89% of nur ses believed t hat
n u r ses, f a m i l y m em b er s a n d p a t i en t s t h em sel v es
sh ou ld par t icipat e in decision - m ak in g pr ocesses. All
r e p o r t s i n c l u d e d a p p r o p r i a t e c o m m u n i c a t i o n ,
especially how t o infor m pat ient s and fam ily m em ber s
about t heir aut onom y.
N u r s e s p r o v i d e d h e t e r o g e n e o u s a n s w e r s
w h en ask ed w h at w er e t h e f u n d am en t al s o f t h ei r
pr ofessional pr act ice. The m ost com m on t hem es w er e
h u m an izat ion in 2 1 . 7 4 % of an sw er s an d r espect in
13.04% . Ot her t hem es also em er ged: et hics, helping
o t h e r s , s c i e n c e , b e l i e f s a n d v a l u e s , f a v o r i n g
aut onom y, focusing on healing, law, fam ily, pr ov iding
qualit y of life and j ust ice/ nonm aleficence.
DI SCUSSI ON
We u n d er st an d t h at it is n ot easy t o f u lly
c o n c e p t u a l i z e “ e u t h a n a s i a ” , “ d y s t h a n a s i a ” a n d
“ o r t h o t a n a si a ”, co n si d er i n g t h e co m p l ex i t y o f t h e
s u b j e c t s . H o w e v e r, i n a w o r k p l a c e i n w h i c h
professionals face som e of t hese sit uat ions, know ledge
about t hese t hem es is ex t r em ely im por t ant .
Eu t h a n a si a i s cu r r e n t l y co n ce p t u a l i ze d a s
t ak in g t h e lif e of a h u m an bein g du e t o h u m an ist ic
co n si d er a t i o n s t o t h e p er so n o r t o t h e so ci et y( 3 ).
Nu r se s’ co n ce p t u a l i za t i o n o f e u t h a n a si a d o e s n o t
include all t hese aspect s. One possibilit y t hat explains
such a finding is t he dissem inat ion of t his concept in
t he m edia. The m edia is m ore accessible t han scient ific
m edium s of infor m at ion and t he concept s pr esent ed
by nur ses ar e sim ilar t o t hose pr esent ed by t he m edia.
Nu r se s sh o u l d b e a w a r e o f t h e i r co d e o f
et hics, w hich clearly prohibit s ( art icle 29) : “ Prom ot ing
e u t h a n a si a o r p a r t i ci p a t i n g i n p r a ct i ce a i m e d t o
facilit at e a pat ient ’s deat h”( 4).
So t h at t h er e ar e n o n eg at iv e im p licat ion s
f or car e d eliv er ed b y in t en siv e car e p r of ession als,
w h o se p r a ct i ce m a n y t i m e s st r a d d l e s t h e d i v i d e
bet w een lif e an d deat h , it is n ecessar y t h at n u r ses
m ast er t his concept so t hey do not violat e t his et hical
code, and ident ify w hen t he t eam is in danger of doing
so , n o t co o p er a t i n g w i t h t h em b u t p o si t i v el y a n d
r esp ect f u l l y d i scu ssi n g t h e su b j ect w i t h a v i ew t o
pr ov ide or t h ot an asia.
As a l i t t l e m o r e t h a n h a l f o f p a r t i ci p a n t s
concept ualized it , dyst hanasia is t he art ificial ext ension
o f l i f e b e y o n d t h e l i m i t d e t e r m i n e d b y co m m o n
b i o l o g i cal p r o cesses, p o st p o n i n g d eat h as l o n g as
p ossib le( 3 ). On e m er ely ex t en d s t h e d y in g p r ocess,
n o t l i f e p e r se. I t i s a t e r m f o r f u t i l e o r u se l e ss
t r eat m ent , w it h no benefit t o t he t er m inal pat ient( 1).
The concept is com plem ent ed by slow and pr olonged
d e a t h , f r e q u e n t l y a cco m p a n i e d b y su f f e r i n g a n d
an gu ish . How ev er, t h is is on ly a com plem en t of t h e
c o n c e p t a n d n o t t h e c o n c e p t p e r s e a s 9 . 1 %
r epor t ed( 1 ).
Nu r ses sh ou ld alw ay s h av e t h is con cep t in
m ind, r eflect about it in r elat ion t o t heir pr act ice in
t he face of t he sever al st ages t hr ough w hich pat ient s’
d i sea ses d ev el o p , so t h a t t h ey d o n o t a ssi st a n y
dyst hanast ic m easur e, adding suffer ing t o people w ho
ar e ex per ien cin g t h e dy in g pr ocess.
H e a l t h p r o f e s s i o n a l s a r e s u p p o r t e d i n
ex t en din g lif e t h r ou gh adv an ced m easu r es in som e
cases, such as in t he case of pat ient s in a veget at ive
st at e but w it h an aut hor izat ion for or gan donat ion or
f or som e ot h er ben ef it f r om t h e per spect iv e of t h e
fam ily or pat ient . I n such cases, t he concept of fut ilit y
does not apply( 9).
On l y a t h i r d o f t h e p a r t i ci p a n t s co r r e ct l y
d e s c r i b e d o r t h o t a n a s i a , t h a t i s , a d e a t h n o t
c h a r a c t e r i z e d b y d y s t h a n a s i a , m i s t h a n a s i a o r
eu t h an asia; a d eat h in it s n at u r al t im e. Th e g r eat
challenge is t o m aint ain t he dignit y of pat ient s in t heir
final st age of life, w her e t her e is com m it m ent t o t he
prom ot ion of w ell being because it allow s pat ient s and
t h ei r f am i l i es t o f ace d eat h w i t h m o r e t r an q u i l i t y,
accept ing deat h as par t of life and not as a disease
t hat needs t o be healed( 3).
Th e m a j o r i t y o f n u r s e s a c k n o w l e d g e
dy st hanasia in t heir daily pr act ice. The lar ge num ber
of p r of ession als w h o ack n ow led g ed t h is p r act ice in
t heir r out ine cor r obor at e t he need of nur ses t o m ast er
t h ese con cept s so t h ey ar e able t o r ecogn ize t h ese
p r a ct i ce s a n d a ct a cco r d i n g l y, t h a t i s, e f f e ct i v e l y
p r o m o t i n g d i s c u s s i o n s w i t h t h e t e a m b a s e d o n
b ioet h ics an d on t h eir ow n cod e of et h ics, alw ay s
a i m i n g t o p r o v i d e a p p r o p r i a t e c a r e , t a k i n g i n t o
account t hat nursing is t he pr ofessional cat egor y t hat
is in const ant cont act w it h t he pat ient and st ay s t he
We k n o w t h a t t h e r a p e u t i c p o ssi b i l i t i e s t o
art ificially m aint ain a life in an I CU are endless. Thus,
t h er e is a gr eat ch an ce of appealin g t o dy st h an asia
p r a c t i c e s , c a u s i n g s u f f e r i n g a n d , i f t h e r e i s n o
appr opr iat e r at ion ale t ak in g in t o accou n t et h ics an d
h u m an izat ion , dist an cin g pat ien t s f r om t h e pr act ice
of or t h ot an asia.
Despit e t he fact t hat t he m aj or it y believed in
t h e i m p o r t a n c e o f t h i s k n o w l e d g e a n d i t s
im p lem en t at ion in car e, 2 5 . 9 % of t h e in t er v iew ed
n u r ses r ep or t ed it w as n ot im p or t an t t o k n ow t h e
concept s of dyst hanasia, eut hanasia and or t hot anasia.
How ev er, t h e k n ow led g e an d ap p licab ilit y of t h ese
con cept s is essen t ial becau se an aw ar e pr ofession al
k n ow s t h at n ot all t ech n ically possible in t er v en t ion s
ar e et h ically cor r ect an d also k n ow s t h e d if f er en ce
b e t w e e n h e l p i n g s o m e o n e t o l i v e a n d i m p e d i n g
som eone’s deat h( 10). Know ledge and r eflect ion about
t hese concept s in each m om ent of a pat ient ’s dy ing
p r ocess en ab le n u r ses t o con t r ib u t e in d iscu ssion s
bet w een t he int erdisciplinar y t eam , pat ient s and fam ily
m em ber s, pr om ot in g appr opr iat e car e.
Th e n u r se s’ r o l e a s w e l l a s t h a t o f o t h e r
p r o f e ssi o n a l s i s t o m a k e a l i n k b e t w e e n e f f i ci e n t
solidarit y and hum an and scient ific com pet ence at t he
ser v ice of fr agile pat ient s w ho ar e passing aw ay( 1).
Th i s s t u d y c o r r o b o r a t e s t h e n e e d f o r
pr ov idin g scien t if ic t r ain in g an d t r ain in g in h u m an e
t r e a t m e n t t o h e a l t h p r o f e s s i o n a l s i n o r d e r t o
a c c o m p l i s h t h e m o s t b e n e f i c i a l c a r e p o s s i b l e( 5 ),
regardless of how t he inst it ut ion w or ks or t he degr ee
of aut onom y nur ses have, since t he aut onom y of t hese
professionals is proport ional t o t heir scient ific capacit y.
Th e a n s w e r s r e g a r d i n g w h a t g u i d e s t h e
a c t i o n s o f t h e s e p r o f e s s i o n a l s w h e n t h e y f a c e
dy st h an asia w er e h et er ogen eou s. How ev er, pr act ice
sh o u l d b e b a se d o n a se t o f m e a su r e s a i m e d t o
achieve a dignified deat h, not ext ended suffer ing, pain
an d an g u i sh . On t h e co n t r ar y, p at i en t s sh o u l d b e
allow ed t o d ie w it h d ig n it y an d h av e car e d eliv er y
based on et hics( 1,4,11), safeguar ding individuals’ r ight s,
en su r in g h u m an ized car e an d secu r it y( 5 ). Fr om t h is
p e r s p e c t i v e , n u r s e s s h o u l d p r o m o t e d i s c u s s i o n s
r e l a t e d t o e a ch i m p l e m e n t e d a ct i o n , t a k i n g i n t o
a c c o u n t t h e s i n g u l a r a n d p a r t i c u l a r m o m e n t o f
pat ient s. The discussion should be dy nam ic and held
j oint ly w it h ot her m em ber s of t he healt h t eam , fam ily
m em bers and pat ient s so as t o crit ically reflect w het her
t h e s e a c t i o n s a r e a l i g n e d w i t h b i o e t h i c a l a n d
hum anized pr inciples of car e and or t hot anasia.
Nu r ses sh ou ld car ef u lly con sid er sit u at ion s
ex per ienced in t heir pr act ice so t hey do not endor se
t he im plem ent at ion of useless t herapies. Not crit ically
t hinking about t hese issues leads healt h professionals
t o m ain t ain life “ at an y cost ”, w it h ou t discu ssin g or
q u e s t i o n i n g , w h i c h c o n t r a d i c t o r i l y f a v o r s
dy st h an asia( 7 ).
The cur r ent nur sing pr act ice, w hose pr ecur sor
is Flor en ce Nig h t in g ale, h as b een g u id ed b y et h ics
si n ce i t s b e g i n n i n g , w h i ch i s p r e se n t e d a s a l i n k
b e t w e e n t h e k n o w l e d g e o f b i o l o g y a n d t h e
h u m an it ies( 1 1 ). Ev en t oday, et h ical pr in ciples def en d
j ust ice, com pet ence, r esponsibilit y and honest y w it h
a v iew t o p r om ot e t h e h u m an b ein g as a w h ole( 4 ).
Nur ses should r et hink t hese pr inciples in r elat ion t o
t he pract ice of dyst hanasia so as t o guide t heir act ions
in ev er y m om en t .
I t i s al so t h e n u r ses’ d u t y t o r esp ect an d
ack n ow led g e t h e r ig h t of clien t s t o m ak e d ecision s
ab ou t t h eir ow n p er son , t r eat m en t an d w ell b ein g ,
and r espect hum an beings in deat h and post - deat h( 4).
Th er ef or e, n u r ses n eed t o en su r e t h at pat ien t s an d
fam ily m em ber s r eceiv e t r ut hful infor m at ion so t hey
can m ak e ap p licab le, f r ee an d con sciou s d ecision s
and ex er cise t heir aut onom y( 5).
The nurses’ role in t he face of any sit uat ion,
an d p ar t icu lar ly in a sit u at ion of d y st h an asia, is t o
e n s u r e c a r e d e l i v e r y b y t h e i r t e a m s a n d o t h e r
pr ofession als t o pat ien t s an d t h eir fam ily m em ber s,
r e g a r d l e s s o f t h e i n s t i t u t i o n a l p h i l o s o p h y o r
organizat ional cult ure. For t hose w ho fight for life and
ar e guided by bioet hics, it is a cer t ain and fundam ent al
t r ut h t hat car e deliver y cannot cease in t he face of an
in cu r able case( 1 ).
Bioet h ics is a sph er e in w h ich pr ofession als
can discuss and r eflect acquir ed scient ific k now ledge
i n r el at i o n t o t h e i n co r p o r at i o n o f n ew h eal t h car e
t echnology, especially in int ensive t her ap y( 1 2 ).
B i o e t h i c s h a s b e e n i n c o r p o r a t e d i n t h e
hist orical- social const ruct ion of nursing, w hich ensures
new fundam ent als t o face daily challenges of link ing
car e/ et hics and car e/ t echnique, int egr at ing pr inciples
a n d c o m p e t e n c i e s i n a c o n t e x t o f c a r e a n d
r esp on sib ilit y f or r esp ect in g h u m an b ein g s, h ealt h
pr om ot ion and r eliev ing suffer ing( 11).
D esp i t e t h e f a ct t h a t o n l y 1 4 . 8 1 % o f t h e
nur ses fully m ent ioned t he four bioet hical pr inciples,
8 2 . 3 6 % believ ed k now ledge of t hem is im por t ant in
t heir daily pract ice, based on t he inform at ion, even if
academ ic per spect ive. We obser ved t hat even lacking
exact know ledge of t he pr inciples, t hey acknow ledged
t h e i r i m p o r t a n ce b e ca u se t h e y a f f i r m t h a t t h e se
pr inciples ar e inst r um ent s t hat help t hem t o pr ov ide
a p p r o p r i a t e, et h i ca l a n d r esp ect f u l ca r e, a v o i d i n g
pot en t ial er r or s.
Few w ere able t o m ent ion t he four bioet hical
p r i n ci p l es, h o w ev er, t h ese p r i n ci p l es sh o u l d g u i d e
p r o f e ssi o n a l p r a ct i ce so a s t o e n su r e i n d i v i d u a l s’
r ig h t s, av oid in g b iolog ical, p sy ch olog ical, social or
spir it ual r isk s and har m . When nur ses ar e guided by
bioet hical principles and reflect on t hem , t hey provide
hum anized care originat ing in act ions based on respect
for t he r ight t o dignified healt hcar e deliv er y( 5).
Com m u n icat ion p er m eat es all car e act ion s
involved in t he dying process as w ell as all dim ensions
o f t h e h u m a n b e i n g . Th e w a y p r o f e s s i o n a l s
com m u n icat e w it h p at ien t s an d f am ily m em b er s is
r em em b er ed f or ev er b y t h ose in v olv ed ( i. e. h ow it
w as w hen a loved one passed aw ay) . Reflect ing about
com m unicat ion in an environm ent w here effect iveness
p r ed om in at es m ean s t o r ecov er t h e im p or t an ce of
t he affect iv e( 13).
The m aj or it y believed t hey should par t icipat e
in decision- m ak ing pr ocesses, including pat ient s and
f a m i l y m e m b e r s, a l w a y s r e f e r r i n g t o a p p r o p r i a t e
c o m m u n i c a t i o n , e s p e c i a l l y u s i n g i t t o p r o m o t e
au t on om y.
Nur ses should also r eflect on t heir inclusion
a n d a c t i v e p a r t i c i p a t i o n i n t h e d e c i s i o n - m a k i n g
process, helping t o solve problem s involving et hics in
an I CU based on or t h ot an asia, bioet h ical pr in ciples,
h u m an ized car e, an d dign it y t o t h e h u m an bein g in
life’s final process as w ell as t o help pat ient s and fam ily
m em ber s( 14). For t hat , scient ific t r aining and t r aining
i n h u m a n e t r ea t m en t i s n eed ed( 5 ). Nu r si n g i s t h e
pr ofessional cat egor y t hat is t he closest t o and spends
t he longest t im e w it h pat ient s, w hich enables t hem t o
obt ain v alu able in f or m at ion abou t pat ien t s so as t o
h a v e a h o l i st i c v i e w o f t h e se p a t i e n t s a n d p a ss
i n f o r m at i o n t o t h e t eam so i t can b e u sed i n t h e
r esolut ion of et hical dilem m as.
I t i s k n o w n t h a t r e s p e c t i n g p a t i e n t s ’
au t on om y an d t h eir r ig h t t o m ak e d ecision s ab ou t
t heir t reat m ent in addit ion t o j ust ice, beneficence and
nonm aleficence, w hich ar e t he fundam ent al pr inciples
o f e t h i ca l n u r si n g ca r e , a r e e sse n t i a l t o a ch i e v e
p e o p l e ’ s i n t e g r a l w e l l b e i n g( 3 ), co r r o b o r a t i n g t h e
con cept of or t h ot an asia.
A ver y open quest ion w as asked t o det er m ine
w h at t h e b asi s o f t h ei r p r o f essi o n al p r act i ce w as,
a i m i n g t o a l l o w p a r t i c i p a n t s t o f r e e l y e x p r e s s
t h em selv es an d t h eir an sw er s w er e h et er ogen eou s.
Hum anizat ion appear ed in t he m aj or it y ( 2 1 . 7 4 % ) of
an sw er s an d et h ics in 8 . 7 % , alt h ou gh , n on e of t h e
n u r s e s c o n s i d e r e d t h e s e a r c h f o r o r t h o t a n a s i a .
Het er ogeneous answ er s show t he need t o st andar dize
l an g u ag e i n t h e p r of essi on al p r act i ce i n r eg ar d t o
e u t h a n a s i a , d y s t h a n a s i a a n d o r t h o t a n a s i a a n d
bioet hical principles. Through const ant respect for t he
four bioet hical pr inciples per m eat ed by hum anizat ion
of care, one can achieve ort hot anasia offering dignit y,
secur it y and t he best car e deliv er y possible.
Nur ses’ act ions should be based on t he sear ch
for or t hot anasia, w hich is t he ar t of pr oviding a good,
h u m an ized an d dign ified deat h t o t h ose u n der t h eir
r espon sibilit y, so as t o in t egr at e et h ics w it h scien ce
and t echnical abilit ies( 3). The four bioet hical principles
of t he principlist m odel should also guide t heir act ions,
w hich should be char act er ized by r esponsibilit y w it h
a v iew t o ensur e pat ient s’ r ight s, offer ing hum anized
c a r e a n d s e c u r i t y , a v o i d i n g r i s k s a n d h a r m t o
pat ient s( 5).
I t is a pr iv ilege t o be in fr ont of a t er m inal
pat ient and lear n his/ her hist or y, because each per son
is m agically unique and, w hen nurses share t his final
m om en t , t h ey can ease an d f acilit at e it . Rem ov in g
t he band of t he daily r out ine and having t he view t hat
daily and sim ple act s have im por t ant m eaning, per m it s
nur ses t o r ej oice and hav e gr at it ude for par t icipat ing
in som et hing so sim ple and hum ane as deat h( 15).
Th e sim u lt an eit y p ar ad ig m is an im p or t an t
r ef lect iv e t ool t h at can aid car e deliv er y becau se it
helps one t o r ecov er t he per spect iv e of hum anit y in
int ensive care. I t considers t he person as a w hole, as
som et h in g t h at is lar ger t h an t h e su m of it s par t s,
an d y et t h at each par t is t h e r epr esen t at ion of t h e
w h ole( 1 6 ). At t en t ion t o each det ail ex pr essed by t h e
pat ient and fam ily m em ber s, w het her v er bal or
non-ver bal, is essent ial t o have a per spect ive of t he pat ient
as a w hole and, t hus, indiv idualize car e, essent ial t o
h u m an izat ion , bioet h ics an d or t h ot an asia.
Th e em p h asis of p er m an en t ed u cat ion an d
u n d er g r ad u at e in st it u t ion s’ at t en t ion t o su p p or t t h e
i m p l em en t a t i o n o f b i o et h i ca l p r i n ci p l es i n n u r ses’
p r act ice con com it an t ly w it h or t h ot an asia is n eed ed .
Th e n u r se sh ou ld d ir ect t h e q u alit y of d iscu ssion s
con cer n in g t h e p at ien t ’s d ir ect car e, cor r ob or at in g
t h e f in d in g s of a st u d y t h at ev alu at ed t h e ap p licat ion
o f b i o e t h i c a l k n o w l e d g e i n c l i n i c a l c a s e s a f t e r
in t en siv e t r ain in g in t h e su b j ect , an d ev id en ced t h at
p r o f e s s i o n a l s j u s t i f i e d t h e i r a n s w e r s w i t h m o r e
d et ai l an d d ep t h an d w i t h b et t er i n co r p o r at i o n o f
t h eo r et i cal l an g u ag e( 1 7 ).
FI NAL CONSI DERATI ONS
Th i s s t u d y s h o w e d t h a t n u r s e s h a v e t o
a cq u i r e m o r e k n o w l ed g e t o ef f ect i v el y i m p l em en t
bioet hical pr inciples and t he pr act ice of or t hot anasia
as w ell as t o em p h asize t h at p er m an en t ed u cat ion
an d u n der gr adu at e in st it u t ion s sh ou ld pay at t en t ion
t o t h i s s u b j e c t i n o r d e r t o p r o m o t e q u a l i t y i n
discussions in int er disciplinar y t eam s and dir ect car e.
The st udy w as car r ied out in a hospit al in São
Paulo and t her efor e gener alizat ion and incor por at ion
of it s findings t o all pr ofessionals in t he cat egor y of
nursing is not possible. Furt her research is needed t o
explore t he difficult ies relat ed t o t he het erogeneit y of
act ions and nur ses’ k now ledge including eut hanasia,
dyst hanasia and ort hot anasia, bioet hical principles and
car e t o t er m inal pat ient s.
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