DYSTHANASI A: NURSI NG PROFESSI ONALS’ PERCEPTI ON
Milene Bar cellos de Menezes1 Lucilda Selli2† Joseane de Souza Alv es1
Men ezes MB, Selli L, Alv es JS. Dy st h an asia: n u r sin g pr of ession als’ per cept ion . Rev Lat in o- am En f er m agem 2009 j ulho- agost o; 17( 4) : 443- 8.
Dy st hanasia m eans slow and painful deat h w it hout qualit y of life. This st udy aim ed t o k now w het her nur ses ident ify dy st hanasia as par t of t he final pr ocess of t he liv es of t er m inal pat ient s hospit alized at an adult I CU. This is an explorat ory- qualit at ive st udy. Dat a were collect ed t hrough sem i- st ruct ured int erviews wit h t en nurses w it h at least one year of experience in an I CU, and int erpret ed t hrough cont ent analysis. Result s indicat e t hat nur ses under st and and ident ify dyst hanasia, do not agr ee w it h it and r ecognize elem ent s of or t honasia as t he adequat e procedure for t erm inal pat ient s. We conclude t hat nurses int erpret dyst hanasia as ext ending life w it h pain and suffer ing, w hile t er m inal pat ient s ar e subm it t ed t o fut ile t r eat m ent s t hat do not benefit t hem . They also ident ify dy st hanasia using elem ent s of or t honasia t o ex plain it .
DESCRI PTORS: t er m inally ill; eut hanasia; nur sing; bioet hics
DI STANASI A: PERCEPCI ÓN DE LOS PROFESI ONALES DE ENFERMERÍ A
Dist anasia significa m uert e lent a, con sufrim ient o y sin calidad de vida. En est a invest igación se buscó conocer si los en f er m er os id en t if ican la d ist an asia com o p ar t e d el p r oceso f in al d e la v id a d e p er son as en est ad o t erm inal, int ernadas en una UTI para adult os. El est udio es de nat uraleza explorat oria, con abordaj e cualit at ivo. Los dat os fueron recolect ados por m edio de ent revist a sem iest ruct urada con 10 enferm eros con un m ínim o de un año de ex per iencia en UTI ; los dat os fuer on int er pr et ados por el análisis de cont enido. Se obt uv o com o r esu lt ado qu e los en fer m er os com pr en den e iden t ifican la dist an asia y se opon en a la m ism a, pr esen t an do elem ent os de or t ot anasia com o pr ocedim ient o adecuado par a pacient es en est ado t er m inal. Se concluy e que los enferm eros int erpret an la dist anasia com o el prolongam ient o de la vida con dolor y sufrim ient o, en el cual los pacient es t er m inales son som et idos a t r at am ient os fút iles que no t r aen beneficios. Tam bién ident ifican la dist anasia, usando elem ent os de la or t ot anasia par a hacer la ex plicit a.
DESCRI PTORES: enfer m o t er m inal; eut anasia; enfer m er ía; bioét ica
DI STANÁSI A: PERCEPÇÃO DOS PROFI SSI ONAI S DA ENFERMAGEM
Dist anásia significa m or t e lent a, sofr ida e sem qualidade de v ida. Nest a pesquisa buscou- se conhecer se os en f er m eir os id en t if icam a d ist an ásia com o p ar t e d o p r ocesso f in al d a v id a d e p essoas em t er m in alid ad e, int er nadas em UTI adult o. O est udo é de nat ur eza ex plor at ór ia, com abor dagem qualit at iv a. Os dados for am colet ados por m eio de ent revist a sem iest rut urada com 10 enferm eiros com , no m ínim o, um ano de experiência em UTI , e int er pr et ados pela análise de cont eúdo. Tev e- se com o r esult ado que os enfer m eir os com pr eendem e id en t if icam a d ist an ásia e se op õem à m esm a, t r azen d o elem en t os d a or t ot an ásia com o p r oced im en t o adequado par a pacient es em t er m inalidade. Conclui- se que os enfer m eir os int er pr et am a dist anásia com o o pr olon gam en t o de v ida com dor e sof r im en t o, on de os pacien t es t er m in ais são su bm et idos a t r at am en t os fút eis que não t r azem benefícios. E t am bém ident ificam a dist anásia, usando elem ent os da or t ot anásia par a ex plicit á- la.
DESCRI TORES: doent e t er m inal; eut anásia; enfer m agem ; bioét ica
1RN, e- m ail: m im ibm @pop. com . br, j oseane. ar s@gm ail. com ; 2Adj unct Pr ofessor, Univer sidade do Vale do Rio dos Sinos, UNI SI NOS, Brazil, e- m ail:
I NTRODUCTI ON
D
yst hanasia is a lit t le known t erm , but which is oft ent im es pract iced in t he healt h area. I t is a subj ect of int erest in bioet hics and according t o t he Bioet hics Dict ionary it is t ranslat ed as “ difficult or painful deat h, used t o indicat e t he ex t ension of t he dy ing pr ocess t h r o u g h t r e a t m e n t t h a t o n l y p r o l o n g s p a t i e n t s ’ biological life. I t has neit her qualit y of life nor dignit y.I t can also be called Therapeut ic Obst inat ion”( 2). I t is a pract ice t hat aim s t o ext end t he life of t erm inal pat ient s, but subj ect s t hem t o m uch suffering. This pr act ice does not ex t end life; it r at her ex t ends t he dy ing pr ocess. The adv ancem ent of science and it s im plem ent at ion oft ent im es com prom ises t he qualit y of lif e of p eop le w h o su f f er, af f ect in g t h eir d ig n it y. Palliat iv e car e an d r esp ect f or p at ien t s’ r ig h t s ar e efficient m eans t o pr ev ent dy st hanasia.
We ch ose t o d eep en u n d er st an d in g of t h e
t hem e of dyst hanasia because it is a realit y in nursing pr ofessionals’ daily pr act ice, w hich is lit t le discussed despit e being a sit uat ion t hat causes m uch suffer ing for pat ient s whose lives are m aint ained wit hout keeping qualit y of life in perspect ive.
This st udy pr ov ides an oppor t unit y t o t hink and encourages discussion not only in nursing but also wit h int erdisciplinary groups since t he problem affect s p a t i en t s a t t en d ed b y p r o f essi o n a l s f r o m d i f f er en t k n ow led g e ar eas. We sou g h t t o w or k w it h n u r sin g pr ofessionals because t hey exper ience dyst hanasia in
I CUs and also because t hrough t hem it is possible t o ident ify new w ays t o at t end t er m inal pat ient s and t o obt ain knowledge about t he t hem e. Hence, t his st udy aim ed t o know whet her nurses underst and and ident ify sit uat ions of dyst hanasia in int ensive care unit s.
We believ e t h is st u dy can f ost er discu ssion about t he t hem e am ong peers and lead people t o re-t h i n k re-t h e d i l e m m a b e re-t w e e n d y s re-t h a n a s i a a n d ort honasia, t hat is, bet ween ext ending life at any cost ,
which causes suffering, or accept ing deat h at t he right m om ent as par t of life. Yet , under t his per spect iv e, w hen nur ses and ot her healt h pr ofessionals ar e able t o iden t if y sit u at ion s of dy st h an asia an d or t h on asia t hey are bet t er prepared t o m ake decisions regarding t he m ost appr opr iat e t r eat m ent and how t o m anage fam ily m em ber s.
METHOD
Th is is an ex p lor at or y - q u alit at iv e st u d y( 3 ).
Resear cher s w ho em ploy qualit at iv e st r at egies ut ilize
ex per iences, ev ent s of daily life and also st r uct ur es
and inst it ut ions as raw m at erial, t hough t hey see t hese
as obj ect iv e hum an act ions. Qualit at iv e r esear ch has
par t icular quest ions. I t at t ends a gap t hat cannot or
could not be quant ified( 3). I t w orks w it h t he universe
of m eanings, reasons, aspirat ions, beliefs, values and
at t it udes( 3).
Ex p l o r at o r y r esear ch i s m o r e t h an si m p l y
ob ser v in g an d d escr ib in g a g iv en p h en om en on ; it
inv est igat es it s com plex nat ur e and ot her fact or s t o
w hich t he phenom enon is r elat ed( 4).
Th e r esea r ch w a s ca r r i ed o u t i n a n a d u l t
int ensiv e car e unit of a hospit al in Por t o Alegr e, RS,
Br a zi l . Th e sa m p l e w a s co m p o se d o f t e n n u r se s
working in an adult I CU and experiencing dyst hanasia
in t heir daily pract ice, bot h genders, from t hree shift s:
m orning, aft ernoon and night . Only t hose wit h at least
on e y ear of ex per ien ce in I CUs w er e con sider ed t o
com pose t h e sam ple.
Th ese p r o f essi o n al s w er e ch o sen b ecau se
t hey experience dyst hanasia in I CUs and also because
t hey can help t o ident ify new ways t o at t end t erm inal
pat ient s and pr ovide bet t er know ledge of t he t hem e.
D a t a w e r e c o l l e c t e d t h r o u g h s e m i
-s t r u c t u r e d i n t e r v i e w -s o n t h e f o l l o w i n g t h e m e -s :
t e r m i n a l i t y, f u t i l e t r e a t m e n t , u n d e r s t a n d i n g o f
dy st hanasia, and aid t o t he t er m inal pat ient . Sem
i-st r u ct u r e d i n t e r v i e w s a sso ci a t e o p e n a n d cl o se d
q u e st i o n s a n d t h e r e se a r ch e r ca n t a l k a b o u t t h e
t h em e u n d er st u d y w it h ou t h av in g t o st ick t o p r
e-f or m u lat ed q u est ion s( 3 ).
I nt erviews were recorded wit h an audio t ape
r ecor der and fully t r anscr ibed aft er w ar ds. They w er e
scheduled and conduct ed in a r oom av ailable at t he
t im e t o ensur e int er v iew ees’ pr iv acy. The int er v iew s
w er e about 30 m inut es in dur at ion in Mar ch 2008 in
t hr ee differ ent shift s: m or ning, aft er noon and night .
Dat a were analyzed t hrough cont ent analysis,
w h ich aim s t o u n d er st an d collect ed d at a, b r oad en
k now ledge in r egar d t o t he st udied subj ect , confir m
or disaffirm t he st udy assum pt ions and obt ain answers
t o i n i t i a l q u e s t i o n i n g( 3 ). Ce n t r a l m e a n i n g s w e r e
u n d er lin ed an d ex t r act ed f r om t h e d at a an d , af t er
c o m p a r i s o n , w e r e g r o u p e d b y s i m i l a r i t i e s a n d
differ ences int o cat egor ies( 3 ).
Cat egories were com posed aft er densificat ion
a n d d a t a s a t u r a t i o n . A f t e r w a r d s , w e s o u g h t t o
u n d er st an d col l ect ed d at a t h r o u g h t h e t h eor et i cal
f r a m e w o r k , e l a b o r a t i n g l i n k s b e t w e e n d a t a a n d
Th e st u d y w as su b m it t ed t o t h e h osp it al’s
Resear ch Et h i cs Co m m i t t ee f o r i t s ev al u at i o n an d appr ov al accor ding t o Pr ot ocol No. 019/ 08. Appr ov al
w as o b t ai n ed o n Feb r u ar y 2 7 , 2 0 0 8 a cco r d i n g t o Resolut ion 196/ 96 fr om t he Nat ional Healt h Council.
A fr ee and infor m ed consent agr eem ent w as pr ov ided t o par t icipant s w her e in t he st udy subj ect ,
obj ect iv es and j ust ificat ions w er e clar ified. Th e fr ee and inform ed consent agreem ent was signed wit h t wo
copies, one for t he par t icipant and t he ot her for t he r esear ch er.
DATA RESULTS AND DI SCUSSI ON
W i t h d a t a d e n s i f i c a t i o n , f o u r a n a l y s i s
ca t e g o r i e s e m e r g e d . Th e se a r e i d e n t i f i e d b y t h e f o l l o w i n g : a ) i d e n t i f i ca t i o n a n d u n d e r st a n d i n g o f
dy st h an asia; b) dy st h an asia or or t h on asia; c) fu t ile t reat m ent : t he fam ily facilit at es dyst hanasia d) nurses’
par t icipat ion .
Fir st cat eg or y : id en t if icat ion an d u n d er st an d in g of d y st h an asia
Th is cat eg or y aim s t o p r esen t an d an aly ze c o l l e c t e d d a t a r e l a t e d t o t h e i d e n t i f i c a t i o n a n d
u n d e r s t a n d i n g o f d y s t h a n a s i a r e p o r t e d b y t h e par t icipant s and based on t heir answ er s.
“ Th e t er m d y st h an asia is d ef in ed as slow , anguishing deat h w it h m uch suffer ing”( 5).
[ ...] dyst hanasia m eans dying w it h pain, right ? Means dying w it h suffering ( S1) .
The ex agger at ed ex t ension of deat h, w her e
pat ient s are subj ect t o a process of int ense pain and su f f er in g, is a pr ocess t h at ex t en ds agony, w it h n o
p o ssi b i l i t y o f h eal i n g o r i m p r o v em en t . I t ex t en d s agony wit h no expect at ion of success or a bet t er qualit y
of life; it does not aim t o pr olong life but r at her t o pr olong t he pr ocess of dy ing.
I believe t hat we do a lot of dyst hanasia, m any t im es we ext end pat ient s’ suffering ( S2).
An ot h er par t icipan t m en t ion s t h e ex t en sion
of suffering not of life.
[ . . . ] w hen y ou ex t end a per son ’s life w it h ou t an y t her apeut ic per spect iv e, it isn’t w or t h it , it w ill only ex t end suffer ing ( S5 ) .
An o t h e r u n d e r st a n d i n g o f d y st h a n a si a i s
r elat ed t o dist ancing one fr om deat h.
[ ...] you dist ance t he pat ient from deat h, use m easures t o dist ance pat ient s from deat h ( S3) .
Dy st hanasia does not benefit pat ient s.
[ ...] you invest som et hing else in pat ient s, only t hat you’re going t o do t hings t hat will not favor t hem ( S3) .
This par t icipant r efer s t o a cr uel deat h.
[ ...] dyst hanasia is dying in a cruel m anner ( S4) . Th e r ep o r t s o f so m e n u r ses i n d i cat e t h ey underst and and ident ify dyst hanasia in t he unit . They
f r equ en t ly iden t if y it w h en ev er y t h in g possible w as a l r e a d y d o n e o r e v e r y p o s s i b l e t r e a t m e n t w a s
p e r f o r m e d a n d w a s n o t e f f e c t i v e . Th e r e i s a n under st anding t hat it r epr esent s a cr uel deat h, w it h
pain and m uch suffer ing, not pr ov iding any benefit ,
and dist ances deat h and life.
When one im plem ent s t herapeut ic obst inat ion
t o t er m inal pat ient s w ho do not hav e any chance of cur e or of changing t heir healt h condit ion, it sim ply
r esult s in ext ending t he dying pr ocess, causing m or e pain and suffer ing t o pat ient s w ho ar e at t he end of
t heir liv es( 6).
Man y p at ien t s ar e su b m it t ed t o a p ain f u l,
a n g u i s h i n g , u n n e c e s s a r y a n d e x p e n s i v e d y i n g pr ocess( 7 ).
I nt erviews indicat e t hat expensive m edicat ion and ex am s ar e used on pat ient s w it h no per spect iv e
on qualit y of life.
[ ...] t here’s no perspect ive of life, so an expensive t herapeut ic is usually used ( S8) .
The r epor t s show t hat t echnology has been inappr opr iat ely used and t he ex agger at ed ex t ension
of life is com m it t ed on a large scale, especially in t he t r eat m ent of t er m inal pat ient s( 6).
Te r m i n a l p a t i e n t s a r e s u b m i t t e d t o
t r eat m en t s, in v asiv e p r oced u r es an d t ech n iq u es in I CUs, in which suffering is great er t han benefit s gained
because cur e is no longer possible.
Second cat egor y : fr om dy st hanasia and or t honasia
Ter m in al pat ien t s ar e t h ose w h o ar e in t h e
final phase of a disease w it h no chance of r ev er t ing
t heir condit ion, even part ially or t em porarily, wit h t he u se o f a n y k n o w n a n d i m p l e m e n t e d t h e r a p e u t i c
m easu r e( 8 ).
Term inal pat ient s are t hose pat ient s in severe healt h condit ions who don’t have any prospect s for qualit y of life aft er leaving t he I CU ( S7) .
As t h e d isease d ev elop s, t er m in al p at ien t s reach a m om ent when it is no longer possible for t hem
t o r e co v e r a n d d e a t h i s i n e v i t a b l e . Th e r a p e u t i c
m easures at t his st age do not increase survival; t hey
[ ...] no pat ient is t erm inal in m y point of view, t here’re pat ient s wit h t herapeut ic lim it s, t he t erm t erm inal pat ient seem s… t erm inal seem s t here’s not hing else you can do for people, but even at t he hour of deat h t here’s a lot you can do for people ( S6) . Or t h on asia m ean s d eat h at t h e r ig h t t im e,
neit her dispr opor t ionat ely abbr ev iat ing nor ex t ending
t he dy ing pr ocess( 9).
Palliat iv e car e con t r ols p ain an d im p r ov es
qualit y of life. I t does not aim t o cur e a disease or
ext end life as long as possible rat her it aim s t o perm it
pat ient s t o liv e peacefully and com for t ably.
Pal l i at i v e car e ai m s t o al l ev i at e su f f er i n g ,
unbear able pain and body degr adat ion but does not
com plet ely elim inat e t hem . Palliat iv e car e pr ogr am s
d o n ot p r op ose eu t h an asia, b u t t h er e is a con cer n
w it h pat ient s’ qualit y of life and w ell- being. Ther e is
no resuscit at ion equipm ent nor do t hey propose heroic
t r eat m ent s at I CUs( 10).
The concept of car e is focused on car e and
n ot on a clien t ’s d ef in it iv e car e. Palliat iv e car e is
associat ed w it h t he w or k of a m ult idisciplinar y t eam ,
t o cont r ol pain and allev iat e sy m pt om s( 11).
I nt er v iew ees’ r epor t s show t he m aint enance
o f co m f o r t as a p r i o r i t y an d r ef er t o el em en t s o f
or t honasia, w hich m eans dy ing at t he r ight t im e, as
o p p o s e d t o d y s t h a n a s i a . Te r m i n a l p a t i e n t s a r e
m aint ained w it h palliat iv e car e, cont r olling pain and
sy m p t om s, w it h a v iew t o im p r ov e t h eir q u alit y of
l i f e.
[ ...] w e have t o invest in pat ient ’s com fort , you know ? Allev iat e suffer ing, y ou k now ? Pr ov ide pat ient s w it h a good analgesia, because t here’s not hing else t o do besides t reat m ent , so, I guess t hat com fort has t o be a priorit y ( S9) .
M a n y p a t i e n t s i n I CU e n d u p r e q u i r i n g
palliat iv e car e. I CU nur ses offer st r ong suppor t and
m an ag em en t of p ain , allev iat in g t er m in al p at ien t s’
suffer ing and pain.
A t erm inal pat ient has a very poor prognosis, you know? A pat ient for whom all possible m easures were im plem ent ed, t he whole t reat m ent and t his pat ient has no… t here’s not hing m ore t hat can be done for him , everyt hing possible was done and now what rem ains is t o m aint ain t he pat ient com fort ably and wait for deat h t o com e ( S1) .
Or t h on asia is a m or e posit iv e dim en sion of
t h e r i g h t t o d i e a n d co n si st s o f d y i n g h u m a n el y,
p eacef u lly, an id eal d eat h . I t is t h e p r ocess of t h e
hum anizat ion of deat h and allev iat ion of pain, but it
d o e s n o t a b u s i v e l y p r o l o n g d e a t h w i t h t h e
im plem ent at ion of fut ile t reat m ent , which would cause
m or e suffer ing t o t er m inal pat ient s.
Or t h on asia is t h e p r act ice of n ot av oid in g
p at ien t s’ d eat h , r at h er it ceases in v est m en t s t h at ext end life at a m edium t erm( 12).
Or t honasia is not applied t o cases lim it ed t o int ense suffering of any nat ure, w het her it is pain or
d i sco m f o r t . I t m e a n s su sp e n d i n g m e a su r e s o n l y r el at ed t o t h e co n cep t o f t h er ap eu t i c o b st i n at i o n ,
focusing on t he m aint enance of well being and t aking necessar y m easur es t o m eet t his goal( 13).
As t r eat m ent s can no longer r est or e healt h, at t em pt s at healing becom e fut ile; one has t o keep in
m ind t hat car e is par t of t he t r eat m ent , not t o incur
dy st h an asia( 9 ).
W h e n t h e t r e a t m e n t n o l o n g e r m e e t s i t s
ob j ect iv es, w h en t h er e ar e n o r eal p ossib ilit ies of s u c c e s s o r i m p r o v e d q u a l i t y o f l i f e , t r e a t m e n t
b ecom es f u t ile. Hen ce, on e n eed s t o st op u seless m e a su r e s a n d t r a n sf e r e f f o r t s t o a l l e v i a t e p a i n ,
suffering, discom fort of dying, providing nat ural deat h, et c. . Deat h has no cur e. I t is noble t o assum e it is
part of life.
Third cat egory: fut ile t reat m ent – t he fam ily facilit at es d y st h an asia
Fut ile t r eat m ent is w hen one does not m eet t h e ob j ect iv e of p ost p on in g d eat h , ex t en d in g lif e,
im pr ov ing, m aint aining or r ecov er in g qu alit y of life, f a v o r i n g t h e p a t i e n t a s a w h o l e , i m p r o v i n g t h e
p r og n osis, com f or t , w ell b ein g , en d in g d ep en d en cy o n i n t e n si v e m e d i ca l ca r e , p r e v e n t i n g o r cu r i n g
disease, alleviat ing suffering and sym pt om s, rest oring
funct ions( 14) .
Medical fut ilit y is under st ood as act ions t hat
d o n o t m a i n t a i n o r r e st o r e q u a l i t y o f l i f e , b r i n g so m e o n e t o co n sci o u sn e ss, a l l e v i a t e su f f e r i n g o r
o t h er w i se b en ef i t p at i en t s; o n t h e co n t r ar y, su ch act ions causes int ense suffer ing( 10).
[ ...] t he physician m akes it clear, but t he fam ily doesn’t want it , t hey prefer t o m ake everyt hing and we feel t hat t he pat ient keeps suffering really, but t hen it ’s what you’re saying about dyst hanasia ( S4) .
A s m e d i c a l t h e r a p y d o e s n o t m e e t i t s obj ect ives, which are t o preserve healt h and alleviat e
su f f er in g , it b ecom es f u t ile or a b u r d en . Th en t h e
ob lig at ion em er g es t o cease u seless m easu r es an d int ensify effort s t o assuage t he discom fort of dying( 15).
Fo l l o w i n g , t h e s t u d y s h o w s t h a t f a m i l y
m em b er s d o n o t accep t t h e co n d i t i o n o f p at i en t s
[ ...] t he fam ily does not accept we t ake out everyt hing, t hat we j ust support t he pat ient , t hat t his pat ient is really t erm inal, you have t o m ake it clear, but t he fam ily does not accept it , it ’s a fam ily’s decision ( S10) .
Fut ile procedures wit h lit t le chance of success
should be abolished( 16).
Ext ending life, t he qualit y of life, is a com plex
concept t hat science and t echnology t ranspose t o t he hum anit ar ian dim ension( 13).
Fu t ile t r eat m en t d oes n ot b en ef it t er m in al p at ien t s; on t h e con t r ar y, it p ost p on es d eat h an d
causes m or e agony, giving unfounded hope t o fam ily
m e m b e r s. Fu t i l e t r e a t m e n t co u l d b e r e p l a ce d b y p a l l i a t i v e ca r e , h o w e v e r, f a m i l y m e m b e r s d o n o t
accep t t h e co n d i t i o n s o f sev er el y i l l p at i en t s an d m anifest t heir desir e t o k eep t he t r eat m ent .
Four t h cat egor y : nur ses’ par t icipat ion
Th e par t icipat ion of n u r ses in t h e decision
-m ak i n g p r o cess i s y et -m o d est , t h at i s, t h er e ar e s i t u a t i o n s w h e n t h e y c o m p l y w i t h p r e s c r i b e d
t reat m ent , which m ost of t he t im e t hey do not agree w i t h , w h i l e t h e y c o u l d i n s t e a d c o n t r i b u t e m o r e
effect ively by defending t he aut onom y of pat ient s and
t heir fam ilies.
The im por t ance of int er disciplinar y dialog is
em p h asized an d t h is b ioet h ical issu e d em an d s t h e involvem ent of healt h professionals and all t hose who,
w it h com p et en ce an d r esp on sib ilit y, ar e w illin g t o r ef lect in et h ical t er m s on t h e b est p r act ice t o b e
im plem en t ed( 1 7 ).
[ ...] I really t hink t hat nursing is not very concerned wit h t his, also because t he nursing work process doesn’t perm it us t o discuss t his issue, deat h.
This report reveals t hat nurses neit her cont est
t he m edical pr escr ipt ion nor do ot her phy sicians and people r espect t he adopt ed pr ocedur e.
[ ...] nobody cont est s a m edical prescript ion, you know, even am ong t hem …t hey respect each ot her a lot and if you t hink t he proposed act ion is t he one, go ahead.
Decisions int errupt ing fut ile t reat m ent include
m o r e a t t e n t i o n t o i m p r o v e t h e n u r se p h y si ci a n
-pat ient - fam ily relat ionship in sit uat ions in which a cure i s n o l o n g er p o ssi b l e. Th i s b eco m es a p r o ced u r e
inv olv ing bot h nur ses and phy sicians( 14).
[ ...] w e can cont ribut e in respect ing t he pat ient as som eon e, y ou k n ow , w h o is u n der m in im u m con dit ion s of su r v iv al… b u t d u r in g sh if t s w e can t alk t o p h y sician s, p u t forwarded som e of our views, som e of t hem are really recept ive, t hey even t alk wit h us as we’re t alking now.
Nu r se s r e p o r t t h a t t h e y ca n n o t i n f l u e n ce
decisions and t hat nur ses should par t icipat e m or e so
as t o pr epar e t he t eam .
[ ...] w e don’t m anage t o influence decisions, don’t m anage t o par t icipat e in t his decision, I guess t hat nur sing should also part icipat e in t his decision so as t o prepare it s t eam .
I n pr act ice, t h e ph y sician h as t o m ak e t h is
decision unilat erally and in isolat ion and does not share
v i e w s d u e t o l a c k o f c o m m u n i c a t i o n a m o n g
pr of ession als. Th er e is also t h e per cept ion t h at t h e
decision t o in t er r u pt a giv en t r eat m en t , con sider ed
fut ile, is not alw ay s unanim ous am ong pr ofessionals
an d su p p or t ed b y d if f er en t p h y sician s in t h e sam e
inst it ut ion. I t is not uncom m on t o see a physician on
dut y t o r esum e a pr ev ious t r eat m ent , m ot iv at ed by
his or her convict ions, creat ing a vicious cycle, difficult
t o r e so l v e , a n d w h i ch r e f l e ct s t h e l a ck o f d i a l o g
bet w een t he m edical t eam it self( 5).
Finally, nursing has sm all part icipat ion in t he
d eci si o n o f p r a ct i ces t o b e a d o p t ed , t h o u g h i t i s
p o ssi b l e , i n so m e ca se s, f o r n u r se s t o t a l k w i t h
p h y si ci an s an d p u t f o r w ar d t h ei r v i ew s r eg ar d i n g
pr ocedu r es. A lack of in t er discip lin ar y w or k am on g
t eam s is ev ident . Decisions r est on a single per son.
FI NAL CONSI DERATI ONS
Accor d in g t o in t er v iew ees, n u r ses id en t if y
dyst hanasia in t heir daily pract ice as a deat h suffered
wit h m uch pain and t he im plem ent at ion of aggressive
t r eat m ent s, w hich only ex t end t he pr ocess of dy ing.
I t ex t ends suffer ing and not life, does not br ing any
t h e r a p e u t i c b e n e f i t a n d c a u s e s h i g h c o s t s t o
inst it ut ions.
Nur ses ident ify dy st hanasia but fight against
i t a n d i n st e a d p r o v i d e o r t h o n a si a , a l w a y s g i v i n g
p r i o r i t y t o co m f o r t a n d p a i n r el i ef i n a ca l m a n d
p leasan t en v ir on m en t aim in g at q u alit y of lif e, t h e
m o st p o si t i v e d i m e n si o n o f t h e r i g h t t o d i e , n o t
ab u siv ely ex t en d in g t h e p r ocess t h r ou g h h ig h - en d
t ech n olog y, b u t r at h er, in t er act ion b et w een t eam s.
Decision - m ak in g lit t le in v olv es n u r ses bu t m ost ly is
r est r ict ed t o ph y sician s.
Dat a collect ed show s t hat nurses underst and
dy st hanasia as ex t ending life w it h pain and suffer ing
and work t heir best t o assure pat ient s’ dignit y in t heir
living and t heir dying, cont rolling sym pt om s of organic
d i so r d er an d p r o v i d i n g co m f o r t an d w el l - b ei n g t o
We conclude that nurses understand dysthanasia
in t he unit and t hat t erm inal pat ient s are subm it t ed t o
fut ile t reat m ent s t hat ext end deat h and do not benefit
t hem . Nurses also ident ify dyst hanasia but put forward
elem ent s of ort honasia t o place a priorit y on providing
com fort, that is, dying at the right tim e.
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