Produção científica de enfermagem acerca da eutanásia: revisão integrativa da literatura/The nursing's scientific production on euthanasia: integrative literature review/Producción científica de enfermería sobre la eutanasia: revisión integradora

Headnote

ABSTRACT

Objective: to describe how euthanasia has been approached in Brazilian scientific publications authored by nurses and to discuss about the described bioethics aspects related to euthanasia. Method: this was an integrative literature review based on the BDENF, SciELO, and LILACS databases using the terms euthanasia and nursing as descriptors in complete texts in Portuguese. Results: a total of 24 articles were found, among them 6 contained complete texts; however, only 4 of them fulfilled the inclusion criteria and established consistent relationship with the subject. Conclusion: the theme is little discussed in the national level by nursing researchers. The selected studies did not address only euthanasia but included the end of one's life, palliative care, dystanasia, orthothanasia, and other actors involved in the decision-making process about one's death. Descriptors: euthanasia, nursing, bioethics.

RESUMO

Objetivo: descrever como a eutanásia tem sido abordada nas publicações científicas nacionais realizadas por enfermeiros e discutir sobre os aspectos bioéticos descritos relacionados à eutanásia. Método: revisão integrativa de literatura nas bases de dados BDENF, SciELO e LILACS, por meio dos descritores eutanásia e enfermagem, utilizando-se textos completos e em português. Resultados: foram encontrados 24 artigos, dos quais 06 possuíam texto completo. Destes, foram selecionadas 04 publicações que atenderam aos critérios de inclusão e estabeleceram relação consistente com a temática. Conclusão: temática pouco explorada no cenário nacional por pesquisadores da enfermagem. Os estudos encontrados não versavam exatamente sobre a eutanásia apenas, mas sobre terminalidade da vida e cuidado paliativo, distanásia, ortotanásia, e falavam de outros atores envolvidos no processo de decisão no fim da vida. Descritores: eutanásia, enfermagem, bioética.

RESUMEN

Objetivo: describir cómo la eutanasia ha sido abordada en las publicaciones científicas nacionales realizadas por los enfermeros y discutir los aspectos de bioética descritos relacionados con la eutanasia. Método: revisión integradora de la literatura en las bases de datos BDENF, SciELO y LILACS, a través de los descriptores eutanasia y enfermería utilizándose textos completos en portugués. Resultados: fueron encontrados 24 artículos, de los cuales 06 tenían texto completo. De éstos, fueron seleccionadas 04 publicaciones que cumplieron con los criterios de inclusión y establecieron relación consistente con la temática. Conclusión: temática poco investigada en la escena nacional por los investigadores de enfermería. Los estudios encontrados no se referían exactamente sobre la eutanasia, sino sobre la terminalidad de la vida y los cuidados paliativos, distanasia, ortotanasia, y hablaban de otros actores involucrados en el proceso de decisiones al final de la vida. Descriptores: eutanasia, enfermería, bioética.

INTRODUCTION

In the field of health and specifically in the everyday nursing activity, we often encounter a variety of situations involving the living and the dying, both at institutional and home levels. Thus, euthanasia poses as a conflicting and painful topic for health professionals, the involved family, and the patient before the completion of life, and is a broad debate topic on bioethics that relates to ethical-moral issues involving the life-death process.1

The word euthanasia had its origin in Greece and meant good death or dignified death.2-3 It has passed through various transformations throughout the ages, and is defined today as the action that aims to end human life based on conceptions that are considered humanistic towards the individual or collective society.4

Its practice is proscribed in Brazil, and involves serious criminal implications because it is considered a crime3; it also constitutes an ethical infraction according to the Nursing Code of Ethics 5, in its article 29, when referred to Prohibitions: To promote euthanasia or participate in practice aimed at anticipating the death of the client.

To think about the healthcare professional as a caregiver brings up the issue of their personal and professional aspects to deal with the shocking reality of the process of death and dying. In this context, nursing has direct implications in the implementation of therapeutic actions that collaborate in the quality of life of those being cared for, from the perspective of the right to health and respect for the dignity of the individual and family in the various phases of the therapeutic process, with this theme being addressed in the present study, especially in areas of high complexity - Adult and Pediatric Intensive Care Unit, of Emergency and Oncology, adding to this and other chronic medical conditions, units or spaces devoted to Palliative Care.

Therefore, the emphasis in human relations becomes crucial in health care with places reserved for reflection and discussion involving bioethical issues, that assist the analysis before dilemmas of professional practice in the context of death, dying, and professional care6, considering here the euthanasia, as a relevant topic to the outbreak of this process by health teams, involving nursing. Thus, this study aims to describe how euthanasia has been discussed in scientific publications carried out by nurses in Brazil.

METHOD

Considering that the summary of results of relevant and worldwide renowned research streamlines the incorporation of new knowledge to practice7, we opted for an integrative review of the literature to delineate this research, which is qualitative and of a descriptive nature.

The integrative review is a research method that allows search, critical evaluation, and synthesis of available evidences on the investigated subject. Its final product represents the current state of knowledge on the investigated topic, implementation of effective interventions in healthcare, cost reduction, and the identification of gaps that lead to the development of future research7.

Six distinct steps, similar to those in conventional research are necessary to perform an integrative review that can contribute to the construction of broad research analyses that collaborate into new approaches. The first step refers to the establishment of the guiding question that will involve the entire research, the choice and definition of the topic, and the identification of descriptors. For this study, the guiding question was defined as: How has euthanasia been discussed in scientific productions published by nurses in national journals? The used descriptors were: "euthanasia", crossed with "nursing" and "bioethics".

In the second step, the inclusion and exclusion criteria should be established for the search to start the selection of studies in databases. The search was conducted in the month of August of 2012 in the following databases: Nursing Database (BDENF), Latin American and Caribbean Literature in Health Sciences (LILACS), and Scientific Electronic Library Online (SciELO). Articles published in Portuguese, with full text available online, in Brazilian scientific journals, and whose authors carry a degree in nursing, were selected. It should be noted that articles with more than one author, in which at least one was a nurse, were also included in the analysis. Articles that appeared in more than one database were considered as one, subjected to analysis, to avoid duplication of articles. Articles with only summary available online and whose results did not present discussion about euthanasia were excluded.

The third step of the integrative literature review defines the information to be extracted. One must therefore organize, categorize, and summarize the information found. An instrument built by the authors was used for the collection of data and contained the following variables: name of the journal, title, authors' degrees, type of study, location of study, year of publication, and main results related to euthanasia.

The fourth and fifth steps were developed along the textual body. The fourth step corresponds to the phases of analysis, evaluation, inclusion, and exclusion of studies through a critical analysis of those selected. In the fifth stage, the interpretation and discussion of results occurs in which the knowledge of gaps and relevant suggestions for improving the quality of professional action are revealed.

The sixth and final step is determined by the presentation of the review. The creation of a document that describes in detail the integrative review is performed. This step consists in drawing up a document that should include the description of the steps followed by the reviewer and the main results highlighted by the analysis of the included articles. It is a work of utmost importance because it produces impact resulting from the accumulation of the existing knowledge on the researched subject.7

RESULTS AND DISCUSSION

The data were organized into two sets, namely those concerning the quantitative description of variables that characterize the articles and those related to the exploration of their contents.

Quantification of the Analyzed Texts

As a result of the application of search terms, 24 articles were found, 13 in LILACS, 10 in BDENF, and 01 in SciELO. After the application of the inclusion and exclusion criteria, and according to the inconsistency with the studied topic in some articles, only 04 texts were selected for analysis. The selected publications included in the study are presented and described in Figure 1, in chronological order of publication.

As for the year of publication, 01 article (25%) was published in 2006, 02 articles (50%) were published in 2009, and 01 (25%) in 2010. As for the journal, 01 article (25%) was published in the journal Bioethics, 01 (25%) in the Cogitare Nursing magazine, and 02 articles (50%) in the Latin American Journal of Nursing. It should be noted that the largest number of publications on the Latin American Journal of Nursing may be due to the flow of publications in this journal, which is a bi-monthly publication, to the detriment of the Bioethics and Cogitare Nursing journals, which publish quarterly and every three months, respectively.

Another highlight is that most journals (75%) are in the area of Nursing, which can demonstrate a preference for publication in journals of own area of work and seems to reflect the effort that the profession has made to self-consolidate as an area of knowledge. This can also demonstrate the need to expand the flow of information to other health areas, which would increase the visibility of Nursing in scientific discussions on the subject because euthanasia is not a subject specific to this area but shared with other health professionals who participate in care.

Regarding the methodology of the studies, 03 articles (75%) are descriptive and exploratory studies; 01 being quantitative, 02 being qualitative, and 01 (35%) being a reflective study. Out of the descriptive studies, 02 (67%) were performed by nurses and 01 (33%) by nursing scholars. As for the data collection type, 02 (66%) used questionnaires and 01 (33%) used an interview. In relation to the data analysis technique, 67% of the articles used the thematic content analysis and 33% used descriptive statistics analysis.

With regards to the place of publication, 02 articles (50%) were published in São Paulo, 01 (25%) was published in Minas Gerais, and 01 (25%) in the State of Paraná. Therefore, the predominance of the Southern and Southeastern regions with regard to publications on euthanasia is noted, which may be due to greater numbers of existing graduate programs in these locations. It is highlighted that, although the Southeastern region has concentrated the largest number of studies, there was no research conducted in the State of Rio de Janeiro.

The results, therefore, were organized, integrated, and presented discursively from 03 themes: 1) The completion of life and palliative care; 2) Concepts related to euthanasia: dysthanasia and orthotanasia; and 3) The social actors involved in the decision-making process at the end of life.

The completion of life and palliative care

Issues related to the completion of life are discussed in this theme, such as the process of death/dying and palliative care at the end of life, i.e., discussions about euthanasia that permeate and involve those related to end of life.

In one of the studies conducted by nursing scholars, it was noted that all of the bioethical themes related to end of life are those that most mobilized opinions. 8 The articles, when talking about the completion of life, reveal the problem of difficulties in dealing with the process of dying/death. Death is part of the human existence, based on the understanding that life is not eternal, and thus, each lived moment should be valued including the very process of dying itself. Thus, to take care of the person who is in this process should be an integral part of health care.9

Death, then, is seen as a process that demands respect, and should be cherished until its natural end. However, the institutionalization of death is what currently occurs, separating it from the everyday life and making people dying away from their loved ones and in unfamiliar surroundings. The interference in the scientific-technical progress in the forms of treatment in the final stages of life will only prolong costs and suffering not only for the patient, but for their families without bringing major benefits.9

Therefore, the person who is on the stage of completion of life, those in the final stages of life due to the evolution of an illness without conditions of reversibility by any applied known therapeutic measure, are subjected to treatments, invasive procedures and techniques in which suffering is greater than benefits because the cure is not possible. The therapy, at this stage, does not increase survival, and only prolongs the process of dying.10

When a person is at this stage, the main objective of care is no longer to preserve life but to make it the most comfortable and dignified as possible.9-10 Palliative care is then discussed. Palliative care involves caring for the person and their dignity, respecting them as human beings, valuing their pain. They aim to prepare and help both the person at the end of life and their families to experience the arrival of death.9

Thus, this type of care reach to control pain, soothe the suffering and degradation of the body, and improve the quality of life rather than trying to cure an incurable disease or extend life to the fullest. This allows the person to live in a peaceful and comfortable way. It is highlighted that the palliative care does not propose euthanasia but worries about the well-being of the person in the final stages of life. Therefore, it does not use instruments for resuscitation or proposes heroic treatments.10

Palliative care also involves the understanding from health professionals on the importance of exercising this practice in everything that is related to it. The palliative care requires the assistance provided by a multidisciplinary team, with nurses, nursing technicians, doctors, psychologists, social workers, spiritual counselors, and even volunteers. The location of this assistance may be the hospital or hospices, as in some countries, which perform the outpatient follow-up, especially with domiciliary care with professional support.9

With regards to palliative care, one article discussed what is called palliative sedation. This type of sedation is presented as terminal sedation, and is also defined with the prescription of psychotropic agents to manage psychological symptoms or let the patient unconscious for certain situations of difficult control, such as in cases of bleeding.9

To choosing of palliative sedation in people in the process of death/dying can trigger ethical problems in professionals involved in the care. Therefore, it is important that some attitudes be stimulated such as the unification of the multidisciplinary team in resolving conflicts of opinions and performance of scheduled encounters with the patient and family for clarifications on issues that may arise.9

This article9 also points out that the term sedation is erroneously linked to euthanasia or assisted suicide, instead of being seen understood as relief of pain and the main focus of care. This results from different given interpretations that involve ethical, moral, and socio-cultural questions that generate opinions in each society, professional, and individual, as well as issues related to the finiteness of life and impotence to cure a disease.

When differentiating euthanasia from sedation, the authors cite that the intention is what distinguishes them. The intention would be to provide quality of life to the terminal patient (beneficence) and not to promote or accelerate their death, which would be maleficence. Thus, it is argued that sedation can avoid the request for euthanasia by patients themselves or family members. It is noted that, although the beneficence and not the maleficence, involve principles of bioethics, they are not discussed as bioethical terms in the cited study.9

Concepts related to euthanasia: dysthanasia and orthotanasia

When discussing euthanasia, this theme is associated with other terms that also involve ethical dilemmas. These terms are the dysthanasia and orthotanasia. As for euthanasia, it was conceptualized in the reflective article as indirectly accelerated death resulting from medical actions performed with the purpose of relieving the suffering of a patient at the end of life. It differentiates voluntary from involuntary euthanasia. The first is death that is caused and consented by the patient. The involuntary euthanasia corresponds to death that is caused without the consent of the patient.9

The article also highlights another concept called assisted suicide, which is often seen as a synonym of euthanasia. It is characterized by the fact the patient requests assistance of another person to fulfill his intention to die because he has no conditions to carry it alone.9 Many nurses admit to not knowing how to conceptualize the term euthanasia or they do it incorrectly11, which makes discussions about the subject difficult on the part of these professionals.

Dysthanasia is conceptualized as the exaggerated prolongation of death, subjected to intense process of pain and suffering. In other words, it is the process that prolongs the agony, without expectations of success or of better quality of life for the patient, and with no possibility of cure or improvement. This concept relates not to prolong life, but rather the process of death, and can be regarded as futile treatment.9-10

In this context, cardiac resuscitation, artificial respiration, intravenous infusions, antibiotic therapies, and other invasive procedures are all primary support measures to assist the patient in the initial period of health recovery. However, when using them in patients requiring palliative care, with no hope of return to health, it is often inappropriate, and therefore, dysthanasia is considered a misconduct.9 The prevalence of new technologies leads into keeping life in a vegetative state by a long and indefinite period of time.

For nurses, dysthanasia is understood as a cruel, painful and suffered death, not bringing any benefit and promoting the expulsion of death and life. It introduces aggressive treatment that only prolongs suffering and not life, and leads to increased spending for the health institution. It is seen as a slow death.10-11

The dysthanasia is also seen as a medical futility, understood as those actions that fail to maintain or restore quality of life, bringing to consciousness, relieving pain, and providing benefit to the patient. On the contrary, they cause a lot of suffering because the treatment does not reach its goals as the result of no real possibilities of success or of better quality of life. Thus, these measures should be avoided and efforts to ease the pain, suffering, and discomfort of dying should be used to ensure natural death.10

The last discussed concept is that of orthotanasia, which means death in its own time 9-10 without abbreviating or extending disproportionately the process of death/dying. It is considered a process of humanization of death and pain relief without causing additional suffering to the person at the end of life.9-10

With respect to the nurses' knowledge about orthotanasia, the professionals conceptualize it as death in its natural time, without delay or advancement, and as death without suffering, or as good death. Many nurses who participated in the research did not know to conceptualize it, or did it in an erroneous manner.11

The social actors involved in the decision-making process at the end of life

The articles also reveal the participation of some social actors, besides the self at the end of life, who are important in the decision-making process when discussing euthanasia and other concepts related to it. They are: the nurse and the patient's family.

The participation of family members is extremely important in the process of death/dying of a loved one. When a disease occurs in someone of the family nucleus, there is a permanent stress, leading to emotional exhaustion, especially when they can see the suffering of the person at the end of their life.9 This situation often leads the family and the person who suffers to wish death to relieve the prolonged suffering.

Conversely, there are some family members who do not accept the condition of their loved one as seriously ill, and prefers to invest all possible therapeutic treatment, keeping life at all costs. It is in this context that decisions about what to do become complex and permeated by bioethical issues.10

Regarding the participation of nurses, it is realized that the influence of this professional in the decision-making process for the patient who is in the process of death/dying is still shy or little active. That is, instead of nurses to contribute to the defense of the patient's and family's autonomy, they only comply with the treatment in which they not always agree.10 However, even when participating in the decisions, the final decision is restricted to the doctor.11

Nurses fight dysthanasia and seek to provide orthotanasia prioritizing comfort and pain relief in a quiet and pleasant environment. This nursing care aims at quality of life, the positive dimension of the right to die, without abusive extensions of cutting-edge technologies and use of sophisticated technologies.10

Nurses believe that their actions are geared to ensure dignity to the patient, in his living and dying, by controlling the symptoms of organic disorder while maintaining comfort and well-being for the person who is dying, offering family support, and valuing gestures as touching, being together, dialoguing, and emotional and spiritual support.9-11 Nevertheless, what guides the professional actions are their beliefs or opinions and values, communication with the team, respect, knowledge/science, ethics, believing in the divine, common sense, speedy resolution of situations, aid to others, favoring autonomy, curative focus, legislation, family, providing quality of life, justice, non-maleficence, and humanization.11

With regard to the nurses' beliefs and their influence in the decision-making regarding the person cared for at the end of their life, this relationship can be shown through the research conducted with nursing scholars, whose majority was against euthanasia, based on the principle of the sacredness of life. Therefore, the influence of morality and religious precepts is also noted in the professionals' stands regarding the completion of life.8 As for the bioethical principles on professional performance, although many nurses know them in an incomplete way, they refer to them as important in daily assistance, directing and adapting it, avoiding mistakes, respecting the patient, and not hurting the ethics.11

The participation of nurses in a multidisciplinary team was also quite emphasized in the analyzed articles. They highlight the importance of interdisciplinary dialogue requiring the involvement of health professionals and of all those who, with competence and responsibility, are willing to reflect on the best ethically conduct to be taken, having always the person being cared for as the focus.10 They emphasize the need of continuing education services and participation of undergraduate institutions aiming to give quality to the discussions about interdisciplinary team.11

CONCLUSION

The results found in this review study indicate the need for new scientific research about euthanasia. It was verified that this topic is still little explored in the national scene by researchers in the field of nursing. The studies found did not deal exactly with euthanasia only, but on the completion of life and palliative care; dysthanasia, orthotanasia, and other social actors involved in the decision-making process at the end of life.

The paucity of studies on euthanasia in Brazil is possibly justified by ethical dilemmas raised in the national scene. It is a complex theme that also involves discussions linked to the BioLaw and the power of the State to protect the lives of all its citizens, including those who, due to their precarious state of health, wish to put an end to suffering, anticipating death. In Brazil, this is considered an illegal practice, and involves main discussions permeating the value of human life.

In situations in which the individual becomes a prisoner of their own body, totally dependent on the satisfaction of basic human needs, there is the dread of being a "burden" or suffering excessively, and the exhaustion of their life project. In the Brazilian Federal Constitution, the recognition of dignity of the human person is clearly expressed grounded in the Democratic State of Rights, and states that no one shall be subjected to torture or to inhuman or degrading treatment, however, in the Organic Law of Health, the preservation of autonomy of people in defense of their physical and moral integrity is recognized, however, it does not authorize them to end their lives.

The development of new and more complex studies about this theme is necessary. The absence of international research was a limitation in this study, although this was not its focus. We recommend that further studies compare these findings with those from other countries.

References

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