Bioethical discussion on end of life patient care

Maingué, Paula Christina Pires Muller; Sganzerla, Anor; Guirro, Úrsula Bueno do Prado; Perini, Carla Corradi

doi:10.1590/1983-80422020281376

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Sumário

RESEARCH • Rev. Bioét. 28 (1) • Jan-Mar 2020 • https://doi.org/10.1590/1983-80422020281376 copy

Bioethical discussion on end of life patient care

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

This study aimed at identifying factors that influence the decision-making of health professionals regarding patients in intensive care units. We carried out a quantitative research in two hospitals in Paraná, between March and May 2018. We defined a sample of 45 members of a multidisciplinary team. As results, we identified the interviewees’ concern in respecting autonomy, protecting dignity and preserving the quality of life of patients and family members by making shared decision. However, we also observed a tendency of therapeutic obstinacy to fulfill the professional duty, which indicated the need for more discussions and training on palliative care to minimize ethical conflicts.

Approval CEP-PUCPR 2.397.069/2017

Decision making; Intensive care units; Palliative care

Characteristics		Freq.	%
Profession	Social worker	1	2.2
	Nurse	9	20.0
	Physiotherapist	22	48.9
	Speech therapist	1	2.2
	Doctor	4	8.9
	Nutritionist	5	11.1
	Psychologist	3	6.7
Marital status	Single	20	44.4
	Separated	2	4.4
	Widow/er	1	2.2
	Live with partner	20	44.4
	Not informed	2	4.4
Religion	Catholic	27	60.0
	Protestant	5	11.1
	Without religion	2	4.4
	Other	5	11.1
	Not informed	6	13.3
Sector in which you work	ICU	20	44.4
	Nursing	5	11.1
	ICU + another sector	6	13.3
	Another sector	11	24.4
	Not informed	3	6.7
Do you work or have worked in ICU?	Yes	45	100.0
Do you work or have worked in ICU?	No	0	0.0
Do you work or have worked with end of life patients?	Yes	45	100.0
Do you work or have worked with end of life patients?	No	0	0.0
Are you trained in palliative care?	Yes	6	13.3
Are you trained in palliative care?	No	39	86.7

Clinical case/question	Response options	Gender		p
Clinical case/question	Response options	Female	Male	p
Case 1	Strongly disagree	20 (52.6%)	5 (71.4%)	0.869
	Disagree	3 (7.9%)	0 (0%)
	Undecided	4 (10.5%)	1 (14.3%)
	Agree	4 (10.5%)	1 (14.3%)
	Strongly agree	7 (18.4%)	0 (0%)
Case 2 Question 10	Strongly disagree	11 (28.9%)	5 (71.4%)	0,103
	Disagree	6 (15.8%)	0 (0%)
	Undecided	3 (7.9%)	1 (14.3%)
	Agree	5 (13.2%)	1 (14.3%)
	Strongly agree	13 (34.2%)	0 (0%)
Case 2 Question 12	Strongly disagree	6 (15.8%)	3 (42.9%)	0.469
	Disagree	4 (10.5%)	0 (0%)
	Undecided	5 (13.2%)	0 (0%)
	Agree	5 (13.2%)	0 (0%)
	Strongly agree	18 (47.3%)	4 (57.1%)
Case 3 Question 14	Strongly disagree	9 (23.7%)	4 (57.1%)	0.101
	Disagree	6 (15.8%)	0 (0%)
	Undecided	9 (23.7%)	0 (0%)
	Agree	7 (18.4%)	0 (0%)
	Strongly agree	7 (18.4%)	3 (42.9%)
Case 3 Question 16	Strongly disagree	1 (2.6%)	2 (28.6%)	0.018*
	Disagree	0 (0%)	1 (14.3%)
	Undecided	1 (2.6%)	0 (0%)
	Agree	4 (10.5%)	1 (14.3%)
	Strongly agree	32 (84.2%)	3 (42.9%)
Case 3 Question 18	Strongly disagree	0 (0%)	0 (0%)	0.591
	Disagree	0 (0%)	0 (0%)
	Undecided	2 (5.3%)	1 (14.3%)
	Agree	7 (18.4%)	1 (14.3%)
	Strongly agree	29 (76.3%)	5 (71.4%)
TOTAL		38 (100%)	7 (100%)

^Appendix Appendix Demographic data Age: _________ Gender: ( ) Female ( ) Male Marital status: ( ) Single ( ) Widow/er ( ) Separated ( ) Lives with a partner Religion: _________ Ethnic origin: ( ) Portuguese ( ) German ( ) Asian ( ) African ( ) Italian ( ) Others Which? __________________________________________________________________________________________ Profession: _________ Hospital sector where you work: ( ) Previously worked in the ICU ( ) Currently work in the ICU Time: _______ years ( ) Works with end of life patients ( ) Worked with end of life patients Time: _______ years Do you have any training in palliative care? ( ) No ( ) Yes Which? __________________________________________________________________________________________________ Decisions about refusing or stopping treatment Have you ever participated in this discussion in the hospital environment? 1 2 3 4 5 Strongly disagree Disagree Undecided Agree Strongly agree If you agreed 1. Name which professionals were involved in the debate. 2. Who do you think should participate in this debate? ( ) Patient ( ) Psychologist ( ) Family ( ) Doctor ( ) Social worker ( ) Nurse ( ) Religious ( ) Nursing technicians and assistants ( ) Others Who? __________________________________________________________________________________________________ __________________________________________________________________________________________________ In the home environment 3. Have you ever talked at home with your family members, especially the elderly, about death and decisions about dying? 1 2 3 4 5 Strongly disagree Disagree Undecided Agree Strongly agree 4. If you had a serious and irrecoverable illness and had a cardiopulmonary arrest, would you like to be resuscitated? 1 2 3 4 5 Strongly disagree Disagree Undecided Agree Strongly agree 5. If you were 85 years old, in good health for your age, and suddenly had a cardiopulmonary arrest, would you like to be resuscitated?? 1 2 3 4 5 Strongly disagree Disagree Undecided Agree Strongly agree 6. If a relative of yours, facing old age or a serious illness, showed the desire not to be resuscitated, and in those circumstances suffered a cardiopulmonary arrest, you would start cardiopulmonary resuscitation (CPR)? 1 2 3 4 5 Strongly disagree Disagree Undecided Agree Strongly agree 7. How would you like to die? ( ) Suddenly ( ) After a consumptive illness ( ) Other How? _________________________________________________________________________________________________ Clinical cases Case 1 This is a 16 year old female patient case. She presented history of esophageal stenosis after ingestion of caustic soda when she was four years old and was admitted for surgical correction due to recurrent pneumonia. She evolved in the postoperative period with mediastinitis, maintaining a septic condition without the prospect for further surgical treatment and had no improvement with clinical treatment. Her condition progressed to multiple organ failure and the patient had cardiopulmonary arrest on the 60th day of hospitalization. 8. Do you think this patient should be reanimated? 1 2 3 4 5 Strongly disagree Disagree Undecided Agree Strongly agree 9. Which factors you believe most influenced your decision? _________________________________________________________________________________________________ Case 2 An 86-year-old woman who lives with her family and has good health conditions for her age, and she had repeatedly told family members that she would like to die suddenly. Then one day she presented a sudden loss of consciousness and cardiopulmonary arrest. 10. If she were your family member, would you call a health team and start cardiopulmonary resuscitation? 1 2 3 4 5 Strongly disagree Disagree Undecided Agree Strongly agree 11. Which factors you believe most influenced your decision? _________________________________________________________________________________________________ 12. If you belonged to the resuscitation team, would you initiate resuscitation techniques? 1 2 3 4 5 Strongly disagree Disagree Undecided Agree Strongly agree 13. Which factors you believe most influenced your decision? _________________________________________________________________________________________________ Case 3 Male patient, 63 years old, diagnosed with heart failure due to ischemic cardiomyopathy, with an ejection fraction of 20%. He was interned in the ICU, in a medical center without conditions for heart transplantation and presented no response to clinical treatment, being dependent on dobutamine and mechanical ventilation for 30 days. If this patient had cardiopulmonary arrest: 14. Would you initiate resuscitation techniques? 1 2 3 4 5 Strongly disagree Disagree Undecided Agree Strongly agree 15. Which factors you believe most influenced your decision? _________________________________________________________________________________________________ 16. Before this fact, during hospitalization, do you think you should talk to the patient to find out what his opinion is? 1 2 3 4 5 Strongly disagree Disagree Undecided Agree Strongly agree 17. Which factors you believe most influenced your decision? _________________________________________________________________________________________________ 18. Before this fact, during hospitalization, you think you should talk to the patient’s family to find out what your opinion is? 1 2 3 4 5 Strongly disagree Disagree Undecided Agree Strongly agree 19. Which factors you believe most influenced your decision? _________________________________________________________________________________________________

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[1] Correspondence: Paula Christina Pires Muller Maingué – Rua Deputado Heitor Alencar Furtado, 1.661, Mossunguê CEP 81200-110. Curitiba/PR, Brasil.