RESEARCH ARTICLES

Conceptions of nurses on the artificial extension of life

Carina Marinho Picanço^I; Dora Sadigursky^II

^IMestre em Enfermagem pela Universidade Federal da Bahia, Programa de Pós-Graduação em Enfermagem. Enfermeira Intensivista do Hospital Geral Roberto Santos, Unidade de Terapia Intensiva. Docente do Curso Bacharelado em Enfermagem do Centro Universitário Estácio. Salvador, Bahia, Brasil. E-mail: carinamarinho@uol.com.br.
^IIProfessor Associado I da Universidade Federal da Bahia, Escola de Enfermagem, Programa de Pós-Graduação em Enfermagem, na linha O cuidar no processo de desenvolvimento humano. Salvador, Bahia, Brasil. E-mail: dora@ufba.br.

DOI: http://dx.doi.org/10.12957/reuerj.2014.15527

ABSTRACT: Patients with no chance of cure, in intensive care unit (ICU), remain targets of therapeutic obstinacy. This descriptive study aimed to analyze the conceptions of the nurses on the care of patients on artificial prolongation of life in ICU. Developed in 2009 in the ICU of a large public hospital in the city of Salvador, Bahia. 17 nurses were interviewed and the data processed according to thematic content analysis of Bardin. As a result we obtained the main category: Realizing the therapeutic obstinacy. And subcategories: Believing in the limit of life; Suffering from the artificial prolongation of life. It is concluded that the nurses believe that there should be limitations in therapeutic approaches and consider the artificial prolongation of life a source of suffering for the patient.

Keywords: Palliative care; intensive care units; therapeutic obstinacy; nursing.

LITERATURE REVIEW

From the beginning of life there is care, because it is necessary to look after life, in order to continue existing.  Living beings always need care, because caring is an act of life which has the purpose of permitting its continuity, in other words, developing and fighting against death³.

In this manner, different people, with different roles, develop care, nevertheless, with similar purposes. Those needing care wish to guarantee survival and avoid death.  And, those who offer care begin to fight against death, in such a manner that they perpetuate the taboo involving this issue. Nevertheless, it should not be permitted for this relentless fight to be the crucial part of the existing care, death is a part of life and should be confronted as something natural and unavoidable.

The encounter between the care giver and the one being cared for is mediated, in a general manner, by intense happiness (birth of a child) or deep sadness (death of a loved one).  Thus, living, illness and dying imply in attaining the concreteness of values. Thus nursing professionals should be sensitive to these values (ethics, spiritual) when caring for human life. For this reason, nursing care should have, as its main characteristic, a stimulus to potentialities of people.  Breakthroughs not yet thought of, become concrete, permitting that a certain beauty of human life, even in its process of organic decline, to go through suffering, which ends up permitting the well-being and comfort that extrapolate the physical, biological and physiological⁴.

Nevertheless, after almost four decades from the propositions of changes in the contemporary    model of death, it is observed that, during the formation process, health professionals, in general, do not receive sufficient information and training to accompany death and the process of dying. Contrary to the imagined, it is in the hospital that the professionals are prepared for not facing death.  There strategies are prepared to control emotional manifestations of professionals, patients and family members⁵.

With the technological advance in the ICU, it became possible to save lives, previously impossible, a great contribution to medicine. It was then possible to prolong life, but without having the adequate comprehension of the therapeutic range.  These efforts, often full of uncertainties, brought to the world of medicine and to society the field of therapeutic obstinacy. The fact is that the training of these new specialists is focused on technology, and does not include an ethical reflection on the therapeutic range of patients with no chance of cure⁶.

In relation to the ICU, it is characterized by a scenario of innovation.  Thus, specialized nursing care to patients considered as critical, strengthens the necessity of constant development of professional competencies, among those working in this area, beyond technical knowledge⁷.  Included within this scenario is palliative care which helps to see the patient as a person in its entirety, understanding the limitation of science.  This change in philosophy is challenging for the multi-professional health team⁸.

METHODOLOGY

A descriptive research, of a quantitative and qualitative nature, performed in two ICUs of a large public hospital in the city of Salvador-Ba. This hospital, inaugurated in 1979, is a hospital of reference for urgency and clinical emergencies, obstetrics and trauma, with a total of 546 beds.  It has the largest ICU complex of the whole state of Bahia with 144 beds.  The data collection period was between January and June, 2009.  The two ICUs selected were an adult ICU (ICU-A) and a pediatric ICU (ICU-P), where a total of 48 nurses work, of which 17 were interviewed, once they complied with the inclusion criteria, in other words, having worked in nursing care for at least two years. These were randomly selected. The quantity of interviews was considered sufficient when the answers to the interviews began to be repeated, in accordance with the data saturation technique. Out of the 17 nurses participating in the research, 10 work in the ICU-A and seven in the ICU-P.

In attendance to the established in the National Health Council Guidelines and Resolution 466/2012 on researches involving human beings⁹, the study was started after the approval of the Research Ethics Committee corresponding to Protocol 07/2009 – Cover Sheet 245684.  After supplying the information on the project, including objective and justification for the research, the Free and Clarified Consent Term was delivered to each nurse, making clear the free choice of participating and/or withdrawing at any phase of the research, as well as making explicit the instrument to be used. The letter E was attributed to each interview, being each one numbered (Ex: E1, E2, E3, E4) to preserve the anonymity of the participants.

Data collection was performed using the semi-structured interview technique. The interview script, previously prepared, tested and corrected, including questions that characterized the profile of the participants and specific and subjective questions on the matter.

For the treatment of socio-economic variables, simple statistical analysis was used (absolute frequency).  For a qualitative approach, the Bardin content analysis method was used, which proposes a set of techniques for verbal communication analysis applied to the discourse, for obtaining indicators, qualitative or not, permitting the description of the content of the messages of the interviewed parties. The method is composed of the pre-analysis, exploration of the material, treatment of the results, inference and interpretation¹⁰.  

In the pre-analysis an exhaustive reading of the wording of the interviews and delimitation of the units of register (discourses). In the following phase, the information is classified, from the units of register with the aim of attaining the comprehension of the text. During the third phase, categorization, classification of the elements in accordance to similarities and differentiation, with posterior regrouping due to common characteristics.

Thus, data analysis permitted the grouping of the results outlining, initially, the profile of the participants of the research in a descriptive and quantitative manner and, subsequently, by means of a qualitative approach, performed the categorization.  The thematic category 1 obtained: Perceiving the death-dying process, with the sub-categories: difficulties in the acceptance of death and accepting death naturally; thematic category 2: Conflicts in nursing care in the face of death with the sub-categories: believing in the limit of life and suffering with artificial prolonging of life. In this article the third thematic category of the master’s degree shall be discussed.

RESULTS AND DISCUSSION

Profile of the deponents

The participants, all of the female gender, had ages between 25 and 45 years, whereby 12 belonged to the interval of 25 to 29 years and the others (5) above 30 years of age.  Most (9) declared to be of the catholic religion, five (5) spiritualists and the remainder, one (1) evangelic, one (1) converted Baptist and only one (1) admitted not to having any religion.

Training time varied from 2 to 22 years, and experience in ICU range from 1 year and 2 months to 19 years.  Eleven have concluded post graduate courses in ICU.  Two are undergoing specialization in ICU and the other (4) concluded other specialties, such as Occupational Health Nursing (2), Oncology (1) and Nephrology (1).

Perceiving therapeutic obstinacy

This category encompasses two subcategories which are analyzed below.

Believing in the limit of life

Nurses admit that life has a limit and the nursing care implies in an encounter which, despite encompassing biomedical science, gives a new dimension to the technique with the aim of enhancing human capacities.  They do not reject suffering and/or death, but extract from these experiences the awareness of human condition of vulnerability and the capacity of man to go beyond the limits of objective conditions¹¹.

Thus, technological advances in the medical area and the senseless quest for immortality by the human being displaces the death scenario from the family home to the hospital environment, in which, generally, the dying being is isolated from his loved ones, confined to the dependency of equipment and invasive procedures, surrounded by professional who are obstinate the cure of disease, persist in prolonging the arrival of death, even when it is already iminent¹².

The interviewed parties demonstrated acceptance for the limit of life, in the following manner, as emphasized in their testimony:

Everything has a limit.  Everyone arrives here with a determined time to leave. (E8)

As of the diagnosis, one must already begin to think about death [...] In these cases without diagnosis, without a concluded prognosis....one witnesses the patient wasting away. (E10)

[...]letting the patient go through the process of being born and dying which is [...] something natural, then I believe that when you reach that point, in the final process of death, [...]. (E5)

For those patients which one sees that there isn’t very much perspective (E13).

As of the diagnosis, one already starts thinking about death. (E6)

Death places the professional in the face of his/her own finitude, generating an internal conflict, doubts about the efficiency, objectives and relevance of the professional care.  In view of this, the nursing professionals need, many times, to remove themselves from what they believe to incorporate what is designated to them.  The offer of a dignified death is a challenge, because it involves the equilibrium of multiple perspectives and necessities of the patient, the family and the professionals’ themselves¹³. Recognizing and accepting the death and dying process is an important stem to avoid ostensive treatments, in order to offer a dignified death, as demonstrated by the nurses:

When life is telling me that time is coming [...] One mustn’t forget that life has an end [...]For certain pathologies in ICU, there is not much in which you can advance [...] There must be a minimum of common sense to know that that life has an ending [...] (E11)

And when one realizes [...] that everything that could be invested has been invested, and that [..] very probably the patient will not recover from that [...]situation, then one begins to work [...]in a position of maintaining [...]a good ending for the patient. [...] a good death [...]. (E17)

The issue of medical futility is also a big challenge.  There are reasons for which doctors must render a good life support treatment, when indicated, but not necessarily supplying all the medical treatments for life support for all the patients. Many are reluctant to suspend treatment because they fear legal consequences, despite the existence of very favorable declarations and policies, both from the American College of Medical Emergencies as well as from the American Medical Association⁸.

Thus, the successful outcome of palliative care, which aims for comforting, quality of life and human dignity in the process of finitude, originates from the commitment, conjunction of knowledge and the actions of the interdisciplinary team. This manner of care should be the responsibility of all t health professional, as well as of clients and caretakers. One sole professional is not capable attending to all the necessities under these circumstances of life, once the care is continuous, and death presents itself in a constant dialogic between certainty and uncertainty, occurring at any moment, in accordance with the research¹⁴, corroborated by the following testimony:

All doctors and all health professionals should understand and acknowledge that there is a limit to all human beings, to all human bodies (E2).

For nursing professional the devaluation of biologicism is considered effective in detriment to the subjectivity that permeates human existence, whose death is inevitable, considering that the Man is a being towards death¹⁵.

Suffering with artificial prolonging of life

The large span of therapeutic possibilities offered, in present days, together with the ambiguities related to decision making at the end of life, generate intense questioning related to therapeutic obstinacy, once multiple and modern treatment could lead to excessive investments, apart from the fact that there is no concise definition as to the meaning of patients with no chance of cure¹⁶.

In this quest for cure, the days of those that not presenting improvement are prolonged. The interviewed parties consider that this artificial prolonging of life is a source of suffering, both to the patient, as well as to the family members and/or the team, as is evidenced in their statements below:

In this attempt to prolong the life of the patient we end up bringing suffering to the patient [...]If it’s time for him to rest.  We try and pretend to be God, prolonging it further (E9)

In my mind we prolong suffering of the patient.  It should be the decision of the patient, if the conditions are there, and to the family members, to decide where the therapeutic limits end or not (E6).

We have the obligation of providing a good death, dignified, without prolonging suffering (E2)

When dealing with pediatrics, for the children with poor prognosis, the fatal outcome is prolonged, which is perceived by the nurses as being unnecessary human, material and family debilitation¹⁷. In this sector, where there is the constant presence of the parents and/or responsible parties, it is possible to perceive a concern extended towards them, as evidenced below.

For patients without perspective of life I believe that [...] to prolong their lives is prolonging suffering, suffering of their parents, suffering of the child (E15)

Some aspects call attention in the above declarations, such as therapeutic limits and good death, which remits to the clinical condition of each patient and to the adoption of an assistance not guided to the cure, but to palliative care that transform the death-process of the patient so a more humane and dignified level.

The futile treatment, from the internment in the ICU, provides a severe violation to the psychological and physical integrity of the terminally ill patient, making it impossible for him to exercise the right of a dignified existence. Such facts victimize the terminally ill patient to invasive medical procedures, detached from any curative purpose, offering only the prolonging of death and isolation from the loved ones¹¹. This is emphasized in the passages below:

I believe that often a suffering is prolonged, which will not lead to anywhere.  Before, patients used to die at their homes, in a more natural manner and today they die inside the ICU, full of tubes, drains. Also, many times doctors are aware that the patient shall not have a normal life, will not survive, and even then, they continue prolonging. Why would medicine develop technologies permitting the prolonging of this suffering (E3).

I believe that this artificial prolonging of life is something aggressive, both for the team as for the family (E7).

Many times, the present structure and dynamics of the family does not permit that this dying being return home and endure his final moments. Studies reaffirm that hospitals should develop a systematic approach to guarantee that, during admission and on a daily basis during hospitalization, patients are able to be identified and accompanied by the team of palliative care¹⁸.

There are various forms to minimize suffering, one being the involvement of the family in the process of pain and loss. A simple manner is to make access and permanence of family members with their loved ones more accessible and flexible, which is reinforced in some of the testimonies:

I am against prolonging the life of a patient when it is possible to verify that death is imminent. I am in favor of palliative care, where suffering is eased. [...] I am in favor of these units where one can maintain the patient, in his final moments, close to the family and with basic care. Because here (at the ICU) it is very cold.  At this time the family wishes to remain the whole time until the last minute in contact with the physical body, and we end up depriving them because there are predetermined visiting hours. (E5)

[...]here at the hospital [...]measure are a little bizarre. (E1)

In this sense, such measures, considered as bizarre in the above statement, are characterized by therapeutic obstinacy, which is one of the most inhumane forms of denial of death, by means of exacerbation of suffering and distress of the final moments of the human being.

Therefore the existence of a team for palliative care is interesting, in order that together with specialists, it may be possible to become involved in discussions on the care and realistic understanding of the results.  These discussions may consider advanced therapies, such as inotropics, vasodilator drugs or heart transplants. Or, alternatively, palliative care, for those who are not eligible for life prolonging techniques¹⁹. And, under this perspective, the interviewed parties manifested the following:

I believe that the dialogue with the family is very important in order not to cause useless suffering to the patient. (E4)

For those patients where it is possible to verify that there is not much perspective and attempting to prolong their lives, it is difficult, [...] they invest in drugs, and medication and they do not respond [...] Sometimes it is best to send them to the room [...] to be with their family [...]. (E13)

In this manner, a policy guided towards healthcare, focused on the comfort of the patient, is necessary and where nurses are indispensable, becoming a connecting link with other professionals and practices²⁰.

CONCLUSION

The interviewed nurses understand that adequate treatment, for seriously ill patients, should be based on the individual response that these present to the implemented therapeutics, as observed in the main identified category – perceiving the therapeutic obstinacy and emerging subcategories – believing in the limit of life and suffering with the artificial prolonging of life.

It is necessary to make it clear, in this conclusion, that one does not propose the switching-off of equipment and the suspension of therapeutic measures. Nevertheless, is suggests a reflection on the matter, aiming for a more natural approach for those who care for patients with no chance of cure, in order to proportionate greater comfort and the necessary care. Therefore, it is necessary to think about palliative care as an alternative for patients not responding to the implemented measures.

In relation to the limits of the research, the necessity of new studies on the theme of therapeutic obstinacy is emphasized, analyzing the conceptions of other members of the multi-disciplinary team and of family members of patients in the death and dying process at the ICUs.

It is necessary to reconsider hospital units, especially in relation to restructuring, to receive these patients through units and/or palliative care teams, aiming for more adequate care, through the comfort and relief from pain of patients and their families.

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