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Palliative care for HIV/Aids patients: ethical observance by nurses


Monica Ferreira de VasconcelosI; Solange Fátima Geraldo da CostaII; Patricia Serpa de Souza BatistaIII; Maria Emília Limeira LopesIV

I Nurse. Master in Nursing by the Federal University of Paraíba. Member of the Center of Studies and Research in Bioethics. João Pessoa, Paraíba, Brazil. Email:
II Nurse. PhD in Nursing, Ribeirão Preto School of Nursing/University of São Paulo. Professor at the Graduate Program in Nursing/Federal University of Paraíba. Member of the Center of Studies and Research in Bioethics. João Pessoa, Paraíba, Brazil. Email:
III Nurse. PhD in Education from the Federal University of Paraíba. Lecturer at the Undergraduate Nursing course and the Graduate Nursing Program. Member of the Center of Studies and Research in Bioethics. João Pessoa, Paraíba, Brazil. Email:
IV Nurse. PhD in Education by the Federal University of Rio Grande do Norte. Lecturer at the Undergraduate Nursing course and Graduate Program in Nursing/Federal University of Paraíba. Member of the Center of Studies and Research in Bioethics. João Pessoa, Paraíba, Brazil. Email:





Objective: to identify the ethical principles observed by nurses providing palliative care for patients with HIV/AIDS. Method: this qualitative, descriptive study was conducted at the infectious disease clinic and the specialized mother-and-child care service of a university hospital. Study participants were eight nurses. Data were collected in October 2012 by semi-structured interview and analyzed using content analysis. Results: the category that emerged from the qualitative analysis was titled: Respect for HIV/AIDS patients' human dignity, confidentiality and privacy. Conclusion: the nurses in the study recognized the importance of ethical principles in providing palliative care for patients with HIV/AIDS. It is hoped that this study will give rise to discussion and thinking on this subject and inform the development of new research.

Keywords: Palliative care; nursing; AIDS; ethics.




Palliative care is defined by the World Health Organization (WHO) as an approach that promotes good quality of life for patients and their families facing diseases that threaten the continuity of life through prevention and relief of suffering. It requires from the multidisciplinary team the early identification, assessment and treatment of pain and other problems of physical, psychosocial and spiritual nature1.

Palliative care consists of active, comprehensive and individualized attention to patients with diseases outside therapeutic possibilities of cure and has as focus of attention the patients and their families 2. Thus, such care is indicated to terminal cancer, non-chronic neoplastic, progressive and infectious diseases, as for example, acquired immunodeficiency syndrome (AIDS).

Nursing professionals should use information and communication as therapeutic tools available when providing care. The actions must act directly on the quality of life of the patient, in order to influence pain relief, provide welfare and interfere with diseases that can generate dependency and discomfort3.

The nurse, as a member of the multidisciplinary team, plays a key role in promoting palliative care for patients with the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) - to minimize the patient's suffering and promote a better quality of life for patients and their families, supported by the philosophy of care and ethical principles that guide the practice of the nursing professional. The diagnosis of this disease causes a great impact on the life of the person living with HIV/Aids and prompts the performance of nursing professionals in different dimensions, with a focus on care as an ethical assumption and appreciation of life4.

It is worth noting that the Code of Ethics of Nursing Professionals points out that these professionals should perform their activities with competence, aiming at the promotion of health to the individual in its entirety, using ethical and legal precepts as guiding axis5. Therefore, it is imperative that, when assisting the patient with HIV/Aids, the nurse take into account the ethical principles included in the above mentioned Code.

Based on these considerations, this study aimed to investigate the bioethical principles considered by nurses when assisting patients with Aids under palliative care in a university hospital of Paraíba.



Palliative care is driven by techno-scientific competence and is based on principles and knowledge inherent to the various specialties and to the possibilities of clinical and therapeutic interventions in various areas 6. In this perspective, care strategies for patients without therapeutic possibilities of cure are developed aiming to effectively control pain and other symptoms caused by the disease, as well as care that includes psychological, social and spiritual dimensions of these patients and their families 7. This is, therefore, a form of care based on knowledge acquired in different specialized fields and through the clinical and therapeutic actions based on such knowledge8.

Among the principles adopted in palliative care provided to HIV/Aids patients, stand out the affirmation of life and the recognition of death as a natural process; the promotion of relief of pain and other symptoms; the integration of the spiritual and psychological needs in the care of the patient in terminal phase and the implementation of support to the family during the process of the disease, death and mourning. These principles are the same suggested by the WHO for palliative care9.



This is a descriptive study with qualitative approach carried out in the clinic of Infectious-Contagious Diseases (ICD), and in the Service Specialized in Maternal and Child assistance (SAE-MI) of the University Hospital Lauro Wanderley (HULW) of the Federal University of Paraíba (UFPB) in the city of João Pessoa-PB. Eight nurses that work in the hospital units, scenarios of this research, participated in the study. Because this is a qualitative research, we used the sampling by accessibility. As inclusion criteria, nurses who were in active in the data collection period and that were for more than one year providing assistance to people with HIV/AIDS were included. In turn, as exclusion criteria, nurses that were on vacation or away from their activities in the period of data collection were excluded.

Data were collected in October 2012 through interviews scheduled with the participants using forms consisting of subjective questions regarding the purpose of the study. Initially, participants were informed about the purpose of the research and its voluntary character. Participants expressed their consent by signing the Informed Consent. The interview took place in an environment of the sector where participants perform their activities, in an atmosphere of cordiality, with an average duration of 20 minutes. To maintain secrecy, a letter and a number was assigned to identify the respondents.

Data collection started after the project was approved by the Research Ethics Committee of the HULW under CAAE nº 04171512.7.0000.5183. The researcher followed the recommendations of Resolution 196/9610 that includes the regulatory guidelines for research involving human beings, in force in the period.

The empirical data acquired through interviews was qualitatively analyzed by the content analysis technique proposed by Bardin11, adhering to the guidelines for implementation of the following stages: pre-analysis, when the documents are selected, the research hypotheses and objectives are formulated in order to operationalize and systematize initial ideas; the exploration of the material, considered the most extensive moment of the study, which may require to perform several readings. This corresponds to the application of the technique on the corpus comprising the text; and treatment of results and interpretations. This is the stage of treatment of results, inference and interpretation.

To ensure the anonymity of respondents, the passages used arising from the collected empirical data were coded by the letter "N" followed by a number following the order of the interviewed nurse, whose sequence contemplated from N1 to N8.

The empirical material obtained allowed the development of the following category: Respect as an ethical principle adopted by nurses to take care of people with HIV/AIDS under palliative care. This category was analyzed by the subcategories: Human dignity, Privacy and Professional confidentiality.



Eight professionals participated in the study. Only one professional has PhD degree and one has Master degree. Most participants had expertise, which is justified by the great difficulty professionals meet to make courses stricto sensu (MS, PhD), as such courses demand a considerable high workload from professionals who are exercising their practical activities.

Human dignity

In the context of palliative care focused on the patient with HIV/Aids, health professionals, especially nurses, should adopt an ethical approach with emphasis on an authentic care without labels or that marginalize the patient, to respect his/her dignity. On this, it is worth mentioning some reports of the interviewed nurses that pointed the importance of respecting the human dignity of patients when promoting palliative care, as shown in the following excerpts:

[...] when promoting palliative care, I seek to preserve the human dignity of patients with HIV/AIDS. (N1)

[...] when taking care of patients with HIV/Aids I seek to respect their dignity. (N2)

At the time of providing care, I respect the dignity of the human person. (N4)

[...] I try to respect the principle of human dignity. (N5)

These statements express that these professionals are concerned about respecting the principle of human dignity, with the promotion of palliative care for HIV/Aids patients, which is inherent to all human beings12. For being proper of the human condition, it is also regarded as an inalienable attribute, which can not be removed or deleted.

Regarding the respect to the dignity of people with HIV/Aids, disrespect to these people is a violation of their rights. Therefore, assistance to these individuals, based on ethical principles, is an ideal to be reached by health professionals13. This ethical conduct is supported by the Code of Ethics of Nursing Professionals5,14 which includes one of the fundamental principles: respect for life, human dignity and human rights.

In this sense, nurses, since their training, are introduced to ethical issues, which are permeated by a number of values ​​related to respect for others and their dignity, especially with regard to care and the sense of justice and conscience of "done duty"15.

It is worth noting that dignity is present when an individual is able to control his behavior, the environment and the manner how is treated by others or even the ability to feel valued in relation to others. It also incorporates the respect for privacy16. When seeking to respect the privacy of people with HIV/Aids, the professional shows respect for their dignity.


Privacy comes from the principle of autonomy, which includes intimacy, private life, honor and image of the human being, which assumes that the person is free to decide to whom and how he/she wants to allow his/her body to be exposed to medical procedures, diagnoses and care or what information regarding his/her health conditions should be confidential17.

Some participants highlighted in their speeches the importance of respecting privacy when implementing palliative care in patients with HIV/Aids, as shown by the following excerpts:

[...] respect for privacy, when caring for patients with HIV/Aids under palliative care, [...]. (N6)

Respect the privacy of patient with HIV/Aids under palliative care [...]. (N7)

[...] I try to protect the patient's privacy, [...]. (N8)

These statements show the ethical stance of nurses enrolled in the study in relation to respect for the privacy of patients with HIV/Aids, in the promotion of palliative care. It is worth mentioning that the privacy of the human being is a principle guaranteed by the Constitution of our country and is supported by the Civil and Penal Code, the Code of Ethics of Health Professionals, and other documents of the legal sphere. The Code of Ethics of Nursing Professionals55 establishes in the Art. 19 that respect for modesty, privacy and intimacy of every human being, even in situations of death and postmortem, is a responsibility and duty of these professionals.

The observance of this article is of fundamental importance to ensure a nursing care that may respect human dignity, and in particular, the dignity of the patient with HIV/Aids under palliative care. In the case of patients with HIV/Aids, their privacy is an aspect considered essential for the promotion of their welfare in hospitals, in order to safeguard their clinical condition and of the other patients. In order to make an effective relationship between the nurse and the person receiving the care possible, a sense of security, empathy and respect for the patient's privacy is necessary. In this sense, the professional must adopt a posture that may transmit reliability18.

The lack of privacy is a constant concern of HIV patients, especially in the hospital setting, use of the condition of being affected by a disease that arouses prejudice, discrimination and stigma, and because they have to share the same space with other patients, with health team professionals and support services, students and researchers that circulate freely in the hospital16. The authors comment that, given this reality, patients with HIV/Aids feel the need to have a place that is theirs alone, as a way to get peace of mind, in an attempt to preserve and recover their individuality.

In this sense, when promoting palliative care for patients with HIV/Aids in the hospital, the nurse should, as far as possible, seek a space that favor maintaining the patients' privacy and, therefore, their safety and well-being.

Professional secrecy

When caring for a person with HIV/Aids under palliative care, nurses must consider the ethical and legal principles that permeate their profession, protecting the confidentiality of information. Some professionals stressed the importance of the professional Code of Ethics5 to guide their actions in relation to the ethical principle of confidentiality, as shown in these lines:

[...] our code of ethics says that professional secrecy must be strictly respected, including cases where the patient wants his condition not to be disclosed even to their families, keeping the prohibition to break confidentiality even after the death of the patient. [...]. (N1)

[...] confidentiality is necessary for the patient to keep his full confidence in the team that assists him. I follow the code's guidelines. (N3)

[...]. I understand that professional secrecy corresponds to the act of protecting the patient's history, revealing issues of his clinical condition only for the professional staff or for those who the patient authorizes. (N6)

The Code of Ethics of Nursing Professionals5 includes, in chapter II, on professional secrecy, five articles that highlight the rights, responsibilities and duties of nursing professionals. This chapter reflects the large responsibility of the nursing professional on the ethical implications permeating professional secrecy. Therefore, it is imperative that nurses who assist patients with HIV/Aids in the context of palliative care follow the observances mentioned about the preservation of confidentiality.

The individual with HIV/Aids deserves a dignified assistance from health professionals, since he or she is in a stage of life that makes him/her physically and psychologically shaken. Moreover, the patient fears for violation of their infected state14,16. Apprehension about the discovery of the diagnosis by others can negatively affect their quality of life, for fear that their situation may become public and they may suffer prejudice and stigma. Thus, the support from the team is essential19.

It is very important that the professional who provides assistance to the patient in a holistic perspective, with a view to improve the quality of the patient's life. Furthermore, he should keep confidentiality on the information that the patient does not want to be revealed. This way, the professional will respect the patient in his dignity and will act ethically in his professional practice.

According to the Code of Medical Ethics20, professional secrecy is considered a right of the patient and only he has the power to decide about the breakup of this secret. This code leaves clear that if the patient express a desire to hide from relatives his health conditions, physicians and all those who are aware of the diagnosis must comply with such a decision, even if the fact is of public knowledge or even if the patient dies21. Thus, professional secrecy has become a right and duty to the extent that, as a right of the patient, creates a specific obligation for health professionals22.

It should be noted that, as a rule, one should not reveal a secret considered in all health professional codes of ethics23. However, there are exceptions, as for example, in the case of obligate reportable diseases. In this case, the disclosure of information is permitted, and legal support is found in the art. 269 ​​of the Penal Code24 that considers as omission when the doctor does not report to the public authority any reportable disease. Although this article only mentions the doctor, it must be respected by all health professionals25. That said, it is clear that these professionals have the obligation to preserve professional secrecy, except in situations where they have legal support.



According to the above exposed in the study, participant nurses adopt ethical principles as respect for human dignity, confidentiality and privacy when providing palliative care for patients with HIV/Aids, who are terminally ill.

The observance of these principles is exceedingly relevant in the application of palliative care to patients without possibility of cure during their hospitalization. In the specific case of HIV/Aids patients, besides the experience of limitations imposed by the disease, they have yet to face a stigmatizing disease that produces prejudice and discrimination. Thus, it is up to the health team, especially the nurse, to assist these patients under palliative care, valuing the confidentiality, privacy, and especially the dignity, up to the finitude of their life.

It is hoped that this study may give rise discussions and reflections on this issue and may support the development of new researches that contribute to spreading the knowledge produced about the ethical principles governing the practice of health professionals, particularly nursing professionals, when providind assistance to patients with HIV/Aids under palliative care.



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