Advance directives of will: nurses' perceptions of benefits and new demands

Saioron, Isabela; Ramos, Flávia Regina Souza; Schneider, Dulcinéia Ghizoni; Silveira, Rosemary Silva da; Silveira, Luciana Ramos

doi:10.1590/2177-9465-EAN-2017-0100

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Brasil

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Sumário

RESEARCH • Esc. Anna Nery 21 (04) • 2017 • https://doi.org/10.1590/2177-9465-EAN-2017-0100 copy

Advance directives of will: nurses' perceptions of benefits and new demands

Directivas anticipadas de la voluntad: percepciones de enfermeros sobre los beneficios y las nuevas demandas

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

Knowing the perception of nurses about benefits and new demands brought by the Advance Directives (AD) in their daily work.

Methods:

Qualitative and exploratory research with data collected in 2016 through semi-structured interviews with 19 nurses from a Hospital in southern Brazil. Data analysis was given by the Discursive Textual Analysis.

Results:

Three categories emerged: The benefits of using ADs in nurses' daily routine; New demands for professionals related to the AD; The AD relevance for patients and their families.

Conclusion:

It is significant that legal, cultural and structural changes take place in order to take advantage of the ADs' benefits. It is essential to extend the access to ADs' information as part of care quality promotion regarding the terminal patients.

Keywords:
Advance Directives; Autonomy; Nursing

Citations	Capture of new emerging
[...] I think it's a path, it gives you a direction [...] I think it’s a guideline, I agree. Especially if you have the matter of the tutor, I think it’s possible. (P07).	The nurses realized that the use of ADs could benefit the work, not only of the nursing category, but of the whole multi-professional team, since being aware of the patient's real decisions and wishes provides comfort and tranquility for professionals, in face of decision-making processes involving unconscious patients.
Sometimes the patient has been here for a long time with us, he/she is lucid, awake and sometimes he/she says he/she does not want them to do it, he/she does not want to be intubated, for example, so he becomes unconscious and the option is to be intubated, then at that moment the document would give you a backing because he/she left it in writing that he/she really does not want to, it wasn’t just said. Because sometimes we say and people think it’s negligence, [...] then that document would back up. (P11).
[...] It is very complex to deal with the other’s life without knowing what he/she would like it to be done... sometimes we leave here heavily in the consciousness of not knowing if we are really doing the best for the patient, and if he could give that signal, of what he/she wants for it, I think it would be very good for our work, very good for the patient [...]. (P17).

Universidade Federal do Rio de Janeiro Rua Afonso Cavalcanti, 275, Cidade Nova, 20211-110 - Rio de Janeiro - RJ - Brasil, Tel: +55 21 3398-0952 e 3398-0941 - Rio de Janeiro - RJ - Brazil
E-mail: annaneryrevista@gmail.com

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[1] Corresponding author: Luciana Ramos Silveira. E-mail: luramos76@gmail.com

Citations	Capture of new emerging
[...] He asks me not to intervene, but I want to intervene, [...] what will defend me? And if I follow, what can interfere with my profession? Can I face any legal proceedings? (P02).	The new demands raise uncertainties in the professionals and the fear of being submitted to a possible judicial process. The absence of a clear position regarding the use of the instrument, or even a Federal Nursing Council (“COFEN”) orientation towards ADs also seems to cause discomfort. In addition, issues related to emotions, cultural, personal and religious values generate doubts, anguish, and conflicts in the relationships between team members and even with patients and families experiencing terminality.
[...] It is difficult, the professional is here working to maintain life. They have their own values, religious beliefs, ethics [...] in a situation like this there may be professionals who are okay with it, but for another it’s not, then this will already generate a conflict in the team. (P07).
[...] create ethical, or religious, or values conflict, and this is a very difficult thing to deal with in reality [...] I have had patients, for example, having lung cancer [...] and the patient, still lucid, to tell me that he did not want the venous access, denying the medication and saying that he wanted to die like that. [...] he/she did not want to stop suffering, today I think that maybe he believed that he deserved it and that he might not deserve a quiet death. So it was a very big conflict because the family split up, part of the family agreed to his request, another part did not [...]. (P18).
Citations	Capture of new emerging
I see this with some concern, documents made in advance, in many moments of life we value one thing, after some time we value another, then the other is no longer so important ... I think we change a lot in life ... serious situations make you wake up to something else. (P10).	There was concern about possible disorders arising from the development of AD. This view can be attributed to the directives that guide the document and to the rapid process of transformation of the technological and therapeutic apparatuses that allow greater success in situations previously foreseen as without therapeutic possibility.
Life is so full of surprises, we see people who were completely sunk and resurfaced, today they are well, they are at home. It’s so unpredictable to know what is going to happen, whether the person will be fine or homeless. It is very difficult [...]. (P15).

Citations	Capture of new emerging
There was a situation where a patient had a cancer and he had a lot of body pain, and we offered to come in with the morphine pump [...] he surprisingly said no, that he would rather be in pain but conscious to keep talking to his family, having his last moments with the family, even with pain [...]. (P17).	The participants expressed the importance of the autonomy of the being, in which each individual decides on his own body. In this sense, ADs would be a tool that will document the patient’s wishes and can facilitate the respect for their autonomy.
[...] If the document proves that that is really the will of the patient, that it was not a moment of delirium or suffering that can change the opinion of the person. (P18).
Citations	Capture of new emerging
[...] In some cases the family does not accept certain behaviors, this document showing the desire of his relative. I think it facilitates a lot; For the family, I think it would have a great advantage, because of the acceptance. (P05).	ADs could bring greater comfort and security for family members to make decisions; since knowing the real will of the patient could alleviate possible anxieties generated by the doubt about the best direction of the situation, mitigating intra-familial conflicts. In addition, knowing the patient's real will can aid in the process of acceptance of terminality by the family.
[...] For the family to decide for the unconscious patient, which is better for him/her, it is a very big weight, and a lot of people did not have this conversation before [...] This week a patient who could be “palliated” was taken to the ICU Because the daughter could not make the decision, the brothers were absent, they did not want to get involved and she alone could not decide and the mother never showed her will, so it's complicated. (P18).
Citations	Capture of new emerging
So the advantage of family members is to know what the patient manifested, but at the right time to apply maybe the family members may conflict. So we do not even know the moment they would like to position themselves. It would create insecurity. (P06).	Even in the face of the patient's wishes expressed in the form of AD, some relatives may disagree with the manifesto, generating intra-family conflicts and questioning the health team, especially in cases where there would be a favorable prognosis in the case of being performed procedures rejected by the patient. There may be difficulties accepting the terminality of a loved one.
[...] For example, the relative does not want this and the patient wants, and then we take a position that would be related to the patient and the relative can question; what would weigh would be that part of the family, that we would be neglecting care. (P11).