Acessibilidade / Reportar erro
Artigos de Atualização • Rev. Bioét. 22 (2) • Ago 2014 • https://doi.org/10.1590/1983-80422014222005   copiar

Diretivas antecipadas de vontade: benefícios, obstáculos e limites

The advance directive: benefits, obstacles and limits

Directivas anticipadas de voluntad: beneficios, obstáculos y limitaciones

Autoria SCIMAGO INSTITUTIONS RANKINGS

Resumos

O conceito de diretivas antecipadas de vontade emergiu em resposta ao avanço tecnológico e ao tratamento médico agressivo empregados em situações ambíguas, como no caso de um prognóstico ruim. O cerne do presente documento é o exercício da autonomia do paciente. A Resolução 1.995/12 do Conselho Federal de Medicina estabelece os critérios para que qualquer pessoa - desde que maior de idade e plenamente consciente - possa definir junto ao seu médico quais os limites terapêuticos na fase final de sua vida. O documento é facultativo e poderá ser elaborado em qualquer momento da vida e da mesma maneira modificado ou revogado a qualquer tempo. Este artigo tem por propósito discorrer sobre seus benefícios, obstáculos e limites, considerando o vasto número de pesquisas realizadas sobre o tema e as experiências positivas e negativas de outros países no intuito de contribuir para a discussão de sua efetiva utilização no Brasil.

Diretivas antecipadas de vontade; Autonomia pessoal; Bioética

The concept of advance directives emerged in response to the technological progress and aggressive medical treatment being employed in ambiguous situations, as in the case of a bad prognosis. The core of this document is the exercise of the patients´ autonomy. The Federal Council of Medicine´s 1.995/2012 Resolution establishes the criteria for anyone - provided that the patient is legally old enough and fully aware - to be able to choose together with his/her doctor the therapeutic limits at the end of life. The document is optional and may be completed at any time in life and, in the same way it can be modified or cancelled at any time. The purpose of this article is to consider its benefits, obstacles and limits considering the vast amount of researches carried out on this theme and the positive and negative experiences from other countries in order to contribute to the discussion about its effective use in Brazil.

Advanced directives; Personal autonomy; Bioethics

El concepto de directivas anticipadas de voluntad surgió en respuesta al avance tecnológico y al tratamiento médico agresivo, utilizándoselo en situaciones ambiguas, como ante un pronóstico negativo. El núcleo de este documento consiste en el ejercicio de la autonomía del enfermo. La Resolución 1.995/2012 del Consejo Federal de Medicina establece los criterios para que cualquier persona - mayor de edad y plenamente consciente - pueda definir, junto con su médico, los límites terapéuticos en la fase final de su vida. El documento es opcional y puede llevarse a cabo en cualquier momento de la vida y la misma manera modificada o revocada en cualquier forma y tiempo. El propósito de este artículo es discutir los beneficios, obstáculos y las limitaciones considerando la gran cantidad de investigaciones realizada sobre el tema y las experiencias positivas y negativas de otros países, con el fin de aportar a la discusión sobre su utilización de manera efectiva en Brasil.

Directivas anticipadas; Autonomía personal; Bioética

  • 1
    Conselho Federal de Medicina. Resolução CFM no 1.995, de 31 de agosto de 2012. Dispõe sobre as diretivas antecipadas de vontade dos pacientes. [Internet]. 2012 (acesso 5 jan. 2013). Disponível: http://www.portalmedico.org.br/resolucoes/CFM/2012/1995_2012.pdf
  • 2
    Lopes AD, Cuminale N. O direito de escolher. Revista Veja. São Paulo: Editora Abril; 2012. Ano 45, no 37. p. 98-106.
  • 3
    Brown BA. The history of advance directives: a literature review. J Gerontol Nurs. 2003;29(9):4-14.
  • 4
    Silveira MJ, Kim SYH, Kenneth M, Langa MK. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010;362:1.211-8.
  • 5
    Ashby M, Wakefield M, Beilby J. General practitioners' knowledge and use of living wills. BMJ. 1995;310(6.974):230.
  • 6
    Fuchs VR. The growing demand for medical care. N Engl J Med. 1968;279(4):190-5.
  • 7
    National Library of Medicine. Advance directives. 1991 (acesso 10 dez. 2012). Disponível: http://www.ncbi.nlm.nih.gov/mesh/?term=advance+directives
  • 8
    Beauchamp TL, Childress JF. Principles of biomedical ethics. 4a ed. New York: Oxford University Press; 1994.
  • 9
    Toller CA, Budge MM. Compliance with and understanding of advance directives among trainee doctors in the United Kingdom. J Palliat Care. 2006;22(3):141-6.
  • 10
    Bogardus ST, Bradley EH, Williams CS, Maciejewski PK, van Doorn C, Inouye SK. Goals for the care of frail older adults: do caregivers and clinicians agree? Am J Med. 2001;110(2):97-102.
  • 11
    Greco PJ, Schulman KA, Lavizzo-Mourey R, Hansen-Flaschen J. The patient self-determination act and the future of advance directives. Ann Intern Med. 1991;115(8):639-43.
  • 12
    Singer PA, Siegler M. Advancing the cause of advance directives. Arch Intern Med. 1992;152(1):22-4.
  • 13
    Emanuel LL, Barry MJ, Stoeckle JD, Ettelson LM, Emanuel EJ. Advance directives for medical care: a case for greater use. N Engl J Med. 1991;324(13):889-95.
  • 14
    Emanuel LL, Emanuel EJ. The medical directive: a new comprehensive advance care document. Jama. 1989;261(22):3.288-93.
  • 15
    Kelner MJ, Bourgeault IL. Patient control over dying: responses of health careprofessionals. Soc Sci Med. 1993;36(6):757-65.
  • 16
    Lo B, McLeod GA, Saika G. Patient attitudes to discussing life-sustaining treatment. Arch Intern Med. 1986;146(8):1.613-5.
  • 17
    Teno JM, Gruneir A, Schwartz Z, Nanda A, Wetle T. Association between advance directives and quality of end-of-life care: a national study. J Am Geriatr Soc. 2007;55(2):189-94.
  • 18
    Bermejo JC, Belda RM. Testamento vital: diálogo sobre la vida, la muerte y la libertad. Madrid: PPC Editorial; 2011.
  • 19
    Kovács MJ. Autonomia e o direito de morrer com dignidade. Bioética. 1998;6(1):61-9.
  • 20
    Hennezel M. A morte íntima. 2a ed. São Paulo: Ideias e Letras; 2004.
  • 21
    Esslinger I. O paciente, a equipe de saúde e o cuidador: de quem é a vida, afinal? Um estudo acerca do morrer com dignidade. In: Pessini L, Bertachini L, organizadores. Humanização e cuidados paliativos. São Paulo: Loyola/Centro Universitário São Camilo; 2004.
  • 22
    Kovács MJ. Bioética nas questões da vida e da morte. [Internet]. Psicol USP. 2003 (acesso 13 dez. 2013);14(2):115-7. Disponível: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-65642003000200008
  • 23
    Pessini L. Distanásia: até quando prolongar a vida? São Paulo: Centro Universitário São Camilo/Loyola; 2001.
  • 24
    Junges JR, Cremonese C, Oliveira EA, Souza LL, Backes V. Reflexões legais e éticas sobre o final da vida: uma discussão sobre a ortotanásia. [Internet]. Rev. bioét. (Impr.). 2010 (acesso 20 jun. 2014);18(2):275-88. Disponível: http://revistabioetica.cfm.org.br/index.php/revista_bioetica/article/view/564/537
  • 25
    Lépargneur H. Bioética da eutanásia: argumentos éticos em torno da eutanásia. [Internet]. Bioética. 1999 (acesso 19 jun. 2014);7(9):41-8. Disponível: http://revistabioetica.cfm.org.br/index.php/revista_bioetica/article/view/292/431
  • 26
    Blasco AC, Montfort FC, Palomar RM. Conocimientos y actitudes de los profesionales de los equipos de atención primaria sobre el documento de voluntades anticipadas. Aten Prim. 2010;42(9):463-9.
  • 27
    Martínez K. Los documentos de voluntades anticipadas. Anales Sis San Navarra. 2007;30(3 Suppl):87-102.
  • 28
    Schiff R, Sacares P, Snook J, Rajkumar C, Bulpitt CJ. Living wills and the mental capacity act: a postal questionnaire survey of UK geriatricians. Age Ageing. 2006;35(2):116-21.
  • 29
    Balint JA. Brief encounters: speaking with patients. Ann Intern Med. 1999;131(3):231-4.
  • 30
    Fazel S, Hope T, Jacoby R. Assessment of competence advance directives: validation of a patient centred approach. BMJ. 1999;318(7182):493-7.
  • 31
    Niebrój LT. Advance directives and the concept of competence: are they a moral barrier to resuscitation? J Physiol Pharmacol. 2007;(5 Suppl):477-84.
  • 32
    Gracia D. Pensar a bioética: metas e desafios. São Paulo: Loyola; 2012.
  • 33
    Tonelli MR. Pulling the plug on living wills: a critical analysis of advance directives. Chest. 1996;110(3):816-22.
  • 34
    Hansot E. A letter from a patient's daughter. Ann Intern Med. 1996;125(2):149-51.
  • 35
    Drought TS, Koenig BA, Raffin TA. Advance directives: changing our expectations. Chest. 1996;110(3):589-91.
  • 36
    Gilligan T, Raffin TA. Whose death is it, anyway? Ann Intern Med. 1996;125(2):137-41.
  • 37
    Tulsky JA, Chesney MA, Lo B. How do medical residents discuss resuscitation with patients? J Gen Intern Med. 1995;10(8):436-42.
  • 38
    Patrick DL, Pearlman RA, Starks HE, Cain KC, Cole WG, Uhlmann RF. Validation of preferences for life-sustaining treatment: implications for advance care planning. Ann Intern Med. 1997;127(7):509-17.
  • 39
    Emanuel LL, Emanuel EJ, Stoeckle JD, Hummel LR, Barry MJ. Advance directives: stability of patients' treatment choices. Arch Intern Med. 1994;154(2):209-17.
  • 40
    Bosshard G, Wettstein A, Bar W. How stable is the attitude of aged people towards life-extending measures? Results of a 3-year follow-up in nursing home residents. Z Gerontol Geriatr. 2003;36(2):124-9.
  • 41
    Smedira NG, Evans BH, Grais LS, Cohen NH, Lo B, Cooke M et al Withholding and withdrawal of life support from the critically ill. N Engl J Med. 1990;322(5):309-15.
  • 42
    Schneiderman LJ, Kronick R, Kaplan RM, Anderson JP, Langer RD. Effects of offering advance directives on medical treatments and costs. Ann Intern Med. 1992;117(7):599-606.
  • 43
    Teno JM, Lynn J, Phillips RS, Murphy D, Youngner SJ, Bellamy P et al Do formal advance directives affect resuscitation decisions and the use of resources for seriously ill patients? J Clin Ethics. 1994;5(1):23-30.
  • 44
    Lo B, Saika G, Strull W, Thomas E, Showstack J. 'Do not resuscitate' decisions: a prospective study at three teaching hospitals. Arch Intern Med. 1985;145(6):1.115-7.
  • 45
    Goodman MD, Tarnoff M, Slotman GJ. Effect of advance directives on the management of elderly critically ill patients. Crit Care Med. 1998;26(4):701-4.
  • 46
    Danis M, Southerland LI, Garrett JM, Smith JL, Hielema F, Pickard CG et al. A prospective study of advance directives for life sustaining care. N Engl J Med. 1991;324(13):882-8.
  • 47
    Degenholtz HB, Rhee YJ, Arnold RM. Brief communication: the relationship between having a living will and dying in place. Ann Intern Med. 2004;141(2):113-7.
  • 48
    Straton JB, Wang NY, Meoni LA, Ford DE, Klag MJ, Casarett D et al Physical functioning, depression, and preferences for treatment at the end of life: the Johns Hopkins precursors study. J Am Geriatr Soc. 2004;52(4):577-82.
  • 49
    Pritchard RS, Fisher ES, Teno JM, Sharp SM, Reding DJ, Knaus WA et al. Influence of patient preferences and local health system characteristics on the place of death. J Am Geriatr Soc. 1998;46(10):1.242-50.
  • 50
    Stone J. Advance directives, autonomy and unintended death. Bioethics. 1994;8(3):223-46.
  • 51
    Fagerlin A, Schneider CE. Enough: the failure of the living will. Hastings Cent Rep. 2004;34(2):30-42.
  • 52
    Das AK, Mulley GP. The value of an ethics history? J R Soc Med. 2005;98(6):262-6.
  • 53
    Fins JJ, Maltby BS, Friedmann E, Greene MG, Norris K, Adelman R et al Contracts, covenants and advance care planning: an empirical study of the moral obligations of patient and proxy. J Pain Symptom Manage. 2005;29(1):55-68.
  • 54
    Schwartz C. Decision making at the end of life: shifting sands. J R Soc Med. 2005;98(7):297-8.
  • 55
    Schwartz CE, Wheeler HB, Hammes B, Basque N, Edmunds J, Reed G et al. Early intervention in planning end-of-life care with ambulatory geriatric patients: results of a pilot trial. Arch Intern Med. 2002;162(14):1.611-8.
  • 56
    Messinger-Rapport BJ, Baum EE, Smith ML. Advance care planning: beyond the living will. Cleve Clinic J Med. 2009;76(5):276-85.
  • 57
    Pearlman R, Starks H, Cain KC, Cole WG. Improvements in advance care planning in the veterans affairs system: results of a multifaceted intervention. Arch Intern Med. 2005;165(6):667-74.
  • 58
    Hawkins NA, Ditto PH, Danks JH, Smucker WD. Micromanaging death: process preferences, values, and goals in end-of-life medical decision making. Gerontologist. 2005;45(1):107-17.

Datas de Publicação

  • Publicação nesta coleção
    19 Ago 2014
  • Data do Fascículo
    Ago 2014

Histórico

  • Aceito
    25 Jun 2014
  • Revisado
    08 Maio 2014
  • Recebido
    23 Fev 2014
Creative Common - by 4.0
This work is licensed under a Creative Commons Attribution 4.0 International License.
Conselho Federal de Medicina SGAS 915, lote 72, CEP 70390-150, Tel.: (55 61) 3445-5932, Fax: (55 61) 3346-7384 - Brasília - DF - Brazil
E-mail: bioetica@portalmedico.org.br
Acompanhe os números deste periódico no seu leitor de RSS