Approaches and reflexions on advance healthcare directives in Brazil

22 articles were considered for analysis with interviews and testimonies of physicians, intensivists and geriatricians, nurses, technicians and Nursing auxiliaries, Medical students, lawyers and Law students.

Conclusion:

there is a small number of papers on the Advance Healthcare Directives in Brazil, and a wide range of approaches that have not yet been clarified. The theme is not widely spread and little clarified in its essence.

Descriptors:
Living Will; Early Directives; Bioethics, Personal Autonomy, Right to Die

Author	Title	Some Results	Conclusions
Piccini et al 2011⁽⁹9 Piccini CF, Steffani JA, Bonamigo EL, et al. [Living will in the perspective of doctors, lawyers and students]. Rev Bioethikos [Internet]. 2011 [cited 2017 Oct 24];5(4):384-91. Available from: https://saocamilo-sp.br/assets/artigo/bioethikos/89/A4.pdf Portuguese. https://saocamilo-sp.br/assets/artigo/bi... ⁾	The Living Will under the perspective of doctors, lawyers and students.	Only 29.2% of respondents had full knowledge of the Living Will meaning; 87.6% would opt for orthotanasia with a terminal patient.	Most professionals adopts the Living Will as a form of respect to the patient's will and, therefore, the patient's autonomy.
Campos et al 2012⁽¹⁰10 Campos MO, Bonamigo EL, Steffani JA, et al. [Living wills: perception of oncology patients and accompanying family members]. Rev Bioethikos [Internet]. 2012 [cited 2017 Oct 24];6(3):253-9. Available from: https://saocamilo-sp.br/assets/artigo/bioethikos/96/1.pdf Portuguese. https://saocamilo-sp.br/assets/artigo/bi... ⁾	The Living Will: the perception of cancer patients and their companions.	Most of the interviewees, both patients and companions, are unaware of the terms "Living Will".	There is an interest among oncology patients and their companions to elaborate the Living Will and add it to national legislation.
Alves 2013⁽¹¹11 Alves CA. [Language, Advance Directives and Living Will: a national and international interface]. Rev Bioethikos [Internet]. 2013 [cited 2017 Oct 24];7(3):259-70. Available from: https://saocamilo-sp.br/assets/artigo/bioethikos/105/1810.pdf Portuguese https://saocamilo-sp.br/assets/artigo/bi... ⁾	Language, Advance Healthcare Directives and Living Will: a national and international interface.	In Brazil, there is already a trend towards the creation of specific legislation to meet Advance Directives, since 1999. In the National Congress, Law No. 6.715, of 2009, provides for amending the Penal Code (PC) to exclude the unlawfulness of orthatanasia.	There is still much legal discussion regarding the contextualization and legality about this topic.
Dadalto et al 2013⁽⁷7 Dadalto L, Tupinambás U, Greco DB. [Advanced directive: a brasilian model]. Rev Bioét [Internet]. 2013 [cited 2017 Oct 20];21(3):463-76. Available from: http://dx.doi.org/10.1590/S1983-80422013000300011 Portuguese. http://dx.doi.org/10.1590/S1983-80422013... ⁾	Advance Healthcare Directives: a Brazilian model.	It was noticed that the Brazilian model should be distanced from the standards of forms used in many US states and Spanish provinces, aiming to leave room for the subjectivity of each patient.	The proposal aims to assist patients and doctors in the Advance Healthcare Directives and should be used as a guide considering each real situation.
Crippa et al 2013⁽¹²12 Crippa A, Buonicore GP, Feijó AGS. [Advance directives of will and the civil responsibility of the Physician]. Rev AMRIGS [Internet]. 2013 [cited 2017 Oct 24];57(4):344-8. Available from: http://www.amrigs.org.br/revista/57-04/0000222859-15_1288_Revista%20AMRIGS.pdf Portuguese http://www.amrigs.org.br/revista/57-04/0... ⁾	Advance Healthcare Directives and the civil responsibility of doctors.	The civil responsibility of medical doctors before Resolution 1.995/2012. Objective and subjective civil responsibility.	Today, there is still little discussion as to the doctor's responsibility as for disobeying these Advance Healthcare Directives.
Bussinguer et al 2013⁽¹³13 Bussinguer ECA, Barcellos IA. [The right to live one's own death and its constitutionality]. Rev Ciênc Saúde Colet [Internet]. 2013 [cited 2017 Oct 24];18(9):2691-8. Available from: http://dx.doi.org/10.1590/S1413-81232013000900024 Portuguese http://dx.doi.org/10.1590/S1413-81232013... ⁾	The right to live one's own death and its constitutionality.	Legislative omission and consideration of the possible legal binding of doctors and relatives of terminally ill patients to their Living Will.	Doctors are subject to the early manifestation of terminally ill patients and are supported by the Constitution in cases in which they are legally questioned about the legality of their subordination to the patient's directives and to the Resolution of the Federal Medical Council.
Nunes et al 2014⁽¹⁴14 Nunes MI, Anjos MF. [The advance directive: benefits, obstacles and limits]. Rev Bioét [Internet]. 2014 [cited 2017 Oct 24];22(2):241-51. Available from: http://dx.doi.org/10.1590/1983-80422014222005 Portuguese. http://dx.doi.org/10.1590/1983-804220142... ⁾	Advance Healthcare Directives: benefits, obstacles and limits.	The heart of AHD: autonomy; the questionable stability of decisions; the ambiguous terminology used in AHD; alternative approaches.	The need for studies in Brazil that will enlighten and clarify the various aspects of AHD, so that dignified death is not only a concept but also a reality.
Pattela et al 2014⁽¹⁵15 Pattela LHD, Alves RGO, Loch JA. [Advanced directives by the patient: a brief introduction to the theme]. Rev AMRIGS [Internet]. 2014 [cited 2017 Oct 24];58(2):162-5. Available from: http://www.amrigs.org.br/revista/58-02/014.pdf Portuguese http://www.amrigs.org.br/revista/58-02/0... ⁾	Patient's Advance Directives: a brief introduction to the topic.	Advance Directives in the Brazilian legal system; approaches in clinical practice.	The ethical-legal recognition of the Advance Directives will have a double role: if, on the one hand, it will provide the doctor with a legal provision to comply with it, on the other, and especially, will guarantee the patient to be treated according to his/her own will in its terminality.
Kovács 2014⁽¹⁶16 Kovács MJ. [Towards death with dignity in the XXI Century]. Rev Bioét [Internet]. 2014 [cited 2017 Oct 24];22(1):94-104. Available from: http://dx.doi.org/10.1590/S1983-80422014000100011 Portuguese. http://dx.doi.org/10.1590/S1983-80422014... ⁾	On the way to death with dignity in the 21^st century.	Portraits of death in the twenty-first century: interdict death, open death, rehumanized death, patients with advanced diseases and their needs. Euthanasia, dysthanasia, orthatanasia, assisted suicide - bioethical issues. The Living Will, Advance Healthcare Directives: documents for orthothanasia.	Death with dignity is the goal of palliative care programs. It seeks to facilitate the patient's autonomy in making decisions about his or her life. The concept of good death, without pain, is resumed with respect to the patients' will, establishing channels of communication with their family and health professionals.
Saldanha 2014⁽¹⁷17 Saldanha RR. [The possible failures of the vital will in the brazilian right in front of the constitutional guarantee of the worthy death]. Rev Bioet Latino Am [Internet]. 2014 [cited 2017 Oct 24];14(1):143-68. Available from: http://www.saber.ula.ve/handle/123456789/39041 Portuguese. http://www.saber.ula.ve/handle/123456789... ⁾	The possible flaws of the Living Will in Brazilian law against the constitutional guarantee of dignified death.	Euthanasia and other procedures of the Advance Healthcare Directives of comparative law Resolution No. 1.995/2012 of the Federal Council of Medicine of the juridical aspects, a principle of human dignity.	Active euthanasia (characterized by an action); passive euthanasia (characterized by an omission): Brazilian law does not allow for either of these hypotheses, although the preliminary draft of the Penal Code provides for the possibility of passive euthanasia.
Salles 2014⁽¹⁸18 Salles AA. [Bioethics and religious processes among terminally ill patients in Brazil]. Rev Bioét [Internet]. 2014 [cited 2017 Oct 24];22(3):397-406. Available from: http://dx.doi.org/10.1590/1983-80422014223021 Portuguese. http://dx.doi.org/10.1590/1983-804220142... ⁾	Bioethics and the processes of religiosity among patients with terminal diseases in Brazil.	Dilemmas of spiritual nature in the terminality of life. The role of Bioethics in the religious processes of terminality, applying the principles of autonomy and otherness.	The health professional must know the main spiritual trends of the country to respect the principles of beneficence and respect for the autonomy of the patient.
Cogol et al 2015⁽¹⁹19 Cogo SB, Lunardi VL. [Anticipated directives will to the terminal patients: integrative review]. Rev Bras Enferm [Internet]. 2015 [cited 2017 Oct 24];68(3):524-34. Available from: http://dx.doi.org/10.1590/0034-7167.2015680321i Portuguese. http://dx.doi.org/10.1590/0034-7167.2015... ⁾	Advance Healthcare Directives to terminal patients: an integrative review.	Perceptions, opinions and behaviors of students and professionals; receptiveness of patients and their families to the directives.	The repercussions of AHD on the world scenario contributing to reflections in Brazil, guided by the CFM Resolution and their legal aspects.
Cassol et al 2015⁽²⁰20 Cassol PB, Quintana AM, Velho MTAC. [Anticipated policy will: perception of nursing staff of blood-oncology]. Rev J Nurs Health [Internet]. 2015 [cited 2017 Oct 24];5(1):04-13. Available from: doi: http://dx.doi.org/10.15210/jonah.v5i1.5497 Portuguese. http://dx.doi.org/10.15210/jonah.v5i1.54... ⁾	Advance Healthcare Directives: perception of a Nursing team of hemato-oncology.	They pointed out that the Advance Directives would be something new for professionals, within the context of care.	Significant repercussions have been observed, ranging from disregarding its use to the conclusion that doctors and family members still have decision-making power over the fate of terminal patients.
Silva et al 2015⁽²¹21 Silva JAC, Souza LEA, Costa JLF, et al. Knowledge of medical students regarding living wills. Rev Bioét [Internet]. 2015 [cited 2017 Oct 24];23(3):563-71. Available from: http://dx.doi.org/10.1590/1983-80422015233093 http://dx.doi.org/10.1590/1983-804220152... ⁾	Knowledge of Medical students about the Living Will.	Few students were aware of the meaning of the term "Living Will". After hearing the definition of the Advance Healthcare Directives, provided by the researchers, the majority stated that they would respect the provisions of the Living Will.	The need to intensify this discussion between society and students of Medicine, given its high relevance to future doctors and the autonomy of patients.
Chehuen Neto et al 2015⁽²²22 Chehuen Neto JA, Ferreira RE, Silva NCS, et al. Living will: What do healthcare professionals think about it?. Rev Bioét [Internet]. 2015 [cited 2017 Oct 24];23(3):572-82. Available from: http://dx.doi.org/10.1590/1983-80422015233094 http://dx.doi.org/10.1590/1983-804220152... ⁾	Living Will: what do health professionals think about it?	Fewer than half of those interviewed said they knew the document. Most of the sample was uncomfortable to follow the determinations of a Living Will.	The majority of health professionals interviewed are unaware of the Living Will and CFM Resolution 1.995/2012.
Cogo et al 2016⁽²³23 Cogo SB, Lunardi VL, Quintana AM, et al. Challenges to implementation of advance directives of will in hospital practice. Rev Bras Enferm [Internet]. 2016 [cited 2017 Oct 30];69(6):969-76. Available from: http://www.scielo.br/pdf/reben/v69n6/0034-7167-reben-69-06-1031.pdf http://www.scielo.br/pdf/reben/v69n6/003... ⁾	Challenges to introduce the Advance Healthcare Directives into the hospital practice.	Fear of legal implications. Advance Healthcare Directives require patient autonomy and adequate communication.	Conflicts, dilemmas and limitations in the applicability of AHD make it impossible for the patients' will to be respected.
Coco et al 2017⁽²⁴24 Cogo SB, Lunardi VL, Quintana AM, et al. Advance directives: wills of health professional and Family caregivers. Rev Baiana Enferm [Internet]. 2017 [cited 2017 Oct 30];31(1):e16932. Available from: doi 10.18471/rbe.v31i1.16932 https://doi.org/10.18471/rbe.v31i1.16932... ⁾	Advance Directives: will of health professionals and family caregivers.	Focus on the applicability of the Advance Healthcare Directives and the will of professionals and family in the maintenance of the dignity and the personal autonomy; insecurity of the applicability of the directives.	Although participants accepted and wanted to implement the Advance Directives, they expressed concerns about their applicability, whether their will were not respected, or that they could change as they faced the final stage situation, their abandonment by professionals and their insecurity regarding diagnoses and prognoses.
Moreira et al 2017⁽²⁵25 Moreira MADM, Costa SFG, Cunha MLDM, et al. Physician's perceptions for including living will in medical practice. Rev Bioét [Internet]. 2017 [cited 2017 Nov 18];25(1):168-78. Available from: http://dx.doi.org/10.1590/1983-80422017251178 http://dx.doi.org/10.1590/1983-804220172... ⁾	The Living Will in medical practice: professionals' comprehension.	Advance Healthcare Directives are important to promote patient autonomy; humanization of medical care in terminality.	It also demonstrates the need to create a legal device regulating its formal use in Brazil.
Buriá et al 2017⁽²⁶26 Burlá C. A aplicação das diretivas antecipadas de vontade na pessoa com demência [Thesis on the Internet]. Porto: Programa Doutoral em Bioética, Faculdade de Medicina da Universidade do Porto - FMUP/Portugal, Conselho Federal de Medicina -CFM/Brasil. 2015 [cited 2017 Nov 26]. 159 p. Available from: https://repositorio-aberto.up.pt/bitstream/10216/82654/2/114101.pdf https://repositorio-aberto.up.pt/bitstre... ⁾	The application of Advance Healthcare Directives in people with dementia.	This instrument, if used with healthy elderly people, anticipates the possible installation of posterior cognitive damage, indicated by demographic and epidemiological data.	It is concluded that qualified professionals can guide elderly people and their families to reflect deeply on health and illness, autonomy and inability.
Oliveira et al 2014⁽²⁷27 Oliveira MLC, Cavalcanti EO, Alves VP, et al. Euthanasia from the perspective of nursing undergraduate students: concepts and challenges. Rev Min Enferm [Internet]. 2014 [cited 2017 Dec 18];18(1):134-141. Available from: doi: http://www.dx.doi.org/10.5935/1415-2762.20140010 http://www.dx.doi.org/10.5935/1415-2762.... ⁾	Euthanasia under the perspective of undergraduate Nursing students: conception and challenges.	Ignorance as for the Living Will.	The Constitution and laws prevent the application of the Living Will.
Nunes 2009⁽²⁸28 Nunes R. Proposta sobre suspensão e abstenção de tratamento em doentes terminais. Rev Bioética [Internet]. 2009 [cited 2018 Jan 18];17(1):29-39. Available from: http://revistabioetica.cfm.org.br/index.php/revista_bioetica/article/view/77 http://revistabioetica.cfm.org.br/index.... ⁾	Proposal on the suspension and abstention of treatment in terminally ill patients.	Listed proposals.	The use of orthotanasia as a medical practice depends on the wide discussion among professionals and the society.
Pan Chacon et al 1.995⁽²⁹29 Pan Chacon J, Kobata C, Liberman S. A mentira piedosa para o canceroso. Rev Assoc Med Bras. 1995;41(4):274-6.⁾	The "noble lie" for the person with cancer.	Only 22% of those surveyed stated that they provided complete information to the patients under their care. Of the practitioners who adopted the "noble lie" in their clinical practice, approximately 90% said they would like to receive complete information if they were in the patients' shoes.	As ethical consequences triggered are the stimulus to the paternalistic and protective attitudes towards patients and the consequent interference in the full exercise of their autonomy.

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[1] Corresponding Author: Luís Carlos Ufei Hassegawa E-mail: hassega@gmail.com