THERAPEUTIC FUTILITY AS AN ETHICAL ISSUE: INTENSIVE CARE UNIT NURSES

Therapeutic futility in intensive care units (ICUs) is still little discussed among nursing professionals responsible for implementing prescribed procedures, which they might disagree on. Therefore, interviews were carried out with ICU nurses to understand how they are coping with the implementation of futile treatments. Based on the analysis of collected data, the following categories emerged: therapeutic futility: what is it?; therapeutic futility extends suffering; therapeutic futility with healing as a priority; coping with therapeutic futility: humanized care? The study indicates the need to evaluate therapeutic measures provided to terminal patients with a view to improving their quality of life in this final phase. When healing is no longer possible, care is necessary with a view to respecting the sick person's integrity because care is the essence of the nursing profession.


INTRODUCTION
There are multiple ethical issues involved in care provided to people who are experiencing the dying process and death in the environment of an intensive care unit (ICU).Much has been discussed on this theme by several professionals from the health area and other areas, specifically the patient's right to die with dignity and therapeutic futility.Therapeutic futility is also employed as a synonym of futile and useless treatment, which leads to a slow and prolonged death accompanied by suffering.It is a medical attitude that, aiming to save the lives of terminal patients, submits them to great suffering.By this attitude, one only extends the dying process, but not life per se (1) .
Along the text, the following terms have the same meaning: futile medical act, dysthanasia, therapeutic futility and therapeutic tenacity.
Nursing is beginning to discuss the issue and articles on the dying process and death appoint to the possibility of extending the life of patients without consideration of their quality of life and real chances of survival, as well as nurses' difficulties and suffering in these situations (2)(3) .The theme is considered of great relevance for nursing because this profession performs many of the prescribed therapies.Thus, health professionals need to discuss these practices so as to define what is currently expected as a model of health and life.
Issues related to therapeutic futility are possibly present in the routine of ICUs where different decisions are taken regarding the treatment of patients in the terminal phase of the disease without previous discussion with the patients themselves, their families and the health team and are usually restricted to one person's consideration, generally the physician on duty (4)(5) .Therapeutic procedures depend on medical criteria, but affect health teamwork as a whole, specifically nursing which, when complying with therapeutics they do not agree with, can suffer intensely and question the values underlying this practice (1,6) .
Therefore, we sought to understand how nurses are facing the implementation of therapeutic measures they consider futile.

METHODOLOGICAL TRAJECTORY
This qualitative, exploratory and descriptive study was developed according to Resolution 196/ 96 (7)  Categories of analysis were elaborated after successive reading of the interviews, which were arranged and classified by similarities and differences according to the described essences and codification of collected data (8) .This permanent relation with the study's theoretical framework aimed to understand how professionals identify situations of therapeutic futility, how they experience it and what factors influence the decision making process, with a view to appointing the feelings experienced and potential strategies to cope with these situations.Four categories of analysis were constructed and are presented herein.

RESULTS AND DISCUSSION
Therapeutic futility: What is this?
To understand how nurses are coping with the implementation of therapeutic measures they consider futile, first, they had to acknowledge the existence of these treatments in the ICUs they work at.The majority was not familiar with the meaning of therapeutic futility (E1, E4, E5, E6) at the moment they were questioned about their understanding and whether these treatments were prescribed in the ICU they worked at.Thus, we opted to read the definition of therapeutic futility (9) after the first question and its respective answer.The reported lack of knowledge on the term reflects the prevalence, even nowadays, of a predominantly technicist model in the hospital context in which practice and technique are overvalued in detriment of a more humanist one (10) .Thus, the nurses' work seems standardized and preserving order in the unit and seeing to the patient's biological needs are the priority.Still, perhaps even these needs are not being met because they are analyzed and defined mostly by health professionals, ignoring the patient's will.Changes in many practices still considered adequate and acceptable in ICUs may be possible through the exercising of thinking.
Although therapeutic futility is a problem routinely faced in ICUs, its perception and questioning by professionals may require further theoretical knowledge.Lack of knowledge on the issue leads to the perception that dysthanasia is normal and necessary in patients' treatment.
Therapeutic futility extends suffering Some nurses explained that they understand therapeutic futility as a way to extend the life of terminal patients, extending their suffering as well.In the therapeutic futility perspective, unspecified investment in the patients' healing treatment, coupled with feelings of hope in patients' improvement, seems to be motivated by nurses' difficulties in dealing with death and the dying process and not by the acknowledgment of powerlessness in preventing them.Thus, therapies are needed that maintain the illusion that cure will be achieved even if one does not see its real possibility.
The implementation of dysthanasia also seems to be based on nurses' religious conception that disease and consequent suffering can be redemption for debt caused by mistakes committed during the patient's life.I keep thinking, gosh, sometimes I think that we have to pay for a lot of things here on earth, it takes so long to die, it gets even longer with them working so hard like this, it extends it even more (E6).This way, extending life as much as possible without considering the quality of life that is being extended, as well as patients' suffering in the process, not questioning their wishes and options regarding what they are putting up with, seems to be justified […] I have very religious people working here at the ICU who believe we have to keep trying as long as there's life (E3).
Quality of life, in terms of therapeutic futility, even if subjective, can be understood as a process of dying without pain and suffering, respecting patients' wishes and allowing them and their family members to share their experiences (10) .

Therapeutic futility with healing as the priority
Other nurses appointed that therapeutic futility means to implement therapy they consider futile, however, necessary because healing patients is a priority, as this report shows: Many of the measures adopted by these professionals might be based on the beneficence principle and they believe that, through maintenance of life, they are favoring the patient and minimizing harm, death, apparently in the faith that "while there's life, there's hope".Expressions like this are frequently heard in the hospital context and show the health professionals' need to deal with conditions of certainty, without time for doubts or questions.Thus, decisions about life and death should be made under these parameters and it is necessary to keep fighting for life until one is certain about death (1) .This way, professionals might be implementing care based on the attempt to avoid the patients' death.
Because the patient is dis-identified during this process, his(er) real potential to recover cannot be disregarded, because there is no time to lose with questioning.When health is only absence of disease and medicine is only technoscientific and curative, the health team' attention tends to restrict itself to the pathology under treatment.However, one has to question if beneficence can be reduced to the simple achievement of cure, regardless of its real possibility and associated suffering.In the perspective of health as global wellbeing, involving physical, mental and social aspects, one has to attend the patient considering beneficence as a set of values that lead to wellbeing (12) .
Oftentimes Resuscitation maneuvers can be implemented due to health professionals' fear of being legally charged with not providing therapeutic care to patients.However, in other situations, there is the option not to perform cardiopulmonary resuscitation and there is no record whatsoever in the patient's file.Even when these maneuvers are performed, the family is not previously consulted.Health professionals seem somewhat afraid and uncertain, and there even seems to be some lack of knowledge on the extent to which one should invest in the patient's cure.
The choice not to resuscitate the patient does not exclude other nursing and medical care because it does not imply in abandoning basic necessary care.
As the patient is considered incurable, therapeutic resources destined to care should overcome those destined to cure.Thus, basic nursing care like oral hygiene, skin care, changing the patient's position, among others, should be maintained (13) .
Coping with therapeutic futility: humanized care?
For issues related to therapeutic futility, some nurses appointed the adoption of humanized care as a coping strategy, though they did not indicate how to put it in practice.We consider that the implementation of humanized care mainly implies personalizing the patient hospitalized in the ICU.It seems to be necessary to listen more to patients, talk about their values related to the dying process and death, life perspective, how the disease symptoms and treatment affect them.It is important that more than one professional talks to the patient, obtains information and discusses it in periodical multiprofessional meetings on the best way to move ahead.Although nurses usually occupy great part of their scarce time with several tasks, which are usually too many, dialog is necessary, due to its essential importance to establish criteria for patients' treatment (14) .
It is also important to clarify options of care and their potential consequences during a dialog between nurse and patient.For patients to have options, they need to know these options.In the palliative care model, which is characterized by the control of patients with active and progressive diseases in an advanced phase, for which the prognostic is limited and care is focused on quality of life, spending time clarifying options to patients and their family members is essential (15) .
Therefore, dialog can be established before procedures and therapies are implemented, asking for the patient's consent, acknowledging the individual and preserving the human nature of relations between individuals who experience radical situations of extreme vulnerability.Asking for consent is a minimum and mandatory procedure that shows responsibility for the patient and protects him(er) from potential abuse, assuring and promoting an ethical relationship between people who do not know each other (16) .
In addition to dialoging with the patient, nurses should also talk to the nursing team, physicians and other professionals who might provide care and also establish co-responsibility and construct teamwork as a way to produce greater commitment of everyone in the patient's benefit, jointly establishing the best actions to be adopted.In this complexity of relations, the set of professionals is responsible for getting involved with patients and family members, including them in the care delivered as a way to make them active and capable of assuming their own care.
We believe that exercising thinking is an important strategy to provide tools for the care of patients in the terminal phase of disease, and also permits reflection on the best actions to be adopted with a view to avoiding dysthanasia.
Ethical issues like therapeutic futility should be included in the education process of nursing professionals, ideally in situations of practice and supervised training, aiming to educate professionals capable of allying technical competence with human sensitivity.
they are implementing futile therapeutics that cause suffering to patients, which leads to antagonistic feelings.[…] sometimes you get angry, 'cause you're doing some futile thing and you're not changing that patient's situation, but then you create bonds and think that it's better and think that deep, deep down, who knows, there's hope (E3).
(11)'re going to die, but because they go through all this suffering and you know it's useless (E5).Some nurses, possibly due to lack of understanding and consideration about what can, orbetter yet, what needs to be done for each patient who experiences a situation of terminal illness(11), reported feeling that