Management of bed availability in intensive care in the context of hospitalization by court order.

Abstract Objective: to identify, from the nurse perspective, situations that interfere with the availability of beds in the intensive care unit in the context of hospitalization by court order. Method: qualitative exploratory, analytical research carried out with 42 nurses working in adult intensive care. The selection took place by non-probabilistic snowball sampling. Data collected by interview and analyzed using the Discursive Textual Analysis technique. Results: three categories were analyzed, entitled deficiency of physical structure and human resources; Lack of clear policies and criteria for patient admission and inadequate discharge from the intensive care unit. In situations of hospitalization by court order, there is a change in the criteria for the allocation of intensive care beds, due to the credibility of professionals, threats of medico-legal processes by family members and judicial imposition on institutions and health professionals. Conclusion: nurses defend the needs of the patients, too, with actions that can positively impact the availability of intensive care beds and adequate care infrastructure.


Introduction
The 1988 Federal Constitution of Brazil guaranteed with citizens the social right to health. As a result, in 1990 the Unified Health System (SUS) was implemented, based on the principles of universality, integrality, equity, decentralization and social participation, with the responsibility of providing public health services for the population (1)(2) . However, this right to health is often not applied, due to the difficulties faced to guarantee universal and equal access, and from these difficulties emerges the movement for the judicialization of health, especially for access to medicines and health services (2) , among which access to an Intensive Care Unit (ICU) bed (3) .
People using the public system have access to an average of 0.9 ICU beds per 10,000 inhabitants and people with private health insurance have access to 4.14 beds per 10,000 inhabitants, the disparity being most pronounced in small towns and cities, in the poorest states of Brazil (4)(5) . There is a mismatch between the offer in the public health system and the incorporation of new technologies in the SUS and the demand for health care by citizens.
And, both in Brazil (6)(7) with in other countries (8)(9) , the commodification of care is expanded, reflecting the notion that care is considered better distributed by the market, which prioritizes the private health system. It results in a context of State minimization in which health systems, the quality of these services and access to them and the best health technologies are unevenly distributed among the people and groups that make up the social and political-economic organization of society (10) .
In the United Kingdom, the number of ICU beds is 0.6/10,000, one of the lowest in Europe (11) , even less than the number of SUS beds. However, its physical infrastructure and human resources are superior to those existing in Brazil. In this perspective, in addition to the absolute number of beds in the ICU, there are many reasons for the unavailability of ICU beds in Brazil and other countries, including: limited equipment and drugs; inadequate professional training; high workloads; shortage of professionals; lack of best practices and protocols; aggressive treatment demands; unnecessary ICU hospitalization; relentless treatment inequality in the distribution of resources; lack of availability of regular hospital beds and home care after ICU admissions; competing interests and that influence in the decisions in the screening and inadequate communication with patient families (1,(12)(13)(14)(15) .
In Brazil, in cases of unavailability of a hospital vacancy in the public service, it is the responsibility of the state manager to provide a SUS bed in a private service, guaranteeing the right of access to health services and adequate care. Thus, policies and strategies were introduced that include the Regulation of State Beds and Hospitalization by Judicial Order to assist in the process of finding vacancies. In this circumstance, aware of the gravity of their relative and the need for a bed in another center, the family turns to the Public Prosecutor's Office or to their lawyer to propose an action to request advance protection. It is an action against the municipality and the State sends it to the State Bed Center (16) .
However, it is argued that patients, admitted to the ICU by court order, may not be the ones who most need care in the ICU, which restricts the possibilities for professionals to act according to their ethical and fairness principles. That is, the application of the law, given or ordered by the judiciary, can result in unintended consequences and even harmful to the health of some patients, such as, for example, the transfer of a more severe patient from an ICU to admit a less serious patient (1) .
It is an ethical problem that expands, as access to justice and the exercise of rights is restricted to people, through individual actions. In addition, these specific situations limit the possibilities for nurses and other health professionals to defend their patients and work for social justice (1) .
The practice of advocacy has been proposed, globally, as a strategy that allows the strengthening of the political, ethical and legal roles of nurses, aiming to ensure their rights and that of the users of the health services in which they work (17)(18)(19) . Specifically in the ICU, the intensive care nurse has a legal and moral duty to guarantee the quality of care for the seriously ill patient and proactive communication in the decision making of the patient, family, and health team (20) .
A Brazilian study (21) coordinates ICU nursing with conceptual aspects of patient advocacy. To this end, when conducting a survey of 451 nurses, it analyzed the actions and factors associated with patient protection by intensive care nurses using the scale Protective Nursing Advocacy Scale, cross-culturally adapted and validated in Brazil (22) . And, the study identified that a greater number of nurses understand the defense of the patient as an important part of their work, as well as the factors that can influence the decision to defend their patients, but they are still unaware on the benefits of the advocacy (22) . Thus, the aim of this study was to identify, from the perspective of nurses, situations that interfere with the availability of beds in the ICU in the context of hospitalization by court order.

Method
Exploratory qualitative analytical research, which belongs to the macroproject, financed by Universal

Discussion
Among the aspects addressed in the "Deficiency of physical structure and human resources" category, there is work overload, linked to the dimensioning of personnel below what is necessary and the precariousness of physical infrastructure and equipment. Therefore, even though hospitalization by court order is a problem in the Brazilian reality (3)(4)(5)(12)(13)(15)(16) , international and national studies address the issue of cost rationalization and access to ICU beds (4,12,24) . Rationing is the allocation of health care resources with limited availability.
It is conjectured, here, that the excessive workload and that overlap in the face of the issue of hospitalization by court order is even more complex, since it can impact the difficulty of implementing the multidisciplinary daily care plan and the negative implications of the manifest conflicts among the health team (27) . Therefore, there is a need to develop resource allocation strategies in order to optimize assistance in caring for all patients in a fair and responsible manner (24) , by means of clear and specific rules and by public policies that even limiting the construction of new ICU vacancies, qualify the existing ICUs.  (28) .
Another worrying aspect referred to the effect of the waiting time per ICU bed, in situations of hospitalization by court order. In this case, studies (13,(29)(30) indicate that the refusal of the patient's access to the ICU or the late admission to the ICU of a patient eligible for the ICU are associated with a higher probability of mortality, disability and additional expenditure of resources due to the longer hospital stay. Still, it can become a serious problem when patients who would need an ICU bed, for example, in the postoperative period of major surgery, are allocated in inappropriate beds and not equipped for the purpose of intensive care 24 hours a day (28,30) . and 3) creating a formal appealing mechanism for conflicts between families and care staff, as a priority program for users and decision makers (13) . Study (32) signals that English and American guidelines highlight that it may be considered unethical to transfer a patient out of an ICU for the sole purpose of making room for another, as the obligations to ensure the care of patients already hospitalized in an ICU outweigh the obligations to accept new patients. In this sense, there is concern about the imprecision in decision making and the possibility of arbitrariness, even though there was more flexibility for professionals who would apply them in real situations. However, a policy guided by a precision value can give more weight to factors that can be easily measured (quality of life) than factors that cannot (equity and need). Therefore, policy guidelines www.eerp.usp.br/rlae 6 Rev. Latino-Am. Enfermagem 2020;28:e3271.

Research participants indicated that
for resource allocation must be explicit about the ethical values at stake, and how they could be measured (32) .
That study (32) corroborates the ethical concern of nurses in this research: the duty to care for the person who is already in the ICU, without risking arbitrariness or inducing wrong or unwise decisions, in the face of according to the specialties of each hospital (34) .
The nurses 'discourse regarding the need to deal with conflicts arising from uncertainty and inconsistent messages about the patients' real prognosis, also reports to the patient's advocacy, as this professional needs to guarantee the best care available, both for through the monitoring of available treatment, which is sometimes not immediately offered to the patient, as in situations of futility of certain treatments and palliative care. The ICU nurse will not always be able to resolve all the family members' demands and expectations, but they must be responsible for indicating to the family which means they can use and making sure that the family is having access to these means (36)(37)(38) .
In the third category, entitled "Inadequate discharge from the ICU", it was considered that the increase in the transfer of patients out of the ICU occurs when the occupation is high, with the consequence of the risk of moving the patients out prematurely. Therefore, even in situations of hospitalization by court order there is an aggravation of the unpredictable, intensivists must be strong defenders of all patients' needs, regardless of scarcity or expense. And, professionals say that when trying to accommodate new admissions, they realize that their safety standards for transferring patients from the ICU are questionable; the characteristics of the patients they proposed for discharge were less restrictive, which could cause a situation dangerous enough to require an ICU bed (13) .
The process of determining the best time to leave the ICU involves a careful assessment of the severity of the disease, as well as the patient's clinical conditions.
Studies have shown that mortality and length of hospital stay are significantly higher in patients readmitted to ICUs after their early discharge (11)  suggesting early discharge and reaffirming the need and importance of defining criteria for discharge from the ICU (39) .

Conclusion
Hospitalization by court order is a problem in the